Clinical communication
OB/GYN
Pregnancy-associated coronary artery dissection: A case report

https://doi.org/10.1016/j.jemermed.2005.05.027Get rights and content

Abstract

We describe the case of a 38-year-old woman who presented with a chief complaint of chest heaviness approximately 2 weeks postpartum. She was otherwise healthy with no cardiac risk factors. Coronary angiography revealed a spiral dissection of the left main coronary artery that extended to the left anterior descending coronary artery. Pregnancy-associated coronary artery dissection is a disease that has in the past carried a high mortality rate. Even today many women die before reaching medical help. Early diagnosis and intervention are crucial. Percutaneous transluminal coronary angioplasty for single vessel disease and coronary artery bypass grafting for multi-vessel disease are becoming the treatments of choice.

Introduction

Myocardial infarction complicates approximately 1 in 10,000 term pregnancies (1). Often, these women have no cardiac risk factors, and the mortality rate has been exceedingly high, approaching 50% (2). Proposed causation includes coronary artery disease, hypercoagulable states, coronary vasospasm, and coronary artery dissection (3).

Originally described in 1931 by Pretty, spontaneous coronary artery dissection is an uncommon, but well-described, entity (4, 5). It seems to have a predilection for women in the peripartum period (6). Including ours, approximately 61 cases of postpartum coronary artery dissection have been reported; 13 cases were antepartum (7). We will review the postulated etiology as well as diagnostic and therapeutic options.

Section snippets

Case report

A 38-year-old G2 P2 woman presented to a community hospital 2 weeks postpartum with a chief complaint of chest heaviness that began while sitting at work and lasted for approximately 90 min before her arrival in the Emergency Department (ED). The heaviness was decrescendo in nature, gradually lessening during transport by ambulance. There was associated nausea, diaphoresis and lightheadedness, but she denied any radiation of pain to the arms or back. No prior episodes were identified; the

Discussion

Spontaneous dissection of the coronary vessels is not unique to pregnancy. It occurs in a wide variety of disorders including Marfan’s syndrome, blunt trauma, sarcoidois, and a number of autoimmune conditions including vasculitis, thyroiditis, and rheumatic heart disease (5, 8, 9, 10, 11). It can be seen as a complication of angiography and angioplasty (5, 12). Many cases are considered idiopathic (5). There is a female to male ratio of 5:1, with predominantly left-sided involvement in females

Conclusion

PACAD is an uncommon disease, but a common cause of myocardial infarction in pregnancy. The emergency physician must include this entity in the differential diagnosis when caring for pregnant and postpartum women with chest pain. Coronary angiography not only reveals the diagnosis, but also may allow for definitive management in some cases. It is likely that PTCA will emerge as the treatment of choice of coronary artery dissection as more experience is gained with this unique problem.

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    Clinical Communications: Obstetrics and Gynecology is coordinated by Colleen Campbell, md, of the University of California San Diego Medical Center, San Diego, California

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