ST-Elevation Myocardial Infarction from Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare but life-threatening condition which occurs due to non-traumatic separation of the coronary artery wall. It is more common in women, with an unclear, non-atherosclerotic mechanism. We report a unique case of spontaneous coronary artery dissection presenting as ST-elevation myocardial infarction (STEMI). A 54-year-old woman presented with fever and recurrent abscess. On presentation, she was tachycardic, tachypneic and hypoxic, requiring nasal cannula. Physical exam was notable for healing a wound on the right lower back, status post incision and drainage, with no erythema, edema, ecchymosis or purulent drainage. Laboratory investigations were remarkable for anemia. EKG showed sinus tachycardia with no ST-segment changes. Her hospital course was complicated by septic shock, renal failure, and acute hypoxic respiratory failure requiring intubation. Following extubation, she complained of sudden-onset, severe chest pain. EKG showed ST-elevations in the lateral and inferior leads, with an elevated high-sensitivity troponin level. Cardiac catheterization revealed SCAD involving the mid to distal right posterior descending artery (RPDA) with TIMI-3 flow in the distal RPDA. Given vessel tortuosity and poor target for stenting, was medically managed with dual antiplatelet therapy, a beta-blocker and an eptifibatide infusion for 12 h post-procedure. Extensive rheumatological workup negative. She remained hemodynamically stable with no new ST changes on subsequent EKGs. This is an uncommon medical emergency requiring prompt recognition, appropriate management and early intervention to prevent unfavorable patient outcomes.