• Images in cardiology

Spontaneous coronary artery dissection is an extremely rare cause of unstable angina and acute myocardial infarction or other ischaemic manifestations. It is more prevalent in young women, particularly in the peripartum period. There are a number of associated conditions such as inborn errors of metabolism and collagen synthesis, atherosclerotic disease, oral contraceptive use, and intense physical exercise, but the complete pathogenesis remains unclear. Treatment usually involves stent implantation or less commonly surgical repair.

A 67 year old woman with a history of hypertension, diabetes mellitus type II, and chronic obstructive pulmonary disease was admitted with acute pulmonary oedema that promptly resolved with conventional medical treatment. The ECG showed a regular rhythm without acute ischaemic changes, and the peak creatine kinase-MB (CK-MB) concentration was 5 mg/dl. Two days after admission the patient experienced chest pain. She was transferred to the coronary care unit and intravenous heparin and glyceryl trinitrate were administered, following which the symptoms resolved. ECG and CK-MB concentration remained unchanged. One day later the patient was brought to the catheterisation laboratory and angiography revealed a large dissection containing thrombus, which involved the mid and distal portion of the right coronary artery, but no evidence of atheroma and TIMI 3 flow (left panel). Since the patient was asymptomatic with clinical management (furosemide, enalapril, nitrates, heparin, and aspirin), it was decided to switch her from unfractionated heparin to enoxaparin treatment (1 mg/kg subcutaneously, twice a day), and to bring her back to the cath lab in a week. Subsequent angiography (right panel) revealed a completely normal vessel.

To our knowledge, this is the first case reported in which a patient received low molecular weight heparin treatment in the context of spontaneous coronary artery dissection with complete angiography and clinical resolution.