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Peripartum Spontaneous Coronary Artery Dissection: A diagnostic Dilemma
Abstract Number: T-48
Abstract Type: Case Report/Case Series
Spontaneous coronary artery dissection (SCAD) in pregnancy is an exceptionally rare event, previously reported in 1 in 20, 000 to 30, 000 deliveries.1 Diagnostic challenges, often due to a paucity of data on the diagnosis, may result in a catastrophic cardiac event in an otherwise young, healthy patient. Mortality from peripartum myocardial infarction (MI) is high and therefore prompt diagnosis is essential for effective management. Absence of risk factors in conjunction with decreased provider awareness of the condition often leads to delays in diagnosis. Although the etiology is undetermined, hormonal changes related to progesterone are thought to play a role in the arterial wall disruption that leads to SCAD.
A 29 year old multiparous African American female with history of anemia and otherwise uncomplicated pregnancy was admitted in labor to our unit, and underwent spontaneous vaginal delivery of a 3025g infant. Her immediate postpartum course was complicated by postdural puncture headache, treated with epidural blood patch on postpartum day (PPD) five. On PPD 13, she presented to the emergency room (ER) with complaints of intermittent chest pain, nausea, and vomiting. Work up (metabolic panel, blood count, D dimer, chest radiography, electrocardiogram (EKG), and CT scan), was negative and she was discharged home. On PPD 16, she returned to the ER with recurrent severe chest pain. She presented with elevated cardiac enzymes, ST segment elevations, and a transthoracic echocardiogram, which showed left main coronary artery dissection and marked left ventricular hypokinesis with an ejection fraction of 25%. She was taken emergently to the coronary catheterization laboratory, where an intra aortic balloon pump was placed. Subsequently she underwent emergency two-vessel coronary artery bypass surgery. Postoperatively her ejection fraction improved to 45%. Her hospital course was uncomplicated and she was successfully discharged from the hospital on postoperative day 7.
Despite prior reports of SCAD as a potential cause of peripartum morbidity and mortality, this diagnosis is often missed. In our case, the patient visited the ER twice over a course of 3 days before the diagnosis was made and treatment initiated. Increased reporting of these cases will hopefully lead to a larger database of patients so that common risk factors may be identified and thus increase awareness for early detection and treatment. Additionally, this will aid in further analysis of management options and treatment outcomes. High suspicion for MI related symptomatology in an otherwise healthy-young patient is key to diagnosis. Development of diagnostic as well as therapeutic algorithms is likely an appropriate next step to assist physicians in the diagnosis and management of these patients.
1. Tex Heart Inst J 2012; 39(5): 683-6
2. J Am Board Fam Med 2013; 26:82–9.
3. Cathet. Cardiovasc. Intervent., 52: 88–94.