DISSECTING COVID-19 - A RARE CASE OF SPONTANEOUS CORONARY ARTERY DISSECTION IN THE SETTING OF RECENT COVID-19 INFECTION

ABSTRACT

CASE A 67 year old woman with no known cardiac history presented after acute onset chest pain while watching TV. The pain was described as a burning, substernal pain associated with shortness of breath and nausea. She had no prior history of similar chest pain and was recently exercising with no complaints. Her pain was not relieved by Tums, so she presented to the ED. A COVID-PCR test was positive on admission, however the patient stated she had the infection three weeks prior to presentation and was asymptomatic. She was given sublingual nitroglycerin which improved her pain. Vital signs and physical exam were unremarkable. Electrocardiogram demonstrated ST elevations in leads V3 and V4 with an initial troponin of 0.1 ng/ml (reference range <0.80 ng/ml). She subsequently was loaded with aspirin, a heparin bolus, and was taken to the cath lab. There, she was found to have a distal LAD spontaneous coronary artery dissection and underwent POBA with restoration of vessel flow. IMPACT/DISCUSSION: Spontaneous coronary artery dissection (SCAD) is a condition predominantly seen in women without conventional risks for coronary disease and an often missed cause of non-atherosclerotic ACS. Most often, patients present with typical chest pain and dynamic ECG changes. Diagnosis of SCAD is made during coronary angiogram, at times with the aid of intravascular ultrasound or OCT. Often, these patients will have associated conditions such as fibromuscular dysplasia, pregnancy/postpartum status, or connective tissue diseases. We describe a unique case of a patient without any cardiac risk factors presenting with SCAD after the resolution of an asymptomatic COVID-19 infection. Cardiac complications of COVID-19 have been extensively described, from myocarditis, myocardial infarction, heart failure, and arrhythmias. However, published literature on the association between COVID-19 and SCAD is sparse, with a few case reports reporting a possible connection. Among these, the majority of patients were acutely symptomatic with COVID-19 and subsequently developed angina during the hospitalization. There was one similar case describing a patient developing SCAD after the resolution of a COVID infection 3 months prior to presentation. However, this patient had factors which could have contributed to the SCAD. SCAD is associated with inflammatory diseases that lead to vessel wall weakness. COVID-19 induces a marked inflammatory and immune response during infection, which has been found to cause endothelial and smooth muscle damage. It is possible the inflammatory response from the infection could promote fragility of coronary vessels and lead to dissection. CONCLUSION: As the relationship between SCAD and COVID-19 continues to be explored, providers must be mindful of the potential cardiac manifestations of the virus. An index of suspicion for SCAD should be maintained in patients with COVID-19 or a history of COVID-19 presenting with acute myocardial infarction with few or no atherosclerotic risk factors.