Spontaneous Coronary Artery Dissection in Anabolic Steroid Misuse

103 The Editor, A 27‐year‐old male professional bodybuilder presented with excruciating retrosternal chest pain, extending to his neck and shoulder. He gave a history of taking traditional medication (containing opium) for the pain that was self‐prescribed but the pain did not subside with that treatment, and his general physician referred him for cardiac evaluation in the emergency department. He gave a history of long‐term anabolic steroid usage and multiple intramuscular injections of human growth hormone in the recent past. There was no history of early coronary artery disease or sudden death in the family. On physical examination, he was well built and nourished with prominent muscles over pectoral girdle, hypertrophied pectoralis, biceps, triceps, rectus abdominis, and quadriceps muscles. In the electrocardiogram, Q waves and S‐T elevation in lead V1–V6 were found. The creatine phosphokinase myocardial band and troponin levels were raised. The patient was referred to the coronary care unit and was treated with intravenous trinitroglycerin, aspirin, clopidogrel, statin, and heparin for acute coronary syndrome (ACS). The transthoracic echocardiogram showed reduced left ventricular systolic function (ejection fraction 40%) with apical hypokinesia. The cardiac troponins increased serially from 3 to 8 (units). Coronary angiography was performed which showed proximal to middle spiral dissection of the left anterior descending artery with severe distal stenosis. The left main right coronary and left circumflex arteries were normal [Figure 1]. The case was referred for surgery by interventional cardiologist as percutaneous coronary intervention was not preferred because of a long segment of dissection in artery, ongoing ischemia, and the presence of significant lesion distal to dissection. Individuals with a history of ACS but without evidence of ongoing ischemia and no significant stenosis on cardiac angiography may be managed with medical treatment. Medical treatment was not a choice in our patient due to ongoing ischemia. Spontaneous Coronary Artery Dissection in Anabolic Steroid Misuse Letter to Editor