# Unmasking Spontaneous Coronary Artery Dissection in a Patient With Misleading Symptoms and Initial Imaging Results

## TL;DR

A 32-year-old man with misleading symptoms and initial test results was eventually diagnosed with a rare heart condition using advanced imaging techniques.

## Contribution

Demonstrates the importance of multimodal imaging in diagnosing spontaneous coronary artery dissection when initial tests are inconclusive.

## Key findings

- Invasive coronary angiography initially missed the dissection but suggested a spasm.
- Cardiovascular magnetic resonance imaging revealed ischemic myocardial injury.
- Optical coherence tomography confirmed the presence of a spontaneous coronary artery dissection.

## Abstract

Spontaneous coronary artery dissection is often missed by conventional, and even invasive diagnostic approaches in patients presenting with acute coronary syndrome.

A 32-year-old man was admitted to the emergency department with acute chest pain after emotional distress. ST-segment elevations and elevated troponin levels were documented. Invasive coronary angiography showed no obstructive coronary artery disease but suspected spasm of the left anterior descending artery. Takotsubo syndrome was considered to be caused by apical wall motion abnormalities on echocardiography. Cardiovascular magnetic resonance imaging revealed ischemic myocardial injury, prompting second-look invasive coronary angiography including optical coherence tomography. A spontaneous coronary artery dissection of the left anterior descending artery with an intramural hematoma and preserved TIMI flow grade 3 was diagnosed, leading to conservative medical management.

Although conventional diagnostic assessments may be misleading, multimodal imaging including cardiovascular magnetic resonance imaging helps to accurately identify subentities and mimics of myocardial infarction with nonobstructive coronary arteries, guiding advanced intravascular imaging and therapy.