Introduction: Spontaneous coronary artery dissection (SCAD) is a tear or separation within the coronary artery wall forming an intraluminal hematoma reducing downstream blood flow leading to myocardial ischemia (MI)(Figure 1A-C)1 . Intraluminal hematomas may develop from ”inside-out” due to endothelial-intimal injury or ”outside-in” due to injury within the vasa vasorum leading to bleeding in the wall. The subsequent false lumen from either mechanism can extend and compress the true lumen to cause MI [2]. Unlike other luminal etiologies of MI, SCAD is not caused by atherosclerotic plaque rupture, coronary intervention, or trauma [3]. With significant MI from intraluminal hematoma, patients can present with signs and symptoms that mimic MI including chest pain with and without radiation, dyspnea, nausea and vomiting. It can also include elevated troponin with electrocardiogram (ECG) changes consistent with ST segment elevation or non-ST segment elevation MI. The diagnosis is made when other etiologies of acute coronary syndrome (ACS) are ruled out and there is an angiographic evidence of non-iatrogenic or non-atherosclerotic radiolucent intimal flap and contrast staining [1]. Left anterior descending (LAD) artery is the most commonly affected branch of the left main coronary [4]. Severe stenosis can lead to heart failure as well as cardiogenic shock amongst other post-MI complications including ventricular arrhythmias, ventricular free wall or septal wall rupture. If angiography is inconclusive, then intracoronary imaging with optical coherence tomography or intravascular ultrasound may be considered before repeat angiography [5].The etiology of SCAD is thought to be multifactorial without a clear underlying cause. Risk factors associated include fibromuscular dysplasia (FMD), peri and postpartum period, hormonal fluctuations, and arteriopathies. SCAD is a rare cause of ACS, although when present, there is a higher prevalence in young females without cardiac risk factors [6]. Stable patients are treated conservatively with medication while percutaneous coronary intervention (PCI) and coronary artery bypass graft are reserved for severe stenosis and acute change in hemodynamics. Use of antiplatelet therapy remains controversial as medications such as acetylsalicylic acid (i.e. aspirin) and P2Y12 receptor blockers can worsen intraluminal hematoma. Dual antiplatelet therapy is recommended for those who undergo stent placement [5]. Similarly, guideline directed medical therapy is initiated for new onset of heart failure. Review of literature reveals 90% recovery within one month with coronary computed tomography angiography [5]. Many cases of SCAD have been reported in young females with ischemic symptoms and angiographic findings in the distal LAD but only few cases highlight proximal coronary involvement. We present a case of a young woman with extensive left main and proximal LAD SCAD requiring intervention.
