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Multidisciplinary Management of Spontaneous Coronary Artery Dissection in a Parturient
Abstract Number: SUN-20
Abstract Type: Case Report/Case Series
Case: 26 year old G6P5 at 37w5d with no PMH presented via EMS to an outside hospital with lethargy, altered mental status, and syncope. Initial troponin at OSH was negative, but increased to 0.342 ng/mL after 2 hours. EKG was classic for coronary artery dissection. She was transferred to our facility for further evaluation and management. CT chest was obtained to rule out aortic dissection, and TTE showed preserved ejection fraction with no regional wall motion abnormalities. Given hemodynamic stability with no evidence of ongoing ischemia, we proceeded with IOL prior to left heart catheterization (LHC). Left radial arterial line was placed, followed by incrementally dosed labor epidural. Hemodynamic perturbations due to epidural and labor were minimized. She had an uncomplicated vacuum assisted vaginal delivery. LHC on postpartum day 1 showed no evidence of coronary artery disease or dissection; cardiology proposed that a spontaneous coronary artery dissection may have sealed itself off, or the etiology of ACS was an embolic event which resolved. She was discharged on PPD2 on aspirin and metoprolol.
Discussion: Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction; incidence is around 0.1% (1). Presentation and symptoms are similar to ACS due to ischemia or emboli, however the patient risk factors are different. Risk factors for SCAD include female sex, pregnancy, connective tissues disorders, HTN, vasculitis, extreme physical activity, and illegal drug use (2). Average age of patients with SCAD is 35-40. 70% occur in women (3)—30% during the peripartum period. Incidence of MI in pregnancy is cited as 1 in 16,129 pregnancies; SCAD accounts for 27% of cases (4,5). Coronary angiography, CT scan, echo, and EKG can assist with the diagnosis.
Treatments include stenting, bypass, and medical management (BP control, aspirin, and anticoagulants). It is vital to coordinate plans for LHC and anticoagulation with delivery and anesthetic plans that minimize risk to patient. Despite the rarity of SCAD, providers should maintain an elevated index of suspicion when peripartum patients present with ACS.
1. Int J Card. 2005; 101: 363-369
2. Cardiovasc Diag Ther. 2015 Feb; 5
3. Am J Cardiol. 1989; 64: 471-474
4. Circulation. 2006;113:1564-1571
5. J Am Coll Cardiol. 2008; vol 52, 3