Abstract | April 5, 2022

Spontaneous LAD in a 62 Year-Old Lad: A Case Report

Presenting Author: Adele Elizabeth Soutar, MD, Internal Medicine PGY-2, Department of Medicine, New Hanover Regional Medical Center, Wilmington, NC

Coauthors: Michael Pietrangelo, DO, Internal Medicine PGY-3, New Hanover Medical Center, Wilmington, NC

Learning Objectives

  1. Upon completion of this lecture, learners should be better prepared to diagnose a spontaneous LAD dissection in the setting of absent risk factors.
  2. Upon completion of this lecture, learners should be better prepared to treat LAD dissection.

Case Presentation: A 62 y.o. male presented to his primary care clinic due to 10/10 stabbing chest pain associated with shortness of breath and diaphoresis. Chest pain was sudden in onset, not relieved with leaning forward. Past medical history was significant for CAD, HTN, COPD with end-stage lung disease and continued tobacco use.

Documented cardiac exam was unremarkable with only noted physical distress. Clinic interventions included sublingual nitro and 324 gm PO aspirin that resulted in relief, but not complete. Of note, the patient was recently discharged from the hospital two days prior. Clinic EKG in comparison demonstrated new ST elevation in leads V2-V6 with possible elevation as well in limb leads with PR depression, this was exemplified on EKG upon arrival demonstrated ST elevation in V3,V4, and V5 indicative of acute MI/ STEMI.

Due to the concern for anterior STEMI with heart score of 7, EMS transported him to the hospital with admission under cardiology service. Prior ASA administered in clinic with initiation of heparin on admission. He underwent emergent radial percutaneous coronary catheterization. Cath report demonstrated reduced and hypokinetic apical LV function with EF of 45%. Additionally, noted normal left main and normal D1 of LAD but large D2 with spontaneous dissection of distal and apical LAD, reaching but not wrapping the apex seen in figure 2 below. Noted TIMI 3 flow, but vessel with diminutive and consistent with dissection.

Final/Working Diagnosis: Spontaneous left anterior coronary artery dissection.

Management/ Outcome/and or Follow-up: Due to high prevalence of SCAD in the setting of fibromuscular dysplasia, CTA head, neck, chest, abdomen, and pelvis were performed, all without evidence for presence. He endorsed resolution of chest pain following cardiac catheterization without subsequent episodes since. Discharged with referral to cardiac rehabilitation and continued on all risk stratifying medications initiated during hospitalization including ASA, plavix, statin, and beta blocker. He was followed one month later in the clinic with complete resolution of any chest pain.

References and Resources:

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