Coronary artery dissection

Background

• Usually presents as an Anterior MI with ST changes in anterior Precordial leads (V1-V3)

Causes

• Hormonal changes in vessel wall (eg pregnancy, contraceptives)
• Shear forces
• Fibromuscular dysplasia
• Underling connective tissue disorder
• Iatrogenic (during coronary angiography)

Clinical Features

• Chest or shoulder pain
• Syncope
• Dyspnea
• Diaphoresis
• Nausea

Differential Diagnosis

ST Elevation

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Evaluation

• EKG
• Labs
  • Troponin may be elevated
• Echocardiography
• Cardiology consultation
• Diagnosis made at time of coronary angiography

Management

• Aspirin, β-blocker, and 1 year of clopidogrel
• PCI can be challenging given vessel wall fragility

Disposition

• Admit

See Also

• Chest Pain
• STEMI