SCAD presenting as pericarditis in a young female
Arthur Davis MD, Justin Price MD, Austin Tutor MD, Jose Tafur Soto MD
Introduction: Heart disease, in particular coronary artery disease (CAD) is underdiagnosed in women and is a leading cause of death in females. Women often present with different or atypical symptoms of acute coronary syndrome (ACS) in comparison to ‘traditional’ presentations in men, leading to under-diagnosis and a cause of this discrepancy. Particularly in young women, SCAD is a known entity and can present with symptoms of ACS. However, SCAD is typically associated with auto- immune disease, fibromuscular dysplasia, pregnancy or other inflammatory conditions. Case Presentation: 38 year old female with past medical history of asthma who presented with 2 days of nausea, chest tightness and pleuritic chest pain which was initially attributed to reflux and/or asthma. ECG on arrival demonstrated non-specific ST changes, however, after episode of worsening chest tightness in the emergency department, repeat ECG demonstrated subtle ST elevations suspicious for pericarditis. Troponin was elevated at 1.8 and ESR/CRP were also elevated. She was subsequently treated with colchicine and pain control with narcotics. Echocardiogram done the following morning revealed apical wall motion abnormalities and she was then taken for a left heart cath. Coronary angiogram demonstrated SCAD of the distal left anterior descending artery and she was medically managed before being discharged 2 days later. Discussion: SCAD is typically associated with inflammatory disease and/or connective tissue disorders such as: pregnancy, fibromuscular dysplasia or lupus and is an uncommon cause of myocardial infarction (MI.) We present a challenging case where initially our patient was misdiagnosed due to the nature of her symptoms. Other than female gender, she had no known significant risk factors for SCAD. Her symptoms were not ‘typical’ for ACS, which corroborates with known gender differences in presentations of ACS, often delaying diagnosis. Conclusion: SCAD is an uncommon cause of myocardial infarction but most often presents in young females with a history of inflammatory disease and/or pregnancy. In female patients, physicians should be aware of gender differences in ACS presentation to prevent potential bias. SCAD is a known, infrequent cause of MI but, particularly in young females, should be considered as a cause of ACS.
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