A 34 year old female with no past medical history that is 2 weeks post-partum from an uncomplicated vaginal delivery presents for acute chest pain that started while she was exercising. Vital signs are within normal limits. On exam, she appears uncomfortable but in no respiratory distress. There is no lower extremity edema. Her EKG demonstrates ST segment elevations in contiguous leads with reciprocal depressions. Based on the leading diagnosis, which coronary artery is most commonly involved?
A: left anterior descending (LAD)
B: left circumflex (LCx)
C: posterior descending (PDA)
D: right coronary (RCA)
Answer: left anterior descending (LAD)
This patient presentation is typical for spontaneous coronary artery dissection (SCAD) which predominantly affects young to middle aged females. Risk factors include pregnancy, postpartum period, and hormonal therapy. Physical stressors such as exercise or emotional stress are classically involved. Unlike acute coronary syndrome, the pathophysiology involves a dissection tear in the coronary artery wall, not an atherosclerotic plaque or embolization. The LAD is most commonly involved in about 32 to 46% of cases. It is diagnosed by coronary angiography. Management varies but is typically conservative with medical therapy. Invasive measures such as coronary stenting is considered in cases with ongoing ischemia or hemodynamic instability.
References:
Hayes SN, Kim ESH, Saw J, et al. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018;137(19):e523-e557. doi:10.1161/CIR.0000000000000564
