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When a nightmare has a replay: recurring spontaneous coronary dissection in a puerpera
Session:
Sessão de casos clínicos
Speaker:
Gualter Santos Silva
Congress:
CPC 2021
Topic:
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Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Gualter Santos Silva; Mariana Brandão; Cláudio Espada Guerreiro; Mariana Ribeiro Da Silva; Diogo Ferreira; Pedro Queirós; Daniel Caeiro; Adelaide Dias; Ricardo Fontes-Carvalho
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">34 years-old puerperal woman, smoker without other atherosclerotic risk factors, family history of cardiac disease or regular medication, presented to the emergency room at the 8<sup>th</sup> day postpartum due to sudden angina associated with vomiting, which began 1 hour prior to the admission. Vital signs were stable. Normal heart sounds were present, without any murmur. No signs of heart failure were present.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Initial electrocardiogram revealed sinus rhythm with pathological ST-segment elevation in leads V2-6, DI and aVL. The diagnosis of ST-Elevation ACS was assumed ant the patient was medicated with aspirin, unfractionated heparin and SL nitroglycerine with resolution of the chest pain and the ST-segment elevation.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Emergent coronary angiography was performed, which documented a 50% long stenosis in the mid portion of the left anterior descending artery (LAD) involving the origin of the second diagonal and another 60% long stenosis in posterolateral artery.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">In view of the discrepancy between clinical, electrocardiographic and angiographic findings, an intravascular optical coherence tomography of LAD was made, identifying an intramural hematoma in the mId LAD, suggestive of spontaneous coronary artery dissection (SCAD) type 2. Considering this diagnosis and the patient’s clinical and hemodynamic stability, a conservative approach was decided, without anti-platelet therapy.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">In the cardiac ICU, TTE revealed apical akinesia with normal left ventricular function. She remained clinically and electrically stable, with a peak hs-cTnT of 5690ng/L. 7 days after admission, a coronary computed tomography angiography revealed similar findings in LAD but a worsening of right coronary artery lesion, suggestive of synchronous SCAD. At 8-day, patient had a new episode of acute chest pain with ST-segment elevation in V4-6, DII, DIII and aVF. Emergent coronary angiography showed a synchronous dissection of the right coronary artery from the ostium to the posterior descending artery. Revascularization was necessary, with full metal jacket PCI. Final result with TIMI 3 flow in the distal vessel. LAD was still patent with normal flow, without evidence of anterior ischemia.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">At day 14, control TTE showed a left ventricle apical thrombus. Anticoagulation therapy with Varfarine was initiated without further complications to mention. The patient was discharged at day 16 under dual antiaggregation therapy (AAS during 1 month + Clopidogrel), Varfarine, beta-blockade and ACE inhibitor. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="background-color:white"><span style="color:black">SCAD is a rare </span></span><span style="background-color:white"><span style="color:black">but potentially catastrophic</span></span> <span style="background-color:white"><span style="color:black">cause of ACS. The optimal management remains controversial. Conservative approach had been advocated in stable patients, although the ideal antithrombotic scheme remains a topic of debate, while revascularization should be performed whenever there is evidence of ischemia. </span></span>This is a singular case due to the rarity of synchronous spontaneous dissection in two vessels.</span></span></p>
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