Letter to the EditorPostpartum spontaneous coronary artery dissection (SCAD) managed conservatively
Section snippets
Background
True spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and sudden cardiac death with a presentation indistinguishable from that due to plaque rupture. Coronary dissection has been described in young women during the peripartum period or in association with oral contraceptive use. The majority of cases of SCAD appear to be idiopathic, although dissections have been linked to Marfan's syndrome, atherosclerotic cardiovascular disease, blunt chest trauma,
Case
A 35 year old Caucasian female, 11 days postcesarean section delivery presented with chest pain at rest. Two hours prior to admission, she first developed chest pain at home that lasted 45 min and resolved. A second episode occurred in the hospital when she came to feed her newborn baby and because of its severity she went to the emergency department. There is no past medical history of diabetes, previous chest pain or hypertension. She smokes 1 pack per day and her current medications were
Pathogenesis
Women with SCAD in the peripartum period frequently present with involvement of LAD artery in 80% of case while the remaining involve Left Main, Right coronary and Left Circumflex arteries. There have been case reports of dissection involving both the right and left coronary arteries. Two case series have found that 22% of the events occur during delivery and 78% in the postpartum period. While most cases occur within 2 weeks of delivery, some case presented as long as 10–12 weeks postpartum.
Treatment
There is no consensus on the treatment of SCAD. Both medical and surgical approaches have been employed, but no randomized control trial has compared the two approaches. Koul A et al., reported a review of 58 cases of pregnancy and postpartum related SCAD. Out of 36 cases who survived initial event 17 (46%) underwent conservative management, 11 (30%) received CABG, 4 (11%) got stent placed and 3 (8%) had to undergo cardiac transplantation. There was 0% mortality in these treated groups [3].
Conclusion
Spontaneous coronary artery dissection should be considered in the differential diagnosis of any young person sustaining an acute myocardial infarction without any risk factors, especially women in the postpartum state [4], [5]. It is recommended that treatment should be tailored to meet individual circumstances. If the symptoms have resolved and patient is stable and has single vessel dissection, medical treatment with anticoagulation, nitrates and B-blockers can produce good results.
References (5)
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Clinical course and long term prognosis of spontaneous coronary artery dissection
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Cited by (10)
Evolving management and improving outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD): a systematic review
2018, IJC Heart and VasculatureCitation Excerpt :Our search strategy returned 273 results. Exclusion of duplicate results and articles not meeting specified a priori criteria (162 articles) resulted in 111 articles describing 138 cases of P-SCAD [5–92]. Demographic case details extracted from all case reports were maternal age, cardiac risk factors (defined as both number of cardiac risk factors and a binary variable), presence of an autoimmune or connective tissue disorder, gravidity/parity status, gestational time or days post-partum at onset of P-SCAD, and whether the pregnancy was a result of in vitro fertilisation (IVF) or a multiple pregnancy.
Non-ST segment elevation myocardial infarction due to near-lethal spontaneous whole left coronary artery dissection
2014, International Journal of CardiologySpontaneous Coronary Artery Dissection in a Postpartum Woman: Literature Review
2011, Journal for Nurse PractitionersCitation Excerpt :Appleby et al2 reported having survival rates of 100%, with exceptional long-term results. Patients should be strongly cautioned against further pregnancies because theories strongly suggest that the etiology of SCAD is related to changes that occur as a result of pregnancy, which may predispose them to future events.4,14 In summary, P-SCAD is a life-threatening cardiac condition that can present up to 12 weeks postpartum.
Increased Subsequent Risk of Coronary Heart Disease in Primary Cesarean Delivery Women: A Population-Based Cohort Study
2019, Journal of Women's HealthPregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases
2017, Circulation: Cardiovascular InterventionsSpontaneous coronary artery dissection: Report of 3 cases and literature review hormonal, autoimmune, morphological factors
2015, American Journal of Forensic Medicine and Pathology