we present the case of a 60-year - old female with a history of polycythemia , chronic obstructive pulmonary disease ( copd ) on home oxygen , and obesity who presented to the emergency room complaining of mild dyspnea on exertion that had been experienced for 3 days . she denied any medical history , including autoimmune disease , connective tissue disorders , or vasculitis . as part of her general workup in the emergency department , she was found to have elevated troponin levels at 0.182 ng / ml ( 0.00.045 ng / ml ) . ecg revealed sinus tachycardia ; there were no st segment changes suggestive of ischemia ( fig . the patient was admitted to the floor and managed as a possible case of copd exacerbation . twelve - lead ekg at the time of emergency department presentation with sinus tachycardia and no acute st segment changes . a nuclear stress test was performed that revealed a large inferior wall reversible defect with associated inferior wall hypokinesis . coronary angiography of the right coronary showed a spontaneous dissection throughout the mid - right coronary artery ( fig . due to poor distal thrombolysis in myocardial infarction ( timi ) 1 flow , it was decided to stent the lesion . a prowater wire was steered toward the mid - right coronary artery which initially went into the false lumen ; we then pulled the wire back and redirected it to the true lumen which was confirmed by the ability to advance the wire into the distal vessel . follow - up angiography showed excellent results with complete tacking of the dissection plane and excellent timi 3 flow at the end of the procedure ( fig . 3 ) . coronary angiography showing a dissection plane throughout the mid - right coronary artery . follow - up angiography showing complete tacking of the dissection plane and timi 3 flow . while a few of the reported cases have been called idiopathic , a predisposed arterial disease or underlying cause has been identified in most of the cases ( 3 ) . intimal tear or bleeding of vasa vasorum with intramedial hemorrhage has been proposed ( 4 ) . younger females in the pregnancy and peri - partum periods are thought to be at a higher risk than the general population which is believed to be secondary to increased hemodynamics during labor and delivery , and possibly hormonal effect on the arterial walls affecting the tunica media ( 5 , 6 ) . it is unclear whether this inflammatory reaction is reactive or causative of dissection by weakening the coronary architecture ( 5 ) . connective tissue disorders such as ehler  danlos type iv and marfans have also been implicated in scad ( 8 , 9 ) . our patient did not have any clinical features usually associated with such connective tissue diseases . she is an elderly female presenting with symptoms initially thought to be suggestive of a copd exacerbation with a troponin elevation secondary to a supply  demand mismatch . this presentation serves as a reminder to include scad in the differential diagnosis even among elderly patients with comorbidities presenting with unexplained troponin elevation . other management strategies have been proposed in the literature ranging from percutaneous coronary interventions to heart transplantation . revascularization in scad is challenging and should be considered in patients with ongoing ischemia ( 10 ) . intravenous ultrasound ( ivus ) may be helpful in confirming the diagnosis . in our patient , ivus was not used due to her narrow lumen coronaries with a concern of possible worsening of the dissection with the bulky ivus catheter . none of the authors have any financial or personal bias that would inappropriately compromise the publication of this work . the authors have not received any funding or benefits from industry or elsewhere to conduct this study .