Spontaneous coronary artery dissection with concomitant vasospastic angina and false lumen enlargement: a case report

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). Although the exact pathophysiological mechanism of SCAD remains unclear, coronary vasospasm has been proposed as a possible associated or triggering factor.

A 39-year-old woman presented with sudden-onset back pain and ST-segment elevation in leads V1–V6 on electrocardiogram. Emergent coronary angiography (CAG) revealed subtotal occlusion with dissection in the mid left anterior descending artery (LAD), and intravascular ultrasound demonstrated that the dissection extended from the mid portion to the ostium of the LAD. We deployed a drug-eluting stent for the mid-LAD and confirmed reperfusion. After the PCI, she developed recurrent chest pain with transient ST-segment elevation in the inferior leads. Emergent CAG demonstrated diffuse severe stenosis in the distal right coronary artery. Both symptoms and electrocardiographic changes resolved spontaneously; coronary vasospasm was considered the most likely cause. On day 17, follow-up CAG revealed progression of stenosis from mild to severe in the mid to ostial LAD and a new dissecting lesion in the mid right coronary artery. Repeat PCI was performed, and the patient remained stable after discharge.

There are some SCAD cases that present acute progression or recurrence. The prognostic factor was unknown, while this case would suggest that vasospastic angina pectoris (VSA) might be associated with those events. Consideration of concomitant VSA may be warranted in the clinical management of patients with SCAD.