An unusual case of Acute Coronary Syndrome

S. Aravinda Kumar¹, Arjun G², Ka Suganthan Nithish³, M. Shamutra³

¹Chief Consultant Interventional Cardiologist, Kauvery Heart City, Trichy, India

²MEM Postgraduate, Kauvery Hospital, Trichy, India

³Duty Medical officer, Department of Cardiology, Kauvery Heart City, Trichy, India

Abstract

Acute Coronary Syndrome (ACS) is a serious condition that occurs when blood flow to the heart is reduced or blocked, leading to heart muscle damage. It is commonly associated with atherosclerosis, a buildup of plaque in the arteries. However, there are certain rare cases where ACS can occur without the presence of atherosclerosis. In this article, we discuss an unusual case of ACS in a young woman and the diagnostic approach taken to determine the best management strategy.

Case Presentation

A 42 years aged pre-menopausal woman already had T2DM for 15 years; ie., since age 27! She also had a family history of precocious CAD in her mother, who had an AMI. However, she had no known history of systemic hypertension, dyslipidemia, smoking, tobacco use, alcohol consumption, or any substance abuse. Her lifestyle was relatively stress-free. Her siblings, however, were healthy with no history of CAD

She had presented with history of chest pain radiating to the left shoulder to an outside hospital where she was diagnosed to have Anterior wall Myocardial Infarction (MI) and treated with loading dose before being referred to Kauvery Heart city for further evaluation.

On examination, she was conscious, oriented, and her vital signs were stable.

ECG at outside hospital:

An Electrocardiogram (ECG) was taken outside which showed ST elevation V2, V3 with reciprocal changes in inferior leads. In our ER, ECG was repeated and it showed significant T wave inversion in antero-septal leads (V2-3-4), and less impressive T inversion in LI, aVL and lateral leads( V5-6) suggestive of evolved anterior wall MI.

ECG at Kauvery Hospital

An echocardiogram (Echo) was performed and showed evidence of regional wall motion abnormality at Left Anterior Descending artery territory and mild left ventricular (LV) dysfunction (EF 45%).

As for blood investigations Troponin T (Qualitative) was positive and other tests such as LFT , Lipid profile , TFT were with in normal limits.

Her clinical presentation clearly suggested Ischemic Heart Disease hence Coronary Artery Angiography was advised for further evaluation of the extent of the coronary artery disease.

Coronary Artery Angiography was then performed, which showed a non-flow limiting thrombotic lesion in the mid-left anterior descending (LAD) artery.

Given her age and risk factors, decision was made to perform Optical Coherence Tomography (OCT) to determine the etiology of the ACS. OCT is a useful tool that provides detailed images of the vessel’s microstructural anatomy, allowing the identification of specific abnormalities such as plaque erosion, plaque rupture, or calcific nodule.

The OCT findings in this case showed Spontaneous Coronary Artery Dissection (SCAD) with a lumen area of more than 5 sq. mm, with no evidence of medial dissection or intramural hematoma (IMH).

SCAD occurs when a tear develops in the inner layer of a blood vessel, leading to the formation of a blood-filled cavity, or hematoma. The hematoma in turn compresses the true lumen of the artery, impairing the blood flow and possibly leading to angina or heart attack. While the exact causes of SCAD are not fully understood, it is believed to be associated with hormonal changes, extreme emotional stress, physical exertion, and the presence of underlying arterial abnormalities.

Discussion

SCAD is an unusual presentation of ACS, primarily affecting young women. The use of OCT, in this case, provided important insights into the etiology of the condition and allowed for a conservative management approach, avoiding interventions such as stenting. Patient was hemodynamically stable and had distal flow in the affected artery without evidence of ongoing ischemia hence patient was managed conservatively with dual anti-platelets, Statins, Beta blockers and anti-anginals.

Stenting was deferred. Most SCAD cases stabilize and heal over a few months with conservative management. The patient was discharged without any complications during her hospital stay.

Conclusion

This case of a 42-year-old female with diabetes mellitus and positive familial CAD highlights the importance of considering SCAD as a possible cause of acute coronary syndrome. Prompt recognition, accurate diagnosis through appropriate angiographic imaging, and confirmation with OCT can lead to timely management decisions, such as deferring stenting and opting for conservative medical therapy. This approach ensures favorable outcomes and optimal long-term cardiac health in these patients.

Further research and awareness are required to better understand and manage these rare cases.

Dr. S. Aravindakumar

Chief Consultant Interventional Cardiologist

Dr. Arjun G

MEM Resident

Dr. M. Shamutra

Duty Medical officer

An unusual case of Acute Coronary Syndrome