Pregnancy-Associated Spontaneous Coronary Artery Dissection

Study Questions:

What characteristics are unique to pregnancy-associated spontaneous coronary artery dissection (SCAD)?

Methods:

Records from the Mayo Clinic registry were reviewed. Women who were pregnant or ≤12 weeks postpartum at the time of SCAD were compared to patients with SCAD not related to pregnancy.

Results:

Of 323 patients with SCAD, 54 were pregnancy-associated, and 269 were not. Women with pregnancy-associated SCAD were more likely to present with ST-segment elevation myocardial infarction (STEMI) (57% vs. 36%, p = 0.009), have left main (24% vs. 5%, p < 0.0001) or multivessel (33% vs. 14%, p = 0.003) SCAD, and have ejection fraction ≤35% (26% vs. 10%, p = 0.007). They were less likely to have a diagnosis of fibromuscular dysplasia than those with nonpregnancy-associated SCAD (42% vs. 64%, p = 0.047). Patients with pregnancy-associated SCAD most commonly presented in the first month, often the first week after delivery. Recurrence rates were similar (10% vs. 23%, p = nonsignificant) between patients with/without pregnancy-associated SCAD.

Conclusions:

Pregnancy-associated SCAD patients typically presented in the first month postpartum, had more high-risk features (left main or multivessel disease and myocardial dysfunction), and were less likely to have extracoronary vascular abnormalities than nonpregnant patients with SCAD.

Perspective:

This paper demonstrates that women who present with SCAD related to pregnancy often present early (within the first week or month postpartum) and can have severe presentations. Clinicians should have a high index of suspicion for SCAD among pregnant and early postpartum women presenting with chest pain. Much more research about SCAD is needed. Factors influencing pregnancy-associated SCAD remain unknown. A portion of women with pregnancy-associated SCAD were found to have a diagnosis of fibromuscular dysplasia, but many do not have extracoronary abnormalities. Hormonal, vascular, and hemodynamic changes of pregnancy may play a role. The influence of lactation is unknown. Recurrence rates among women with pregnancy-associated SCAD (10%) did not differ significantly from nonpregnancy-associated SCAD (23%). Predictors of recurrence are unknown. Only a small number of women with a history of SCAD have undergone subsequent pregnancy, and additional research is needed about this subset of women.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Prevention, Vascular Medicine, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD & Pediatrics, Congenital Heart Disease, CHD & Pediatrics and Arrhythmias

Keywords: Acute Coronary Syndrome, Chest Pain, Coronary Vessel Anomalies, Dissection, Fibromuscular Dysplasia, Hemodynamics, Myocardial Infarction, Postpartum Period, Pregnant Women, Secondary Prevention, Stroke Volume, Vascular Diseases


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