Presentation and Therapy of Spontaneous Coronary Artery Dissection and Comparisons of Postpartum Versus Nonpostpartum Cases

Study Questions:

What are the clinical characteristics, and diagnostic and management challenges, of patients admitted with a diagnosis of spontaneous coronary artery dissection (SCAD)?

Methods:

The investigators reviewed medical records and coronary angiograms of patients admitted to their institution (St. Vincent Heart Center of Indiana) with the diagnosis of SCAD from 1999 through 2010. A definite diagnosis of SCAD required the agreement of two blinded board-certified interventional cardiologists who reviewed all images separately. Baseline characteristics and clinical outcomes were compared between postpartum versus nonpostpartum cases.

Results:

Baseline characteristics of patients (n = 23) included mean age 45 ± 11 years, female gender in all (100%), history of hypertension in 13 (57%), and postpartum in 7 (30%) patients. Eleven (48%) had ST-segment elevation on initial electrocardiogram. SCAD involved the left main in 5 patients (21.7%), left anterior descending coronary artery in 16 (70%), left circumflex coronary artery in 8 (35%), and right coronary artery in 6 (26%) patients. Four patients (17%) underwent coronary stenting and 6 (26%) required urgent bypass surgery. Comparison between postpartum and nonpostpartum patients revealed significant differences in mean peak troponin levels: 50 ± 34 ng/ml versus 21 ± 23, p = 0.04, mean left ventricular ejection fraction: 34 ± 6% versus 49 ± 9, p < 0.01, proximal coronary segment distribution: 6 (86%) versus 3 (19%), p = 0.004, and left anterior descending coronary artery distribution: 7 (100%) versus 9 (56%), p = 0.04, respectively. Repeat coronary angiographies were performed in 11 patients (46%) during a mean follow-up of 39 ± 38 months, and 10 (91%) were found to have healed SCAD, including those who had undergone bypass surgery.

Conclusions:

The authors concluded that patients with SCAD were characterized by female gender, absence of coronary risk factors, and a high rate of vascular healing without residual stenosis.

Perspective:

In this study, patients with SCAD were characterized by relatively young females with an absence of traditional coronary risk factors aside from hypertension, a high postpartum rate, a high incidence of infarction, a high rate of vascular healing without residual stenosis, and generally a good long-term prognosis. Furthermore, this study suggests that resolution of the dissection over time can be anticipated in all patients with SCAD, providing the rationale for an initial conservative strategy in most patients with SCAD.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and CHD & Pediatrics, Congenital Heart Disease, CHD & Pediatrics and Imaging, CHD & Pediatrics and Interventions, CHD & Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging, Hypertension

Keywords: Prognosis, Infarction, Follow-Up Studies, Coronary Angiography, Coronary Vessel Anomalies, Postpartum Period, Risk Factors, Electrocardiography, Indiana, Hypertension


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