When Should We Consider the Diagnosis?

Given how easy it is to miss TCAD and how rare it is, when should we consider the diagnosis? TCAD should be considered in a young person with a history of recent chest trauma followed hours to weeks later with anginal symptoms plus any combination of ischemic ECG changes, troponin elevation, or wall motion abnormalities on point-of-care ultrasound (POCUS). Typical angina symptoms after trauma in a young patient without traditional cardiac risk factors warrant a work-up for TCAD. Patients complaining of chest pain after sustaining blunt chest trauma should undergo a prompt cardiovascular work-up with ECG and serial troponins to screen for cardiac contusion, dysrhythmias, and for cardiac ischemia as a result of TCAD. The Eastern Association for the Surgery of Trauma (EAST) recommends that an ECG and cardiac biomarkers be obtained for all patients in whom blunt cardiac injury is suspected.⁶ A key pitfall in patients who have recently sustained trauma to the chest is assuming that a borderline ECG and positive troponin are due only to cardiac contusion, which does not warrant activation of the cardiac catheterization lab. Similarly, patients with multiple rib fractures, a risk factor for TCAD, may have their chest pain attributed solely to the fractures, and the diagnosis of TCAD may be overlooked. Patients with angina-type symptoms, ongoing dyspnea after initial treatment of other traumatic injuries, cardiac dysrhythmia, and/or elevated troponin should be considered for CT angiography of the coronary arteries and/or angiography in the cath lab. Even a borderline ischemic-appearing ECG and positive troponin should trigger the provider to consider the diagnosis of TCAD and discuss this possibility with an interventional cardiologist for consideration of emergency coronary angiography.

PCI is the most common treatment done to repair the coronary artery dissection in patients who have sustained a myocardial infarction. In the very rare case of left main coronary artery dissection, coronary artery bypass grafting (CABG) is the treatment of choice. In those patients with TCAD who are stable without evidence of coronary ischemia, the treatment of choice is often conservative, with observation and repeat angiography.⁶

It is my hope that increasing awareness of TCAD by emergency providers will improve the diagnostic yield and improve morbidity and mortality in these patients. If we consider TCAD in young people with a history of recent chest trauma followed hours to weeks later with anginal symptoms plus any combination of ECG changes, troponin elevation, or ischemic PoCUS findings, the emergency medicine community will save many lives!