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Spontaneous Coronary Artery Dissection in the Postpartum Period: A Rare Phenomenon
Description
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A3485 - Spontaneous Coronary Artery Dissection in the Postpartum Period: A Rare Phenomenon
Author Block: A. Botsch, S. M. Khoncarly, N. Niraula; Critical Care and Pulmonary Medicine, Summa Health, Akron, OH, United States.
Introduction:
Pregnancy-associated acute myocardial infarction (AMI) occurs in approximately 6.2 of 100,000 pregnancies. Of those, spontaneous coronary artery dissection (SCAD) accounts for approximately 25%. Less than 200 cases of pregnancy-associated SCAD are reported in the literature and the etiology remains poorly understood. Patients conventionally believed to be at risk for SCAD include those with connective tissue disease and/or atherosclerotic disease. Interestingly, SCAD is unique to the otherwise healthy, young, pregnant or postpartum female.
Case:
A two-week post-partum 31-year old G5P3 Caucasian female, with history of asthma, presented with acute shortness of breath and sharp, radiating chest pain with no aggravating or alleviating factors. Initial ECG demonstrated ST-segment elevation in the anterolateral leads. Upon arrival to the emergency department, the patient was found to have ST-segment elevation in the lateral leads only with reciprocal changes including a new right bundle branch block (RBBB). Decision was made to perform a cardiac catheterization which revealed SCAD of the left main trunk extending to the mid-left anterior descending (LAD) coronary artery. Ventriculogram revealed significant global hypokinesis of the myocardium with a left ventricular ejection fraction (LVEF) of 25-30%.
Given the patient’s age and extent of the dissection, percutaneous coronary intervention (PCI) was not considered the best long-term option and she was emergently taken for two vessel coronary artery bypass grafting (CABG). Post-operatively, she recovered without major events. Hospital stay was unremarkable, except for hypotension with preserved mean arterial pressures preventing initiation of beta-blockade and ACE inhibitor, the mainstay treatment of post-CABG patients. She was discharged home on hospital day 7 with instructions to complete cardiac rehabilitation.
At 4 months post-operatively, stress echocardiogram demonstrated improved LVEF to 50% with apical hypokinesis and ischemic ECG findings consistent with scarring in the LAD territory. In recovery, her ECG normalized quickly. Overall, she demonstrated return to good functional capacity.
Discussion:
Theories have been proposed that hemodynamic changes, expansion of blood volume, and elevated progesterone levels in pregnancy contribute to vascular friability and increased tendency for dissection. This case report highlights the importance of a broad differential when assessing peripartum and postpartum females. Chest pain in a young female can often present atypically and may be unintentionally overlooked by clinicians. If left unidentified, SCAD poses potentially irreversible and often fatal consequences. Failure to understand the aforementioned changes in physiology can lead to potentially dangerous and life-threatening clinical events.
Author Block: A. Botsch, S. M. Khoncarly, N. Niraula; Critical Care and Pulmonary Medicine, Summa Health, Akron, OH, United States.
Introduction:
Pregnancy-associated acute myocardial infarction (AMI) occurs in approximately 6.2 of 100,000 pregnancies. Of those, spontaneous coronary artery dissection (SCAD) accounts for approximately 25%. Less than 200 cases of pregnancy-associated SCAD are reported in the literature and the etiology remains poorly understood. Patients conventionally believed to be at risk for SCAD include those with connective tissue disease and/or atherosclerotic disease. Interestingly, SCAD is unique to the otherwise healthy, young, pregnant or postpartum female.
Case:
A two-week post-partum 31-year old G5P3 Caucasian female, with history of asthma, presented with acute shortness of breath and sharp, radiating chest pain with no aggravating or alleviating factors. Initial ECG demonstrated ST-segment elevation in the anterolateral leads. Upon arrival to the emergency department, the patient was found to have ST-segment elevation in the lateral leads only with reciprocal changes including a new right bundle branch block (RBBB). Decision was made to perform a cardiac catheterization which revealed SCAD of the left main trunk extending to the mid-left anterior descending (LAD) coronary artery. Ventriculogram revealed significant global hypokinesis of the myocardium with a left ventricular ejection fraction (LVEF) of 25-30%.
Given the patient’s age and extent of the dissection, percutaneous coronary intervention (PCI) was not considered the best long-term option and she was emergently taken for two vessel coronary artery bypass grafting (CABG). Post-operatively, she recovered without major events. Hospital stay was unremarkable, except for hypotension with preserved mean arterial pressures preventing initiation of beta-blockade and ACE inhibitor, the mainstay treatment of post-CABG patients. She was discharged home on hospital day 7 with instructions to complete cardiac rehabilitation.
At 4 months post-operatively, stress echocardiogram demonstrated improved LVEF to 50% with apical hypokinesis and ischemic ECG findings consistent with scarring in the LAD territory. In recovery, her ECG normalized quickly. Overall, she demonstrated return to good functional capacity.
Discussion:
Theories have been proposed that hemodynamic changes, expansion of blood volume, and elevated progesterone levels in pregnancy contribute to vascular friability and increased tendency for dissection. This case report highlights the importance of a broad differential when assessing peripartum and postpartum females. Chest pain in a young female can often present atypically and may be unintentionally overlooked by clinicians. If left unidentified, SCAD poses potentially irreversible and often fatal consequences. Failure to understand the aforementioned changes in physiology can lead to potentially dangerous and life-threatening clinical events.
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