Courtesy of Dr. Pablo Baglioni.

Between the years 2000 and 2015, the authors of this article searched for reports on spontaneous coronary artery dissection (SCAD) in pregnant or immediate post-partum women aiming at defining the clinical characteristics of this pathology and offering management recommendations.

Information on 120 women was analyzed; 116 were between 22 and 52, mean age was 34 ±4 years. As regards risk factors, 14% had a family history, 12.5% were smokers or ex-smokers, 10% dyslipidemic, 5% hypertensive, and 4% diabetic.

When the variable was communicated (numbers between brackets), preeclampsia or eclampsia (n=65) was reported in 8 cases (12%), hyper coagulopathy disorders (n=42) in other 4 patients, use of illicit drugs (n=49) in only one patient, use of hormones before pregnancy (n=38) was reported in 7 women, 4 had used oral contraception and other 3 had been treated with hormones for infertility.

The time of presentation was communicated in 119 patients. In 21 of these patients (17.5%), spontaneous coronary artery dissection presented during the third trimester; in other 7 (6%), in the second trimester, and there were no cases in the first trimester. 72.5% of cases presented during post-partum, between days 3 and 210.

115 patients had acute myocardial infarction, 87 with ST elevation (75.5%). 47 patients (62%) had anterior MI, other 14 (18%) had anterolateral MI, and 15 (20%) inferior MI.

58 patients with STEMI and 10 with non-STEMI underwent emergency coronary angiography and the rest had one during hospitalization. Spontaneous dissection was corroborated in 191 coronary arteries: 60% in only one artery, 22.5% in two arteries and 3 or more in 17.5%.  

The left main coronary artery was involved in 43 cases (36%), the left anterior descending artery in 86 patients (72%), the left circumflex in other 28 cases, and the right coronary artery in 18 cases. It is worth mentioning that during coronary angiography, a total occlusion was found in 31 patients (26% of cases), and 5 presented with non-STEMI.

Coronary angiography was performed in 44 patients. Success was reported in 22 patients (50%), including 3 that had presented SCAD. 37 patients received a stent: 14 a bare metal stent, and 11 a DES. The kind of stent was not reported for the rest of patients.

CABG was performed in 44 women, 6 for failed PCI and 18 for complex coronary anatomy, including 9 cases with three vessel disease. Other 11 cases were managed conservatively at first and then referred to surgery after persistent ischemic symptoms, development of STEMI, cardiogenic shock or dissection extension.

54 patients were treated conservatively. However, 18 of them were treated during hospitalization: 11 with CABG and 7 with PCI.

36 patients remained under conservative treatment: 25 presenting STEMI, 29 with a single vessel dissection, 6 with left main dissection, and left anterior descending in 21.

10 patients were treated with thrombolytics; 8 of these were further treated with PCI or CABG in.

Maternal mortality occurred in 5 patients: 4 during post-partum and one before labor.

3 cases of fetal death were reported, all in women with left main dissection: two had been taken to surgery and one had survived STEMI.

96 patients were followed up for 305 ±111 days. Coronary angiography was repeated in 39 patients after 84 ±57 days. Procedure was scheduled and performed in 23 women: 5 still showed SCAD, and 3 involved a new vessel.

Coronary angiography was repeated in other 16 patients in the presence of ischemic symptoms, with changes in the ECG in 9 of them (all of them presented dissection, 3 in the same vessel and 6 in a new vessel). 6 patients reported isolated chest pain (5 showed SCAD). In one case the reason to repeat the coronary angiography was not reported and SCAD persistence was found.

During this follow up period, 14 patients received a coronary angiography: 9 had a previous one and 5 were treated conservatively.

As regards CABG during this period, it was performed in 4 patients, 18 hours after the first surgery, because of failed graft, in one case, and in three others because of dissection extension to the left main. 

Of the 36 patients medically treated during initial admission: 17 underwent repeated angiography and 8 were found to have SCAD. 13 of these patients underwent a scheduled coronary angiography: 2 showed SCAD persistence in the same artery, and other 2 in a new artery.

Editorial Comment

The use of PCI as revascularization strategy for peripartum patients is under discussion. For one thing, the procedure can fail in more than 50% of cases. In addition, a conservative strategy has had, in some series, more than 90% success, with good hospital evolution.

This is a limited study, for it is retrospective, based on reports and on one series only. In many cases, data are incomplete. Besides, there is no direct comparison between demographic and angiographic characteristics. Nevertheless, it provides interesting information that should be taken into account when treating this disease.

We should highlight the importance of thinking SCAD as a cause of infarction in young healthy women mostly during immediate postpartum or in their third trimester of pregnancy, and bear in mind that SCAD is associated more often with anterior MI or remarkably lower ejection fraction than that of non-pregnant women. PCI will be successful only in half of patients, and late evolution of patients treated conservatively will show a significant percentage of dissection persistence, as well as new dissections.

Left main compromise should be considered at diagnosis, since injecting contrast could exaggerate the dissection.

Pregnancy related spontaneous coronary artery dissection is only 5% of all SCAD cases, but the more compromised the ventricular function, the more aggressive and extensive it will be, compared to non-pregnancy related SCAD.

The mechanism of SCAD has not been entirely explained but it is thought to be associated to pregnancy related hemodynamic and hormonal stress, and vascular degeneration. The study showed that most women with SCAD had given birth multiple times, hence had been repeatedly exposed to hormonal and hemodynamic stress.

Courtesy of Dr. Pablo Baglioni. Hemodynamics, San Juan de Dios Hospital.

Title: Pregnancy and the Risk of Spontaneous Coronary Artery Dissection. An analysis if 120 Contemporary Cases.

Reference: Ofer Havakuk, Sorel Goland, Anil Mehra, Uri Eikayam, Circ Cardiovasc Interv 2017 Mar, 10(3).

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