Spontaneous coronary dissection as an unusual cause of acute myocardial infarction When the trigger is not physical, but the damage is real.

Abstract

Introduction: Spontaneous coronary dissection (SCD) is a rare but significant cause of acute myocardial infarction (AMI). It accounts for 1% to 4% of acute coronary syndromes in the general population. Its prevalence increases notably in women, reaching up to 35% in women under 50 years old without traditional risk factors and 15% in women over 60 with non-atherosclerotic AMI. The pathophysiology involves rupture of the coronary wall, resulting in an intramural hematoma and secondary luminal stenosis. Intense emotional stress and physical trauma are present in up to 59% of cases, acting as triggers in those with underlying vascular vulnerability.

Case report: A 78-year-old woman, functionally independent and without comorbidities, with only a family history of early heart attack. She presented with oppressive chest pain of recent onset, triggered by an episode of mild discomfort 30 hours prior, following an intense emotional argument. The ECG showed ST-segment elevation on the inferolateral side, indicating an acute infarction. Ultrasensitive troponin was significantly elevated (3.36 ng/mL). Echocardiogram revealed a preserved ejection fraction (60%) with posteroseptal baseline hypokinesia. Coronary angiography excluded atherosclerosis and detected spontaneous coronary dissection (SCAD) in the circumflex artery. The dissection was classified as type 2A (helical with double lumen and visible flap), but with good coronary flow (TIMI 3-4).

Management: Because of the lesion’s nature (SCAD type 2A with good flow), conservative management—including double antiplatelet therapy, rest, and monitoring—was selected. The patient experienced a favorable clinical course with no recurrences. She was discharged on day four, with follow-up in cardiology and psychosocial support, emphasizing the role of emotional stress as a potential trigger for SCAD.