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Spontaneous Coronary Artery Dissection in the Setting of a Socially Challenging Parturient: A Case Report
Abstract Number: F1D-6
Abstract Type: Case Report/Case Series
Case Report: An otherwise healthy 32-year-old G3P2002 (NSVD x2) at 29w6d presented to our ED with sharp, burning chest pain that radiated to her left shoulder. Her EKG showed ST elevations in the anterior leads with elevating troponin (0.63 to 83 to 110), though bedside TTE showed no discernible wall motion abnormalities. She subsequently underwent emergent CT angiography with and without contrast to rule out aortic dissection. During this time, her chest pain persisted with waxing and waning severity despite medical management. Formal TTE showed reduced LV function (EF 40%) with akinesis of the mid-anteroseptal and apical walls, prompting a LHC to rule out flow-limiting, proximal disease. A multidisciplinary team including interventional cardiology, obstetrics, maternal fetal medicine, anesthesia and cardiovascular surgery accompanied the patient to the cath lab. LHC revealed a spontaneous coronary artery dissection (SCAD) in her mid-LAD with TIMI 3 flow distal to the lesion, thereby requiring no further intervention aside from medical management. After transfer out of ICU patient stated her husband was not supportive and had nothing to do with her or current pregnancy; she was living with her aunts. She planned to move out of state to live with a friend any day, but agreed to stay in the area until her scheduled 37-week CS delivery given new cardiac findings. Despite this verbal commitment, she signed out AMA. She attended two obstetric appointments before skipping her third, at which time her phone number was disconnected; as were those of her emergency contacts.
Discussion: Acute MI is a leading cause of morbidity and mortality worldwide. It remains rare during pregnancy with research reporting incidence of 6 in 100,000 women.1,2 Pregnancy-associated SCAD is a rare condition typically presenting in the first postpartum month of young and otherwise healthy women.3 Clinical presentation varies from CP symptoms alone to STEMI, ventricular fibrillation and even death.4 It therefore requires a high index of suspicion combined with timely management for improved maternal and fetal outcomes. Given these factors, there is no general consensus in medical literature with regard to optimal treatment. Case reports span multidisciplinary literature supporting the success of conservative management, percutaneous coronary intervention and surgical revascularization.5 It is important to assemble a multidisciplinary team for the development of an individualized plan for each patient that minimizes risk to the mother and fetus, while maximizing likelihood of successful outcome. Our patient's decision to sign out AMA sparked further discussion exploring the conflict between maternal autonomy and the rights of the fetus;6 a profound ethical dilemma woven throughout medical literature.
J Am Coll Cardiol. 2008; 15;52(3):171-80
In Heart J. 2016;68(2):S25-7
Ht Views. 2012;13(2):53-6
Rev Obstet Gynecol. 2012;5(3-4):144-150