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Outcome and follow-up The patient had no further pain after day 2 and transthoracic echo on day 8 showed normal left ventricular systolic function with an ejection fraction of 55% and no valve disease of significance. There was hypokinesis of the basal and middle sections of the posterior and inferior wall. A full rheumatology  and vasculitic screen, including: anticardiolipin and antineutrophil cytoplasmic antibodies, C3 and C4 complement levels, rheumatoid factor and general immunoglobulin levels found no abnormal results and a syphilis antibody test was also negative. The patient was discharged home after 14?days and referred for outpatient cardiology follow-up and anticoagulation. Her angiogram, 2?months after discharge, showed complete resolution of the coronary arterial dissections (videos 4�C6). Video 4 Follow up angiogram showing complete resolution of the dissection in the large obtuse marginal branch (compared to video 1). Download video file.(342K, flv) Video 5 Follow up angiogram showing complete resolution of the dissection in the distal left anterior descending [http://www.selleckchem.com/products/SB-431542.html Smad inhibitor] artery (compared to video 2). Download video file.(320K, flv) Video 6 Follow up angiogram showing complete resolution of the dissection in the distal posterior descending artery (compared to video 3). Download video file.(212K, flv) Discussion The mechanisms of SCAD are poorly understood. The  vast majority of SCADs occur in women in the peripartum period, and usually affect a single coronary artery.7 Other risk factors include Ehlers-Danlos and Marfan syndromes. Coronary atherosclerosis and its associated risk factors appear to play a role in a minority of cases of SCAD.8 Interestingly, of the handful of reported cases of triple SCAD,1�C6 only one appeared to be associated with peripartum physiology.1 It is also unclear how the acute event of triple SCAD is triggered. In the only reported postmortem pathological study of triple SCAD, a common dissection origin was neither identified nor considered likely.5 Furthermore, all of the cases occurred in young to middle-aged patients, in whom consistent risk factors were not apparent and in whom the likelihood of significant coronary atherosclerosis was generally very low. As aforementioned, the case presented here is exceptional among the rare  reports of triple SCAD, in that the patient was 78?years old at the time of presentation. It is unclear how or why three coronary arteries became dissected. Angiographically at least, it appears there was no common dissection origin and the patient was simply walking at the time of the onset of her symptoms. Given the fact the patient had a second sudden episode of chest pain 1?day after admission, we cannot exclude the possibility that the three dissections first visualised upon angiography 6?days postadmission could have taken place serially at separate times within the 24?h period following the presenting episode.