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Spontaneous Coronary Artery Dissection in an Anorexic Patient: A Rare and Challenging Case
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A3449 - Spontaneous Coronary Artery Dissection in an Anorexic Patient: A Rare and Challenging Case
Author Block: D. Sedhom, E. Hiltner, C. Patel, J. Prister; Department of Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
Introduction: Spontaneous coronary artery dissection (SCAD) is important cause of acute coronary syndrome (ACS) in young females. SCAD has been associated with fibromuscular dysplasia (FMD), cardio-circulatory stress and hormonal therapy. Anorexia nervosa (AN) is a complex condition hallmarked by a proinflammatory state and endocrine imbalances ultimately affecting hypothalamic-pituitary pathways. AN leads to structural and functional cardiovascular complications. However, despite a large data-base highlighting cardiovascular complications of AN, it is not associated with SCAD. We present a unique, challenging case of a SCAD in a young female with anorexia nervosa.
Case Description: A 34 year old female with a history of AN receiving paraenteral feeds presented with fevers and failure to thrive (FTT). She was febrile with a heart rate of 130. Chest x-ray was consistent with pneumonia. She underwent bronchoscopy due to fevers that did not dissipate following antibiotics and was found to have multi drug resistant (MDR) pseudomonas. Her fever curve improved following intravenous (IV) antibiotics. However, her tachycardia persisted despite clinical improvement. Multiple repeat electrocardiograms (EKG) showed sinus tachycardia which were presumed to be secondary to infection. She developed chest pain on hospital day 12 and her heart rate increased to 160. Repeat EKG showed ST elevations in the anteriolateral leads. Bedside echocardiogram showed hypokinesis at the apex and she urgently underwent cardiac catheterization. She was found to have a dissection of the left anterior descending artery (LAD) and 2 stents were placed. There was no angiographic evidence of FMD or pulmonary embolism. Following a staged percutaneous intervention, she was found to have spontaneous dissection of the left main coronary artery, LAD and left circumflex. No further stents were placed and she was medically managed on aspirin, ticagrelor and metoprolol. She improved following medical therapy and mental health referral. Screening for connective tissue disease was negative.
Discussion: Eating disorders are difficult to manage, multi-organ syndromes. Our patient with advanced AN presented with sepsis which is associated with SCAD due to the hemodynamic stress on the coronary arterial walls. It is unclear whether various hormonal imbalances contribute to poor smooth muscle development thereby predisposing patients to arterial dissection and complications. The case described is exceedingly rare and highlights the importance of investigating the underlying cause for sinus tachycardia. Further studies are needed to further investigate the connection between hormonal imbalance and smooth muscle wall integrity.
Author Block: D. Sedhom, E. Hiltner, C. Patel, J. Prister; Department of Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
Introduction: Spontaneous coronary artery dissection (SCAD) is important cause of acute coronary syndrome (ACS) in young females. SCAD has been associated with fibromuscular dysplasia (FMD), cardio-circulatory stress and hormonal therapy. Anorexia nervosa (AN) is a complex condition hallmarked by a proinflammatory state and endocrine imbalances ultimately affecting hypothalamic-pituitary pathways. AN leads to structural and functional cardiovascular complications. However, despite a large data-base highlighting cardiovascular complications of AN, it is not associated with SCAD. We present a unique, challenging case of a SCAD in a young female with anorexia nervosa.
Case Description: A 34 year old female with a history of AN receiving paraenteral feeds presented with fevers and failure to thrive (FTT). She was febrile with a heart rate of 130. Chest x-ray was consistent with pneumonia. She underwent bronchoscopy due to fevers that did not dissipate following antibiotics and was found to have multi drug resistant (MDR) pseudomonas. Her fever curve improved following intravenous (IV) antibiotics. However, her tachycardia persisted despite clinical improvement. Multiple repeat electrocardiograms (EKG) showed sinus tachycardia which were presumed to be secondary to infection. She developed chest pain on hospital day 12 and her heart rate increased to 160. Repeat EKG showed ST elevations in the anteriolateral leads. Bedside echocardiogram showed hypokinesis at the apex and she urgently underwent cardiac catheterization. She was found to have a dissection of the left anterior descending artery (LAD) and 2 stents were placed. There was no angiographic evidence of FMD or pulmonary embolism. Following a staged percutaneous intervention, she was found to have spontaneous dissection of the left main coronary artery, LAD and left circumflex. No further stents were placed and she was medically managed on aspirin, ticagrelor and metoprolol. She improved following medical therapy and mental health referral. Screening for connective tissue disease was negative.
Discussion: Eating disorders are difficult to manage, multi-organ syndromes. Our patient with advanced AN presented with sepsis which is associated with SCAD due to the hemodynamic stress on the coronary arterial walls. It is unclear whether various hormonal imbalances contribute to poor smooth muscle development thereby predisposing patients to arterial dissection and complications. The case described is exceedingly rare and highlights the importance of investigating the underlying cause for sinus tachycardia. Further studies are needed to further investigate the connection between hormonal imbalance and smooth muscle wall integrity.
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