Spontaneous coronary artery dissection and hemodynamic instability: Can emergent PCI be life saving? Report of two cases and literature review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. It occurs predominantly among younger females and typically in the absence of atherosclerotic coronary artery disease. It is associated with peripartum period, connective tissue disorders, vasculitides, and extreme exertion. Presentations vary greatly, and this condition can be fatal. Given its rarity, there are no guidelines for management of SCAD. We present the cases of two female patients, with no coronary artery disease risk factors or recent pregnancy, who were presented with non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI), respectively, secondary to SCAD. Both had excellent outcome after emergent percutaneous intervention. Our first patient was presented with NSTEMI with ongoing chest pain and dynamic electrocardiogram (ECG). Emergent left heart catheterization was significant for first obtuse marginal (OM1) dissection, confirmed by optical coherence tomography. Percutaneous coronary intervention (PCI) with two bare metal stents was performed with resolution of symptoms and ECG changes. The second patient is known to have syndrome, presented with STEMI and emergent coronary angiography showed left anterior descending dissection with intramural hematoma confirmed by intravascular ultrasound and treated with a drug-eluting stent with resolution of symptoms and ST changes. Her hospital course was complicated by post-myocardial infarction pericarditis that was improved with colchicine. Both the patients were observed in the coronary care unit for 24 hours. Both remained asymptomatic at 6-month follow-up. SCAD is a rare cause of acute coronary syndrome. In patients with early presentation, limited disease, and ongoing symptoms, emergent cardiac catheterization with percutaneous intervention has excellent outcome. More studies are needed to establish evidence-based management guidelines.