Jason DarrahPGY-3

Internal Medicine ResidencyGundersen Lutheran Medical Foundation

La Crosse, WI

34 Year Old Caucasian Female

2 Months Postpartum

Retrosternal Chest Pain

Radiation Into Left Arm

Pain Between Her Shoulder Blades

Associated N/V, Diaphoresis

No Known Cardiac Risk Factors

Family History of RBBB

Meds: Probiotics, Prenatal Vitamins

Non Smoker

Hypertensive

Exam Was Unremarkable

EKG: ST elevations in I, II, aVL + RBBB

Troponin I and CKMB WNL

Hospital Day 3: “Heartburn”

Troponin Increased

Repeat Angiogram

Stent placed to 1st Diagonal – Small Plaque

Lipoprotein Analysis• Total 180, LDL 90, HDL 66, Trig 63• Lp(a) 107 mg/dL (<30 mg/dL)

Rare Cause of Acute MI

Women > Men • Peripartum

LAD – 60-80%, RCA - Men

1. Peripartum

2. Atherosclerotic

3. Idiopathic

4. Other Causes• Connective Tissue

Disease, SLE, Cocaine, Vigorous Exercise, Coronary Spasms

Sudden Cardiac Death

Acute Coronary Syndrome

Asymptomatic Unstable Angina

EKG Changes, Increased Cardiac

Markers

Intimal Tear

Rupture of the Vasa Vasorum

Heart. 2010; 96:803

Adventitia

External

elastica

Intim

a

Internal

elastica

Media

Vasa vasorum?

Eosinophils?

Clot False lumen

Increased Hemodynamic Stress

Hormonal Effects on Arterial Wall

Periadventitial Infiltrate of Eosinophils

Heart 1996;75:453

Coronary Angiography • Intimal “Flap”

Intravascular Ultrasound (IVUS)

Optical Coherence Tomography (OCT)

JACC. 2012; 59:1075.

Medical • Heparin/LMWH, ASA, Plavix, BB, Nitrates

Emergent Angiography PCI

CABG

Consider Fibrinolytic Therapy

Prognosis is Good

One Case Report Published

Implicated in Aortic Dissection

Independent Risk Factor for CAD

Journal of Cardiovascular Medicine 2011; 12:446-451

Rare cause of ACS

Women – Peripartum

Angiography

Questions?

1. Alfonso, F., et al. Diagnosis of Spontaneous Coronary Artery Dissection by Optical Coherence

Tomography. Journal of the American College of Cardiology. 2012, 59:1073-9.

2. Adlam, D., et al. Management of Spontaneous Coronary Artery Dissection in the Primary

Percutaneous Coronary Intervention Era. The Journal of Invasive Cardiology. 2010, 22:549-553.

3. Basso, C., et al. Spontaneous Coronary Artery Dissection: A Neglected Cause of Acute Myocardial

Ischaemia and Sudden Death. Heart. 1996, 75:451-454.

4. Buys, E.M., et al. Extension of a Spontaneous Coronary Artery Dissection Due to Thrombolytic

Therapy. Catheterization and Cardiovascular Diagnosis. 1994, 33:157-160.

5. DeMaio, S.J., et al. Clinical Course and Long-Term Prognosis of Spontaneous Coronary Artery

Dissection. The American Journal of Cardiology. 1989, 64:471-474

6. Irani, F., et al. Spontaneous Coronary Artery Dissection: To Treat or Not to Treat – 2 Atypical Cases

and a Review of the Literature. American Journal of Therapeutics. 2012, 19:62-65.

7. Leone, F., et al. Acute Myocardial Infarction from Spontaneous Coronary Artery Dissection: A Case

Report and Review of the Literature. Cardiology in Review. 2004, 12:3-9.

8. Patrignani, A., et al. Spontaneous Coronary Artery Dissection and Elevated Levels of

Lipoprotein(a) in a Young Man: A Causal Association? Journal of Cardiovascular Medicine.

2011, 12:446-451.

9. Shamloo, B.K., et al. Spontaneous Coronary Artery Dissection: Aggressive vs. Conservative

Therapy. The Journal of Invasive Cardiology. 2010, 22:222-228.

10. Vrints, Christian JM. Spontaneous Coronary Artery Dissection. Heart. 2010, 96:801-808.

11. Zupan, I., et al. Double Vessel Extension of Spontaneous Left Main Coronary Artery Dissection in

Young Women Treated with Thrombolytics. Catheterization and Cardiovascular Interventions.

2001, 52:226-230.