Unusual Distal LAD Spiral Dissection in Young Male


OlisaemekaAchike,Ibrahim Osman*

Citation: Unusual Distal Lad Spiral Dissection in Young Male. American Research Journal of Clinical Case Reports; V1, I1; pp: 1-12

Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract:

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). The true incidence of SCAD is underestimated. The pathophysiology is still not fully understood and its management can be challenging.Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death. Standard therapy has not been established; current treatments range from conservative management to percutaneous revascularization or coronary artery bypass surgery. SCAD greatly mimics ACS, and this diagnosis should be considered when evaluating young patients who present with ACS with or without classical risk factors for coronary artery disease.

We report a case of a 39-year old man who presented with diabetic ketoacidosis (DKA) and presentation of ACS. He had multiple risk factors for CAD such as a smoking history of two pack-years, hypertension and poorly controlled diabetes mellitus type I. Once the clinical findings were suggestive of acute anterior and inferior myocardial infarction, the patient underwent emergent cardiac catheterization, which revealed distal left anterior descending coronary artery dissection. 

Conclusion: This case highlights the fact that although SCAD is a rare entity, it is increasingly being recognized as a significant cause of ACS. Urgent angiography should be considered if SCAD is suspected, because early diagnosis and appropriate management significantly improves the outcome.


Description:

Introduction

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of acute coronary syndrome (ACS), with a reported angiographic incidence of 0.1–1.1% (1,2). Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death (3). It occurs predominantly in women, with a female: male ratio of 2:1. The majority of patients are young adults, with amean age of 46 years for men and 38 years forwomen (1). In > 70% of cases, the diagnosis is made on postmortem examination (4,5). SCAD can present with sudden death and, unless an autopsy is performed, the true number of cases will remain underestimated. Other factors leading to underestimation of its prevalence are false-negative results on coronary angiography and spontaneous closure of the dissection (6).

We report a case of a 39-year-old male who presented with chest pain for 4 days and electrocardiographic findings of anterior myocardial infarction. He was found on angiography to have SCAD of the distal left anterior descending (LAD) coronary artery.

Case
A 39-year oldCaucasian male with past medical history of hypertension, diabetes mellitus type Iandtobacco usepresented with multiple complaints includingnon-exertional substernal chest pain,epigastric abdominal pain and emesis ongoing for 3 days.Chest painhad been preceded by dyspnea on exertion over a period of one week. Physical examination showed mild epigastric tenderness. Blood pressure was 119/79 mm Hg, with a pulse rate of 111 beats per minute and respiratory rate of 13 breaths per minute. His temperature was 36.7°C (98 °F). Oxygen saturation was 100 % on room air. Electrocardiography (ECG) showed sinus tachycardia, left posterior fascicular block, ST elevation in the anterior and inferior leads(Figure 1). Transthoracic Lab work revealedelevated cardiac troponin 2.95 ng/mL, blood glucose of 984 mg/dL, HbA1c=10.7 %, creatinine 1.73 mg/dl, hemoglobin of 8.8 g/dL, Sodium level 124 mEq/L and Potassium level of 6.7 mEq/L. Arterial blood gas showed pH of 7.20, bicarbonate level 9 mEq/L, PCO2 14 mm Hg. He was admitted to intensive care unit for diabetic ketoacidosis and a stat cardiology consult was placed. Stat bedside echocardiography showed absence of thickening of the apex and periapical region, gigantoid, multilobar, complex, separate pendular mobile thrombi (Figure 2a to 2e). Urgent coronary angiography showed total occlusion of distal portion of LAD artery with spiral dissection of LAD (figure 3) thought to be subacute or chronic, given collateral branches from diagonal branch supplying cardiac apex.

                           

He received loading dose of aspirin 325 mg then 81 mg daily, loading dose of clopidogrel 600 mg once and then 75 mg daily, unfractionated heparin intravenous bolus of 60 units per kilogram then 12 units per kilogram intravenous infusion, atorvastatin 80 mg nightly and metoprolol tartrate 25 mg twice daily. He was placed on Warfarin with INR target of 2-3 given his left ventricular thrombus. He was also placed on intravenous insulin per diabetic ketoacidosis protocol. Afterwards hospital course was stable. He was discharged home with plan for outpatient cardiology follow up.