Pain at the Game: Spontaneous Coronary Artery Dissection

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Date of download: 5/30/2016 Copyright © The American College of Cardiology. All rights reserved. From: Randomized Comparison of 64-Slice Single- and Dual-Source.

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Pain at the Game: Spontaneous Coronary Artery Dissection Gagan D. Singh, MD, Marin Nishimura, BS, Jason H. Rogers, MD, Ezra A. Amsterdam, MD The American Journal of Medicine Volume 127, Issue 12, Pages 1160-1163 (December 2014) DOI: 10.1016/j.amjmed.2014.08.002 Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 1 (A) an electrocardiogram (ECG) was obtained on presentation during active chest pain. (B) Another was ordered after administration of sublingual nitroglycerin, while the patient was free of discomfort. (C) Three hours after presentation, a third ECG was performed for reevaluation. The patient had no chest pain at this point. The American Journal of Medicine 2014 127, 1160-1163DOI: (10.1016/j.amjmed.2014.08.002) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 2 Coronary angiography of the left anterior descending artery was carried out. (A) This is the right-anterior-oblique cranial projection. (B) The left-anterior-oblique cranial projection is shown. Note that the left anterior descending coronary artery courses down the interventricular septum where there is an abrupt decrement in luminal diameter (arrows) with a ribbon-like appearance of the artery distally. The remainder of the epicardial coronary artery system has no significant angiographic evidence of atherosclerotic coronary artery disease. The American Journal of Medicine 2014 127, 1160-1163DOI: (10.1016/j.amjmed.2014.08.002) Copyright © 2014 Elsevier Inc. Terms and Conditions

Figure 3 Combined intravascular imaging was performed in a patient with suspected spontaneous coronary artery dissection. (A) An angiographic image of a long lesion in the left anterior descending coronary artery suggests spontaneous coronary artery dissection. (B) The proximal aspect of the diseased segment shows an intimomedial membrane and a double lumen appearance by optical coherence tomography (OCT). (B’) The same is evident on intravascular ultrasound (IVUS). At this site, the complete vessel is visualized by both techniques, although thrombus in the false lumen is more clearly depicted by IVUS. (C) More distally, OCT detects a severely narrowed lumen and a side branch exit from the true lumen (4 o'clock position). The thickness of the intimomedial membrane is well visualized (5 to 11 o'clock position), but severe attenuation prevents visualization of dorsal structures. (C’) IVUS displays the false lumen content better and detects the side branch take-off from the true lumen (3 o'clock position). *Denotes wire artifact. Reproduced, with permission, from Paulo et al 2013.7 The American Journal of Medicine 2014 127, 1160-1163DOI: (10.1016/j.amjmed.2014.08.002) Copyright © 2014 Elsevier Inc. Terms and Conditions