Dizziness and Pre-Syncope: An Unusual Clinical Presentation of a Spontaneous Coronary Artery Dissection as Revealed by Optical Coherence Tomography

A 52-year-old woman was admitted to our hospital with a 2-day history of nausea and dizziness and a subsequent pre-syncope. Because of a known bipolar disorder, an emergency psychiatric evaluation was performed and an attempted suicide as suggested by relatives was considered unlikely. Subsequently, an increased troponin T level was observed (0.101 μg/l) and coronary angiography was performed.

Coronary angiography revealed a highly variable degree of stenosis of the middle right coronary artery (A and B, arrows) that was unresponsive to intracoronary nitrate administration. Notably, when there was a high degree of stenosis cardiac arrhythmias, in particular sinus bradycardia and atrioventricular-block II were observed. Subsequent intracoronary optical coherence tomography readily disclosed a spontaneous coronary artery dissection (SCAD) with hematoma formation in the false lumen (FL) (D and E) and a visible intimal tear (D, arrow). The SCAD was successfully sealed by stent (ST) implantation and control coronary angiography revealed Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 and a patent ST without distal propagation of the dissection (C and F). The patient no longer had symptoms of dizziness, and it was clearly established that the SCAD, rather than a psychiatric disorder, was responsible for the symptoms of the patient. The * indicates the optical coherence tomography catheter.