Spontaneous Coronary Artery Dissection Beyond the Typical Demographic: Multivessel Involvement in a Male Patient

Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute myocardial infarction, predominantly affecting younger women without traditional atherosclerotic risk factors. The underlying pathophysiology remains incompletely understood and is thought to involve a complex interplay between arterial wall vulnerability and precipitating stressors. Moreover, challenges persist in achieving timely diagnosis and defining optimal management strategies. Occurrence of SCAD in men is particularly rare, often leading to diagnostic uncertainty and potential delays in appropriate management. We report the case of a 43-year-old man with a history of hypertension and obesity who presented with a non-ST-elevation myocardial infarction (NSTEMI). Given his risk profile, an atherosclerotic aetiology was initially presumed. However, coronary angiography demonstrated distal left anterior descending (LAD) artery tapering with an appearance that was thought to be consistent with SCAD. Owing to his atypical demographic for SCAD, this angiographic impression generated a diagnostic dilemma, prompting further evaluation with cardiac magnetic resonance imaging (CMR), which revealed a multivessel infarction pattern. An interval repeat angiogram later demonstrated evolving features of healing SCAD in both the LAD artery and right coronary artery, confirming the diagnosis of multivessel SCAD. Although intracoronary imaging would have been ideal to enhance diagnostic clarity, it was not performed due to the distal location of the suspected SCAD lesions and variable operator experience with intracoronary imaging.  This case underscores the importance of considering SCAD even in atypical demographics such as male patients, where preconceived diagnostic assumptions may delay recognition. Greater awareness of its variable angiographic appearance and clinical patterns can help reduce diagnostic uncertainty and improve timely management.