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A woman in her early 60s with a medical history of chest pain requiring a coronary angiogram (which demonstrated only mild luminal irregularities) approximately 1 year prior to presentation, hypertension, long-standing dyslipidemia, and multiparity presented to the emergency department with a sudden onset of dull, pressurelike chest pain radiating to the left arm. The pain started at rest, was 10 of 10 in severity, and was not alleviated by changing position. She also experienced concomitant nausea and diaphoresis. Her family history was notable for hypertension, and no other systemic diseases were reported. On physical examination, her blood pressure was 115/76 mm Hg, heart rate was regular at 72 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation level was 98% on room air. The patient was afebrile. Physical examination also revealed mild bibasilar crackles and jugular venous distention, and no murmurs or lower extremity edema. Laboratory test results demonstrated an elevated troponin, and the 12-lead electrocardiogram showed marked ST-segment elevations in leads V2 to V5 (Figure, A). The ST-segment elevation myocardial infarction (STEMI) pager was activated, and the patient was transferred urgently to the catheterization laboratory. Coronary angiography of the patient’s left anterior descending coronary artery was performed, and the findings are depicted in the Figure, B.
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Spontaneous coronary artery dissection
C. Treat medically with aspirin, β-blocker, clopidogrel, and a statin
Spontaneous coronary artery dissection (SCAD) is a nontraumatic and noniatrogenic separation of the coronary arterial wall, typically leading to the formation of a false lumen, in the presence or absence of significant obstructive coronary artery disease.1 While the precise pathophysiological mechanism remains unclear, a tear in the intima of a coronary vessel or the development of an intramural hematoma due to bleeding from the rupture of the vasa vasorum have been suggested as possibilities.2,3 The disease process tends to affect women, particularly young women, with underlying fibromuscular dysplasia or other connective tissue disease (such as Marfan syndrome, Loeys-Dietz syndrome, and Ehlers-Danlos syndrome type 4).4 Hormonal therapy and postpartum or multiparous state are also known risk factors. Without early detection and treatment, SCAD can be life-threatening.3,5,6
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Corresponding Author: Prakriti Gaba, MD, Department of Internal Medicine, Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (firstname.lastname@example.org).
Published Online: June 12, 2019. doi:10.1001/jamacardio.2018.4511
Conflict of Interest Disclosures: Dr Parikh reported receiving nonfinancial support from Abbott Vascular, Medtronic, Boston Scientific, Philips, and CSI Inc. He has also reported serving as a paid consultant for Terumo, Asahi, Siemens, Heartflow, and Merrill LifeSciences and receiving grants and institutional support from Shockwave Medical, TriReme Medical, and Surmodics Inc outside the submitted work. No other disclosures were reported.
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