Clinical communicationOB/GYNPregnancy-associated coronary artery dissection: A case report
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.
References (30)
- et al.
Spontaneous coronary artery dissection
Ann Thorac Surg
(1987) - et al.
Coronary artery dissections
Cardiol Clin
(1984) - et al.
Dissection of the left coronary artery complicating retrograde left heart catheterization
Chest
(1970) - et al.
Clinical course and long-term prognosis of spontaneous coronary artery dissection
Am J Cardiol
(1989) - et al.
Spontaneous coronary artery dissection and eosinophilic inflammationa cause and effect relationship?
Am J Med
(1982) - et al.
Dissecting aneurysm (hematoma) limited to coronary artery. A clinicopathologic study of six patients
Am J Med
(1973) - et al.
Transesophageal echo detection of postpartum coronary artery dissection
J Am Soc Echocardiogr
(2001) Myocardial infarction in pregnancy
J Obstet Gynaecol Br Commonw
(1970)- et al.
Myocardial infarction during pregnancya review
Obstet Gynecol
(1985) - et al.
Postpartum myocardial infarctionassociation with primary coronary artery dissection
Cleve Clin J Med
(1995)
Dissecting aneurysm of coronary artery in a woman aged 42rupture
Br Med J
Spontaneous coronary artery dissectionthe clinical spectrum
Angiology
Coronary artery dissection during pregnancy and the postpartum periodtwo case reports and review of literature
Catheter Cardiovasc Interv
Diagnosis of coronary artery dissection following blunt chest trauma by transesophageal echocardiography
J Trauma
Spontaneous primary dissection of the coronary artery
Ir J Med Sci
Cited by (13)
Spontaneous Coronary Artery Dissection in a Postpartum Woman: Literature Review
2011, Journal for Nurse PractitionersCitation Excerpt :The majority of patients did not have cardiac risk factors.1,3 Electrocardiogram, echocardiography, and laboratory values are essential in the evaluation of P-SCAD; however, coronary angiography is the gold standard in diagnosis.6–8 Coronary computed tomography (CT) imaging may prove useful in diagnosing and monitoring patients and guiding treatment decisions.9,10
The Athlete's Heart 2007: Diseases of the Coronary Circulation
2007, Cardiology ClinicsCitation Excerpt :The term “spontaneous coronary artery dissection” is reserved for those cases without prior intravascular trauma or atherosclerosis. Spontaneous coronary artery dissection is a rare condition with an uncertain incidence rate that occurs most frequently in young women during the peripartum period or in association with oral contraceptive use [65–69]. Spontaneous coronary dissections are also observed in patients with underlying connective tissue disorders, such as Marfan's syndrome, Ehlers-Danlos syndrome, and fibromuscular dysplasia [70–72].
Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality
2023, American Journal of PerinatologyPregnancy-Related Coronary Artery Dissection: Recognition of a Life Threatening Process
2018, Dimensions of Critical Care NursingPregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases
2017, Circulation: Cardiovascular Interventions
Clinical Communications: Obstetrics and Gynecology is coordinated by Colleen Campbell, md, of the University of California San Diego Medical Center, San Diego, California