In December 2009, a 43-year-old woman with a history of non-ST-segment–elevation myocardial infarction (NSTEMI), hypertension, and prolactinoma presented with substernal chest pain. Upon having been diagnosed with prolactinoma 18 years earlier, she had taken bromocriptine for 9 years, after which the therapy was changed to cabergoline. Five years before the current presentation, she had an episode of chest pain that was diagnosed as NSTEMI. At that time, coronary angiography revealed an 80% stenosis in the 1st obtuse marginal branch, for which no intervention was performed (). Six months later, the patient had similar chest pain; however, there was no angiographic evidence of coronary artery disease (). Three years thereafter, she experienced chest pain and underwent a myocardial perfusion scan that showed no clear evidence of prior myocardial infarction or ischemia. During the current presentation (her 4th evaluation for chest pain), an electrocardiogram (ECG) and measurement of cardiac biomarkers showed no ischemia. An exercise thallium study was scheduled. After the exercise component, she reported chest pain, and an ECG showed ST-segment elevation in the inferior leads.
Fig. 1 Coronary angiograms of the 1st obtuse marginal branch show A) an 80% stenosis 5 years before the current presentation (arrow), B) the disappearance of this lesion 6 months later (arrow), and C) no evidence of disease during the current (more ...)
After this, the patient's cardiac enzyme levels increased, and serum troponin peaked at 31 ng/mL. Coronary angiography was performed. Of note, the obtuse marginal branch showed no evidence of stenosis (); however, there was an extensive, spontaneous dissection of the right coronary artery (RCA) and a reduced left ventricular ejection fraction of 0.45 with global hypokinesia (). The dissection was too extensive for stenting or operative correction, so it was decided to continue with medical management. The patient was discharged from the hospital with instructions to take aspirin, atorvastatin, metoprolol, diltiazem, and nitroglycerin. Three weeks later, echocardiography showed an ejection fraction of 0.50 to 0.55 with inferobasal hypokinesis and moderate mitral regurgitation.
Fig. 2 Coronary angiogram shows extensive dissection of the right coronary artery (arrows).