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Postpartum Spontaneous Coronary Artery Dissection (SCAD)
Abstract Number: RF4BD-306
Abstract Type: Case Report Case Series
Introduction: Pregnancy associated myocardial infarction (PAMI) is defined as MI occurring during pregnancy or during the first 6-12 weeks postpartum. (1) Among various etiologies for PAMI, spontaneous coronary artery dissection (SCAD) is the most common cause. SCAD is defined as non-iatrogenic dissection of an epicardial coronary artery that is not associated with atherosclerosis or trauma. The impact of SCAD in the peripartum period is immense and prompt recognition and treatment are key to outcomes.
Case Presentation: 29 yo otherwise healthy G2P2 female presented with a 2-week history of chest pain (CP), and dyspnea following an uneventful SVD 3-weeks prior. After discharge from SVD on POD #8, the patient experienced severe substernal chest pain and called EMS. On evaluation, the patient’s vitals were normal and episode was attributed to anxiety by EMS providers and no further workup was completed. On POD# 14, (at 2 wk f/u with obstetric service) the patient was tearful about continued CP. Her EKG showed small TWIs, but no other abnormalities. She was sent home. On POD #21 she again presented to ED and workup demonstrated troponin leak (5.7ng/mL), NSTEMI with LVEF- 40-45% and hypokinesis of inferolateral wall. Left heart catheterization showed multiple stenoses of LMA (60%), LCx (100%) and distal LAD (90%). On POD#23, the pt underwent three vessel CABG with intraoperative findings highly suggestive of P-SCAD (significant clot edema). Pt currently in cardiac rehabilitation with continued wall motion abnormalities.
Discussion: Pregnancy associated SCAD (P-SCAD) is a dangerous condition that can lead to significant cardiac morbidity and mortality. P-SCAD is estimated to occur in only 1.8 per 100,000 pregnancies, but the incidence is rising. It is thought to be caused by due to changes in estrogen and progesterone levels predisposing women to vasa vasorum rupture (2). Clinically, women with P-SCAD generally presents with chest pain, dyspnea and STEMI, predominantly left main involvement, multivessel involvement and severe left ventricular dysfunction. Our patient was atypical in presentation with NSTEMI diagnosis although she did have multi-vessel involvement and classic symptomology. In general, the diagnosis of PAMI is made utilizing clinical symptoms, cardiac biomarkers and EKG changes. Unfortunately, as in this case, the diagnosis can be delayed due to low suspicion in healthy patients and attribution of symptoms to anxiety. In addition, cardiac biomarkers are not specific to the diagnosis, as 4% of healthy women have elevated troponins in 8-24 hr postpartum period Therefore, severe consistent CP in the peripartum period must be thoroughly evaluated and include considerations for PAMI and SCAD in order to provide timely therapy.
1 Paratz ED et al. IJC Heart & Vasculature 2018 18: 1-6.
2 Honigberg MC et al. Curr Treat Options Cardio Med 2018 20: 58.
3 Smith R et al. Int J Obstet Anesth. 2015; 24 (1): 30-4.