CureusA Bidirectional Relationship Between Spontaneous Coronary Artery Dissection and Stress-Induced Cardiomyopathy in a Perimenopausal Woman: A Case Report

⚠️ Small Study / Early Comparative Evidence

This case report describes a 48-year-old woman presenting with shoulder pain, ST-segment elevation, and markedly elevated cardiac biomarkers who was ultimately found to have both Yip-Saw Type 2 spontaneous coronary artery dissection (SCAD) involving the mid-distal LAD and echocardiographic findings consistent with stress-induced cardiomyopathy (Takotsubo syndrome). The authors propose a potential bidirectional relationship in which either condition may precipitate the other. While the report cannot determine the initiating event, it illustrates the importance of considering concomitant SICM when ventricular dysfunction extends beyond the territory supplied by the affected coronary vessel, particularly in women presenting with non-atherosclerotic acute coronary syndromes.

Clinical Considerations

• A 48-year-old perimenopausal woman presented with ST-segment elevation and markedly elevated troponin levels, initially mimicking a traditional acute coronary syndrome.
• Coronary angiography demonstrated Yip-Saw Type 2 SCAD involving the mid-distal LAD with preserved distal flow and no evidence of obstructive atherosclerotic disease.
• Echocardiography revealed apical ballooning and an ejection fraction of 40%, findings consistent with stress-induced cardiomyopathy.
• Wall-motion abnormalities extended beyond the LAD territory, supporting the possibility of concomitant SICM rather than isolated SCAD-related ischemia.
• Conservative management with antiplatelet therapy, beta-blockade, and ACE inhibition was associated with complete angiographic and functional recovery on follow-up.
• Absence of OCT or IVUS imaging limited definitive determination of the primary initiating event and confirms the diagnostic uncertainty common to these presentations.

Practice Applications

• Recognize SCAD as an important non-atherosclerotic cause of acute coronary syndrome in middle-aged women.
• Consider concomitant stress-induced cardiomyopathy when ventricular dysfunction exceeds the expected coronary distribution.
• Integrate angiographic, biomarker, and echocardiographic findings rather than relying on a single diagnostic modality.
• Interpret overlapping SCAD and SICM presentations cautiously, acknowledging that the initiating pathology may remain uncertain.
• Discuss conservative management strategies when coronary flow is preserved and clinical stability is maintained.