Breaking the Algorithm: Unearthing Life-Threatening Multivessel Spontaneous Coronary Artery Dissection (SCAD) After a Negative Observation Unit Workup

Spontaneous coronary artery dissection (SCAD) is an underrecognized, non-atherosclerotic cause of acute coronary syndrome (ACS) that disproportionately affects younger women. We present the case of a 34-year-old woman with hypertension who presented to the emergency department with acute chest pain, dyspnea, and vomiting, only one week after a reassuring chest pain evaluation in an observation unit. Prehospital electrocardiography demonstrated arrhythmia with premature ventricular contractions, followed by inferior-lateral ST-T changes on subsequent tracings. These acute findings prompted coronary angiography, which confirmed SCAD. This case highlights that SCAD may occur even after a negative observation-unit evaluation and emphasizes the importance of maintaining a high index of suspicion for SCAD in young women presenting with recurrent ischemic symptoms. In addition, it includes the potential limitations of conventional chest pain algorithms in detecting non-atherosclerotic causes of ACS and calls for potential branchpoints in risk stratification pathways to incorporate additional cardiovascular syndromes.