we present the case of a 60-year - old female with a history of polycythemia , chronic obstructive pulmonary disease ( copd ) on home oxygen , and obesity who presented to the emergency room complaining of mild dyspnea on exertion that had been experienced for 3 days .
she denied any medical history , including autoimmune disease , connective tissue disorders , or vasculitis .
as part of her general workup in the emergency department , she was found to have elevated troponin levels at 0.182 ng / ml ( 0.00.045 ng / ml ) .
ecg revealed sinus tachycardia ; there were no st segment changes suggestive of ischemia ( fig .
the patient was admitted to the floor and managed as a possible case of copd exacerbation .
twelve - lead ekg at the time of emergency department presentation with sinus tachycardia and no acute st segment changes .
a nuclear stress test was performed that revealed a large inferior wall reversible defect with associated inferior wall hypokinesis .
coronary angiography of the right coronary showed a spontaneous dissection throughout the mid - right coronary artery ( fig .
due to poor distal thrombolysis in myocardial infarction ( timi ) 1 flow , it was decided to stent the lesion .
a prowater wire was steered toward the mid - right coronary artery which initially went into the false lumen ; we then pulled the wire back and redirected it to the true lumen which was confirmed by the ability to advance the wire into the distal vessel .
follow - up angiography showed excellent results with complete tacking of the dissection plane and excellent timi 3 flow at the end of the procedure ( fig .
3 ) . coronary angiography showing a dissection plane throughout the mid - right coronary artery .
follow - up angiography showing complete tacking of the dissection plane and timi 3 flow .
while a few of the reported cases have been called idiopathic , a predisposed arterial disease or underlying cause has been identified in most of the cases ( 3 ) .
intimal tear or bleeding of vasa vasorum with intramedial hemorrhage has been proposed ( 4 ) .
younger females in the pregnancy and peri - partum periods are thought to be at a higher risk than the general population which is believed to be secondary to increased hemodynamics during labor and delivery , and possibly hormonal effect on the arterial walls affecting the tunica media ( 5 , 6 ) .
it is unclear whether this inflammatory reaction is reactive or causative of dissection by weakening the coronary architecture ( 5 ) .
connective tissue disorders such as ehler  danlos type iv and marfans have also been implicated in scad ( 8 , 9 ) .
our patient did not have any clinical features usually associated with such connective tissue diseases .
she is an elderly female presenting with symptoms initially thought to be suggestive of a copd exacerbation with a troponin elevation secondary to a supply  demand mismatch .
this presentation serves as a reminder to include scad in the differential diagnosis even among elderly patients with comorbidities presenting with unexplained troponin elevation .
other management strategies have been proposed in the literature ranging from percutaneous coronary interventions to heart transplantation .
revascularization in scad is challenging and should be considered in patients with ongoing ischemia ( 10 ) .
intravenous ultrasound ( ivus ) may be helpful in confirming the diagnosis . in our patient
, ivus was not used due to her narrow lumen coronaries with a concern of possible worsening of the dissection with the bulky ivus catheter .
none of the authors have any financial or personal bias that would inappropriately compromise the publication of this work .
the authors have not received any funding or benefits from industry or elsewhere to conduct this study .
 spontaneous coronary artery dissection is a poorly understood phenomenon that usually affects women during pregnancy or the immediate post - partum period . 
 we present the case of a 60-year - old female with chronic obstructive pulmonary disease who presented with vague complaints of shortness of breath , dizziness , and weakness with a mildly elevated troponin . 
 she denied any anginal symptoms . 
 as part of her initial workup , a nuclear stress test revealed inferior wall reversible changes . 
 coronary angiography revealed spontaneous right coronary artery dissection which was treated with a drug - eluting stent . 
Case presentation
Discussion
Disclosure
Conflict of interest and funding