Balancing Haemorrhagic and Thromboembolic Risk in Spontaneous Coronary Artery Dissection: A Case Report

Spontaneous coronary artery dissection (SCAD) represents a significant non-atherosclerotic aetiology of acute coronary syndrome.In stable individuals, conservative treatment is often favoured; yet, making antithrombotic choices becomes challenging when SCAD is associated with bleeding and a simultaneous compelling indication for anticoagulation.A 69-year-old woman with longstanding atrial fibrillation, hypertension, chronic kidney disease, and previously impaired left ventricular systolic function presented with an inferior ST-segment elevation myocardial infarction (STEMI).She was receiving apixaban for atrial fibrillation and had taken her usual dose on the morning of presentation.An invasive coronary angiogram demonstrated spontaneous dissection of the right coronary artery.This was managed conservatively because she remained haemodynamically stable and pain-free.Serial echocardiograms demonstrated a mild initial increase in the pericardial effusion, without tamponade physiology, followed by stability on subsequent imaging.CT coronary angiogram performed three days after presentation revealed global haemopericardium measuring up to 20 mm and a large left atrial appendage (LAA) thrombus.Apixaban was withheld because of the SCAD and concern that anticoagulation could exacerbate the haemopericardium.Conversely, her longstanding atrial fibrillation and persistent LAA thrombus posed a substantial systemic thromboembolic risk.Serial echocardiograms and repeat cardiac CT demonstrated a stable pericardial collection without tamponade physiology or evidence of ongoing haemorrhage.After multidisciplinary team discussion, we restarted anticoagulation with renal-adjusted rivaroxaban 15 mg once daily.The patient remained clinically stable, and subsequent echocardiography demonstrated progressive regression of the pericardial effusion.However, repeat cardiac CT three months later suggested persistence of the LAA thrombus.This case illustrates how serial multimodal imaging can support individualised anticoagulant decisions when haemorrhagic and thromboembolic risks directly conflict.A negative CT coronary angiogram examination for a residual dissection flap should not supersede a compelling invasive angiographic diagnosis.