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A 45 year old, pre-menopausal woman, without any known risk factors for coronary artery disease, presented in the emergency department with acute onset of chest pain. The ECG showed transient ST segment elevation of 3 mm in leads V3–V6. Although creatine kinase (CK) and CK-MB were not increased, troponin I elevation (3.1 ng/ml) was observed during hospitalisation in the coronary care unit. Because of the transient appearance of the ST segment elevation, thrombolysis was not administered. Instead the patient received nitrates, β blockers, aspirin, and heparin and her symptoms were controlled.
Coronary angiography showed a long segment dissection extending from the proximal left anterior descending artery (LAD) to the distal segment of the vessel (panel A). Contrast media entrapment was observed at the origin of the dissection (panel B). The left ventriculogram showed pronounced hypokinesia of the anterolateral and apical segments with a calculated ejection fraction of 40%.
Because of the transient ST segment elevation, there was a high probability of coronary spasm or spontaneous dissection of the LAD, as the ECG changes were present in the anterior leads. Therefore, a thrombolytic agent was not administered and the conservative approach was preferred.