Double Jeopardy: Spontaneous Coronary Artery Dissection and Stress-Induced Cardiomyopathy

Spontaneous coronary artery dissection (SCAD) and stress-induced cardiomyopathy (SIC), or Takotsubo syndrome, are distinct nonatherosclerotic causes of acute coronary syndrome that predominantly affect women and share physical and emotional triggers.Their simultaneous occurrence is uncommon and presents diagnostic and therapeutic challenges.We report a 74-year-old woman with hypertension and a prior cerebrovascular accident who presented with severe, persistent chest pain and a high-sensitivity troponin level of 9,143 ng/L.She was diagnosed with non-ST-segment elevation myocardial infarction and treated with intravenous heparin and nitroglycerin.Because of persistent symptoms and high-risk features, urgent coronary angiography was performed and demonstrated SCAD involving the apical left anterior descending coronary artery.Echocardiogram demonstrated apical ballooning with preserved basal contractility, raising concern for concomitant SIC.Myocardial infarction due to SCAD remained in the differential diagnosis.The patient was initially hemodynamically stable following catheterization with plans to obtain a cardiac MRI for further evaluation; however, on hospital day 2, she developed complete heart block that progressed to asystolic cardiac arrest, and she died despite prolonged resuscitative efforts.This case highlights the potential coexistence of SCAD and SIC, and emphasizes the importance of carefully evaluating patients with apparent Takotsubo cardiomyopathy for concomitant coronary pathology.It also illustrates the potential electrical and clinical complications associated with these overlapping conditions and supports a possible shared catecholamine-mediated or bidirectional pathophysiologic relationship.