ABSTRACT

Introduction: Spontaneous coronary artery dissection is an exceptionally rare cause of acute coronary syndrome (ACS) with a reported incidence of 1–4% of all ACS cases. It is most prevalent in young women with the left anterior descending artery and left main are the most common arteries involved.

Case Report: The patient is a 75-year-old man with a prior medical history of hypertension, gastroesophageal reflux disease (GERD), and pulmonary fibrosis presented to the emergency department (ED) with syncope. The patient reported a burning sensation over the central chest different from his GERD. On physical exam, the patient had a 3/6 holosystolic murmur throughout the left pericardium. His laboratory workup was benign with negative troponins and normal electrocardiogram (EKG). Chest X-ray during this time revealed no acute processes and computed tomography angiography (CTA) of the chest was positive for a 4.1 mm fusiform ascending aortic aneurysm. 2D Echo revealed new cardiomyopathy with ejection fraction (EF) of 35–40% with trivial mitral regurgitation (MR) and mild aortic regurgitation. Left heart catheterization revealed left main stenosis of 75%, left anterior descending (LAD) with ostial stenosis of 80% and 30% stenosis of the left circumflex and right coronary artery (RCA). The LAD had a proximal eccentric plaque which under intravascular ultrasound (IVUS) revealed a dissection. The patient underwent a coronary artery bypass grafting (CABG) and did well until discharge home. His postoperative course was complicated by new onset of atrial fibrillation/flutter. The patient was discharged to rehab with Eliquis, baby aspirin, Coreg, and Digoxin.

Conclusion: Our case is unique in view of the unconventional age group, gender, and odd symptomatology. We hope to increase the awareness among medical practitioners for this high morbidity diagnosis if not identified correctly.