A Rare Case of Chronic Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare and underrecognized cause of acute coronary syndrome (ACS), particularly in young and middle-aged women without traditional cardiovascular risk factors. While most cases heal spontaneously, a subset may persist, evolving into what can be considered a chronic coronary artery dissection (CCAD). This chronic form remains poorly defined and rarely documented.  A 44-year-old woman with a history of ST-elevation myocardial infarction (STEMI) presented several months later with recurrent chest pain. Coronary angiography revealed a persistent dissection in the mid-left anterior descending (LAD) artery without signs of active ischemia or evolving intramural hematoma. No advanced imaging was performed, but the stability of angiographic findings over time and the absence of ischemic symptoms supported the diagnosis of a chronic dissection. The initial STEMI was retrospectively considered to have resulted from an unrecognized SCAD. Given the lack of ischemia and the risks associated with intervention in SCAD, conservative management was continued. The patient remained asymptomatic and free of major cardiac events over a 12-month follow-up period. Chronic dissection may be overlooked in patients with a history of SCAD. Although angiography remains the main diagnostic tool, it has limitations, and adjunctive imaging such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), or coronary computed tomography angiography (CCTA) may help confirm chronicity. Current understanding of the long-term course of SCAD, including recurrence risk and follow-up strategies, is still limited. CCAD should be considered in patients with recurrent chest pain and prior SCAD history. Further studies are needed to better define its prognosis, recurrence risk, and optimal monitoring strategies.