PMC9046929_01
ECG (inferior leads) on presentation to hospital whilst abroad. Left: arrival at hospital. Right: 30 min later.
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F1
She presented to the local hospital ~90 min later where an initial ECG demonstrated a rhythm at ~70 beats per minutes with slightly widened QRS complexes and an absence of regular atrial activity, likely compatible with an accelerated idioventricular rhythm (Figure 1, left panel). These modifications subsequently resolved 30 min later, with a return to sinus rhythm, but with fragmented QRS complexes, Q waves, and T-wave inversion now noted in inferior leads (Figure 1, right panel).
12-lead ECG on presentation to our hospital 1 week after the initial chest pain.
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F2
A 12-lead ECG revealed inferior Q waves with marked infero-lateral T-wave inversion (Figure 2).
Invasive coronary angiography (ICA) with intravascular imaging by optical coherence tomography (OCT). (A,B) ICA of the left coronary arteries revealing an absence of significant coronary artery disease. (C) ICA of the right coronary artery revealing a focal irregularity of the posterior left ventricular artery (PLV), magnified in the inset (white arrow). (D) OCT of the PLV reveals a false lumen with intramural haematoma (white asterisk) confirming the diagnosis of SCAD.
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F3
Invasive coronary angiography revealed coronary arteries free of significant stenoses except for a subtle irregularity of the posterior left ventricular artery (Figures 3A-C). Given the suspicion of SCAD, optical coherence tomography (OCT) was performed, revealing an intramural haematoma of the posterior left ventricular artery with a patent true lumen, thus confirming the diagnosis of SCAD (Figure 3D).
Cardiac magnetic resonance imaging with gadolinium. (A-C) Short-axis view with transmural late gadolinium enhancement of the mid-inferior left ventricular wall with subendocardial extension toward the apex. (D) Two-chamber view demonstrating an inferior infarction of the mid segment with extension toward the apex. (E) T2 imaging with oedema of the mid-inferior segment. (F) Post-contrast T1 mapping of the infarct.
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F4
Subsequent cardiac MRI (CMR) confirmed the presence of an MI of the mid-inferior wall [transmural late gadolinium enhancement (LGE)] with extension to the distal inferior territory (subendocardial LGE) (Figure 4).