IJCS | Volume 31, Nº6, November / December 2018

DOI: 10.5935/2359-4802.20180072 672 CASE REPORT International Journal of Cardiovascular Sciences. 2018;31(6)672-675 Mailing Address: Cybelle Nunes Leão Hospital Santa Isabel - Rua Frei Cornélio, 200. Postal Code: 36500-000, Laurindo de Castro, Ubá, Minas Gerais - Brazil. E-mail: cynunesleao@gmail.com Spontaneous Dissection Of Left Anterior Descending Coronary Artery: Case Report Cybelle Nunes Leão,¹ Marilia Medeiros Vitório Machareth,¹ Pedro Henrique D'avila Costa Ribeiro,² Bruno dos Santos Farnetano,¹ Isaac Nilton Fernandes Oliveira,¹ Rafael Américo Damaceno¹ Hospital Santa Isabel, 1 Ubá, MG - Brazil Faculdade Governador Ozanam Coelho, 2 Ubá, MG - Brazil Manuscript received September 30, 2017; revised manuscript November 13, 2017; accepted March 27, 2018. Acute Coronary Syndrome; Cardiac Catheterization; Coronary Artery Disease. Keywords Introduction Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). 1-5 It usually affects young women with no risk factors for coronary disease. 3,5-8 The real incidence of this disease in the population in general is unknown. 1,3-6 However, as has been observed in more recent studies, the prevalence of SCAD has increased due to the growth in the use of coronary angiography (from 0.2% to 4%). 5 Because it is a poorly studied disease, its etiology remains little known and, therefore, the prognosis and therapeutic approach are still uncertain. 1,6,7 The percutaneous coronary intervention, surgical myocardial revascularization and clinical treatment are therapeutic options. 3,5,8 Case Report A 26-year-old female, with no cardiovascular risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, smoking and alcoholism) or other relevant pathological antecedents, under use of oral contraceptives only, woke up due to oppressive precordial pain associated with diaphoresis and dyspnea. After seekingmedical attention, shewas admitted to an emergency care unit in her hometown 18 hours after the beginning of the clinical picture. The electrocardiogram showed ST elevation in leads V1 and V2 and ST-segment depression in leads DII, DIII and aVF. After administration of acetylsalicylic acid (ASA) 200 mg, shewas referred to a referral hospital. Afterwards, the patient was hemodynamically stable, with sinus cardiac rhythm, eupneic, normotensive andwith decreased pain. A coronary angiography was carried out 24 hours after the beginning of the symptoms and revealed dissection from the ostium to the proximal third of the ADA, with 90% obstruction and intramural thrombus (Figure 1), in addition to left ventricular anteroapical akinesia. The other coronary arteries showed no obstructive lesions. Because the patient was hemodynamically stable and had no precordial pain, a non-interventionist strategy was chosen through clinical treatment of SCAD. Adouble antiplatelet therapywas started, with clopidogrel (loading dose of 300 mg followed by 75 mg/day maintenance dose) and ASA (loading dose of 200 mg and 100 mg/ daymaintenance dose), in adittion to full anticoagulation with enoxaparin (2mg/kg/day divided into 2 doses per day). After 8 days of treatment, an intravascular ultrasonography (IVUS) and a newcoronary angiography were performed, confirming the finding of anterior descending CAD and significantly improved artery stenosis with 50% blockage in the proximal part. The exams did not evidentiate aortic arch disease. The IVUS confirmed the finding of anterior descending coronary artery dissection and showed the presence of intramural hematoma with a thrombosed false lumen (Figure 2). Minimum lumen area of ​5.5mm². The patient was discharged after 12 days from the beginning of the symptoms. She was asymptomatic and themarkers of myocardial necrosis were normal. She was instructed to maintain the use of ASA and clopidogrel and scheduled a new imaging examination (coronary angiography or coronary angiotomography) for six months after the acute event.