Methods:
Chest plain radiograph did not reveal any acute cardiopulmonary
abnormalities. The initial ECG showed T-wave inversion in lead V1 and
biphasic T-wave in lead V2 (Figure 2A) , while the subsequent
ECG one hour later showed persistent T-wave inversion in lead V1, V2,
but a new biphasic T-wave in lead V3 (Figure 2B) . Cardiology
was consulted who recommended serial cardiac troponin which continued to
increase to 0.241 ng/mL, 0.650 ng/mL, and 0.728 ng/mL. The patient was
given an aspirin load of 324 mg and urgent echocardiography revealed a
mildly reduced ejection fraction of 45% with akinetic apical anterior,
apical septal, apical inferior, apical lateral and apex left ventricular
wall segments (Figure 3A-B) . She was started on a heparin,
eptifibatide, and nitroglycerin. A cardiac catheterization was performed
and revealed coronary dissection in the left main coronary artery from
the ostium to the distal in addition to a second dissection in the
proximal and mid LAD (Figure 4A-B) . Three drug-eluting stents,
one in the left main coronary and two in the proximal and mid LAD, were
placed without complications. The patient was started on aspirin 81 mg
daily, clopidogrel 75 mg daily, atorvastatin 40 mg daily, lisinopril 5
mg daily, and metoprolol succinate 50 mg daily. Initial FMD workup
including computed tomography angiography (CTA) of the head, neck and
chest was unremarkable. The patient was safely discharged home with
plans to enroll in the SCAD registry and repeat echocardiogram to assess
for left ventricle recovery. Unfortunately, the patient was lost to
follow up despite multiple attempts to establish communication with the
patient by the cardiology team.