A 54-year-old female experienced short-term chest pains the day before admission. Two hours prior to admission, she reported severe chest pain radiating to her shoulders. She is hemodynamically stable with no significant arrhythmias.
Her vital signs include a blood pressure of 120/80 mmHg and a heart rate of 70 beats per minute.
Notable risk factors include hypertension, hypothyroidism, a history of smoking, menopause, and thyroid carcinoma surgery seven years ago. She has had no previous cardiovascular events. Additionally, it’s worth mentioning that her father passed away from pancreatic cancer.
ECG at admission:
TEE was preformed, EF 56%:
Lab values: Troponin 6.8, GFR 77 ml/min/1.74m2, K+ 4.6, Gly 5.5, HOL 4.9, HDL 1.82, LDL 2.39, CRP 3.2
Initial therapy: ASA 300mg, Ticagrelor 180mg, Heparin 7000 i.v., Rosuvastatin 40mg
Coronary angiography:
Discharge therapy: ASA 75mg, Clopidogrel 75mg, Rosuvastatin 20mg, Bisoprolol 2.5mg , Ramipril 2.5mg, Euthyrox 100mcg
Control Coronary Angiography – 1 month after:
Initial and 1 month after
Six months following a previous episode of SCAD, the patient experienced severe chest pain radiating to both arms after strenuous activity. The patient remains hemodynamically stable with no significant arrhythmias observed.
Vital signs at the time of presentation show a blood pressure of 135/80 mmHg, a heart rate of 54 beats per minute, and a troponin level of 13.7.
ECG:
TEE was preformed, EF 61%:
Coronary angiography:
Discharge therapy: ASA 75mg, Clopidogrel 75mg -discontinued after a month, Rosuvastatin 20mg, Bisoprolol 2.5mg , Ramipril 2.5mg, Euthyrox 100mcg
What do you think is the reason for SCAD and ACS?
How long would you keep DAPT after the first and second events?
It’s a little strange for SCAD to start from the catheter.
Dear Dr Topic, at the first attack
of ACS, SCAD was at distal part of LAD (IIB type), and we can see spontaneous healing this segment after 1 month. But after six months, we see a SCAD at the RIM (repeated and migrating, SCAD)
I hope that you agree with me.
It is obvious that at the first manifestation of ACS the SCAD was on the LAD (clearly seen angiographically), and during the repeated manifestation the SCAD was verified on the RIM (also clearly seen angiographically). A potential cause of recurrent SCAD may be FMD, and imaging studies of the carotid and renal arteries should be performed. As for the duration of the dual antiplatelet therapy, I am of the opinion that since the case was treated conservatively, the duration of DAPT (ASA+Clopidogrel) is sufficient to last one month, after which Aspirin should be continued.
Thank you for comments, we will performing MSCT for detecting FMD,
But, I think that the main reason for hematoma growth or recurrent SCAD, occur with uncontrolled physical activity, increased heart rate and raise in BP. Most patients with SCAD do not have a history of hypertension, but as a rule, they often have a sudden increase in blood pressure before the event (often in the premenstrual days)
Very interesting case with repeat episode of SCAD firs on LAD after 6 m on RIM. Therapy all time was correct with ASA, BB, AVEI, Eutirox, Statin! My Question is: What we can to do, additional, for this patients to prevent new episode of SCAD?