- Email: [email protected]
Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively
International Journal of Cardiology 129 (2008) e53 – e55 www.elsevier.com/locate/ijcard
Letter to the Editor
Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively Nishant Kalra a,b,⁎, Jeff Greenblatt a , Syed Ahmed c a
Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, United States b College of Human Medicine, Michigan State University, Flint, MI, United States c Hurley Medical Center, Flint, Michigan, United States Received 10 April 2007; accepted 23 June 2007 Available online 12 September 2007
Abstract Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and has been described in young women during the peripartum period. Management of these patients has been controversial. A 35 year old Caucasian female, 11 days postcesarean section delivery presented with acute myocardial infarction. She underwent angiography within a few hours of presentation, which showed dissection of LAD. Repeat angiography six days later showed improvement of dissection. Patient showed clinical improvement on conservative treatment and no recurrence of symptoms over the past two years follow-up. There is no consensus on the treatment and our case is one of the cases managed successfully with conservative treatment. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Spontaneous dissection; Coronary artery dissection; Postpartum; Angiography; Left anterior descending (LAD)
1. Background
2. Case
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, intense physical exercise, use of contraceptives, Kawasaki disease, systemic lupus erythematosus and cocaine use. Management of these patients has been controversial. Here we present a case of a young postpartum woman who developed SCAD and was managed conservatively with an uneventful follow up for two years.
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 prenatal vitamins and ferrous sulfate. Her admission EKG demonstrated ST segment elevation in inferior leads. Urine toxicology was negative for cocaine. Blood pressure on admission was 130/ 75 and the physical examination was normal. An echocardiogram showed global hypokinesis with ejection fraction of 40%–45%. She was started on IV heparin, nitroglycerin, integrillin and a B-blocker and was admitted to CCU. Troponin peaked at 58.4 ng/mL. She underwent angiography within a few hours of presentation, which showed lesion in the LAD (left anterior descending) and clean RCA (right
⁎ Corresponding author. One Hurley Plaza, Suite 212, Flint, Michigan 48503, United States. Tel.: +1 810 257 9682, +1 810 496 0249 (Home); fax: +810 762 7245. E-mail address: [email protected] (N. Kalra). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.06.118
e54
N. Kalra et al. / International Journal of Cardiology 129 (2008) e53–e55
mately 75% of patients with SCAD die suddenly. The prognosis of patients surviving the initial event is good, with an 82% survival rate [3,4]. 4. Treatment
Fig. 1. Mid LAD dissection.
coronary artery). Although the lesion was read as 40–50% stenosis, upon further review the lesion was a long segmental dissection of mid LAD (Figs. 1 and 2). Left ventriculography revealed global hypokinesis. Clinically the patient showed improvement with no further episode of chest pain. Because the repeated angiography after six days showed improvement of the dissection, no stent was placed. Repeat left ventriculography revealed improvement in anterior wall motion but hypokinesis of posterior basal and infero-apical wall. The patient has no recurrence of symptoms over the past two years and a follow up myocardial perfusion study revealed a fixed inferoapical defect without evidence of inducible ischemia.
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]. However coronary dissection may regress spontaneously. Our case was conservatively managed and the patient had no recurrence of chest pain in long-term follow up of two years. On initial presentation it was thought that patient has acute inferior wall ST elevation MI, but no lesion was found in RCA. Most probably patient had spasm or a thrombotic lesion of RCA and dissection of mid LAD simultaneously. Follow up revealed fixed defect in RCA territory and resolution of stunned myocardium to normal in LAD territory. There are no guidelines about the long-term management of these patients. However it may be appropriate that these patients be cautioned against recurrent pregnancies and avoidance of strenuous activity that could potentially predispose them to spontaneous coronary dissection. 5. Conclusion Spontaneous coronary artery dissection should be considered in the differential diagnosis of any young person
3. 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. Changes in arterial wall during pregnancy secondary to excess progesterone lead to smooth muscle cell proliferation, reduction in collagen and alterations in protein and mucopolysaccharide content of the media. These changes combined with shearing stress of parturition lead to an intimal tear. Robinowitz et al and Borczuk et al., [1,2] reported that eosinophilic inflammatory infiltrates along the dissection plane may play a causal role as eosinophils have potential collagenolytic and cytotoxic activity. Approxi-
Fig. 2. Radiolucent line separating true from false lumen.
N. Kalra et al. / International Journal of Cardiology 129 (2008) e53–e55
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 [1] Rabinowitz M, Virmani R, Mcallister Jr HA. Spontaneous coronary artery dissection and eosinophilic inflammation: a cause effect relationship. Am J Med 1982;72:923–8.
e55
[2] Borczuk AC, van Hoeven KH, Factor SM. Review and hypothesis: the eosinophil and peripartum heart disease (myocarditis and coronary artery dissection)-coincidence or pathogenetic significance? Cardiovasc Res Mar 1997;33(3):527–32. [3] Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature. Catheter Cardiovasc Interv 2001;52:88–94. [4] DeMaio Jr SJ, Kinsella SH, Silverman ME. Clinical course and long term prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989;64:471–4. [5] Dhawan R, Singh G, Fesniak H. Spontaneous coronary artery dissection: the clinical spectrum. Angiology Jan–Feb 2002;53(1):89–93.
Letter to the Editor
Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively Nishant Kalra a,b,⁎, Jeff Greenblatt a , Syed Ahmed c a
Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, United States b College of Human Medicine, Michigan State University, Flint, MI, United States c Hurley Medical Center, Flint, Michigan, United States Received 10 April 2007; accepted 23 June 2007 Available online 12 September 2007
Abstract Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and has been described in young women during the peripartum period. Management of these patients has been controversial. A 35 year old Caucasian female, 11 days postcesarean section delivery presented with acute myocardial infarction. She underwent angiography within a few hours of presentation, which showed dissection of LAD. Repeat angiography six days later showed improvement of dissection. Patient showed clinical improvement on conservative treatment and no recurrence of symptoms over the past two years follow-up. There is no consensus on the treatment and our case is one of the cases managed successfully with conservative treatment. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Spontaneous dissection; Coronary artery dissection; Postpartum; Angiography; Left anterior descending (LAD)
1. Background
2. Case
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, intense physical exercise, use of contraceptives, Kawasaki disease, systemic lupus erythematosus and cocaine use. Management of these patients has been controversial. Here we present a case of a young postpartum woman who developed SCAD and was managed conservatively with an uneventful follow up for two years.
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 prenatal vitamins and ferrous sulfate. Her admission EKG demonstrated ST segment elevation in inferior leads. Urine toxicology was negative for cocaine. Blood pressure on admission was 130/ 75 and the physical examination was normal. An echocardiogram showed global hypokinesis with ejection fraction of 40%–45%. She was started on IV heparin, nitroglycerin, integrillin and a B-blocker and was admitted to CCU. Troponin peaked at 58.4 ng/mL. She underwent angiography within a few hours of presentation, which showed lesion in the LAD (left anterior descending) and clean RCA (right
⁎ Corresponding author. One Hurley Plaza, Suite 212, Flint, Michigan 48503, United States. Tel.: +1 810 257 9682, +1 810 496 0249 (Home); fax: +810 762 7245. E-mail address: [email protected] (N. Kalra). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.06.118
e54
N. Kalra et al. / International Journal of Cardiology 129 (2008) e53–e55
mately 75% of patients with SCAD die suddenly. The prognosis of patients surviving the initial event is good, with an 82% survival rate [3,4]. 4. Treatment
Fig. 1. Mid LAD dissection.
coronary artery). Although the lesion was read as 40–50% stenosis, upon further review the lesion was a long segmental dissection of mid LAD (Figs. 1 and 2). Left ventriculography revealed global hypokinesis. Clinically the patient showed improvement with no further episode of chest pain. Because the repeated angiography after six days showed improvement of the dissection, no stent was placed. Repeat left ventriculography revealed improvement in anterior wall motion but hypokinesis of posterior basal and infero-apical wall. The patient has no recurrence of symptoms over the past two years and a follow up myocardial perfusion study revealed a fixed inferoapical defect without evidence of inducible ischemia.
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]. However coronary dissection may regress spontaneously. Our case was conservatively managed and the patient had no recurrence of chest pain in long-term follow up of two years. On initial presentation it was thought that patient has acute inferior wall ST elevation MI, but no lesion was found in RCA. Most probably patient had spasm or a thrombotic lesion of RCA and dissection of mid LAD simultaneously. Follow up revealed fixed defect in RCA territory and resolution of stunned myocardium to normal in LAD territory. There are no guidelines about the long-term management of these patients. However it may be appropriate that these patients be cautioned against recurrent pregnancies and avoidance of strenuous activity that could potentially predispose them to spontaneous coronary dissection. 5. Conclusion Spontaneous coronary artery dissection should be considered in the differential diagnosis of any young person
3. 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. Changes in arterial wall during pregnancy secondary to excess progesterone lead to smooth muscle cell proliferation, reduction in collagen and alterations in protein and mucopolysaccharide content of the media. These changes combined with shearing stress of parturition lead to an intimal tear. Robinowitz et al and Borczuk et al., [1,2] reported that eosinophilic inflammatory infiltrates along the dissection plane may play a causal role as eosinophils have potential collagenolytic and cytotoxic activity. Approxi-
Fig. 2. Radiolucent line separating true from false lumen.
N. Kalra et al. / International Journal of Cardiology 129 (2008) e53–e55
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 [1] Rabinowitz M, Virmani R, Mcallister Jr HA. Spontaneous coronary artery dissection and eosinophilic inflammation: a cause effect relationship. Am J Med 1982;72:923–8.
e55
[2] Borczuk AC, van Hoeven KH, Factor SM. Review and hypothesis: the eosinophil and peripartum heart disease (myocarditis and coronary artery dissection)-coincidence or pathogenetic significance? Cardiovasc Res Mar 1997;33(3):527–32. [3] Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature. Catheter Cardiovasc Interv 2001;52:88–94. [4] DeMaio Jr SJ, Kinsella SH, Silverman ME. Clinical course and long term prognosis of spontaneous coronary artery dissection. Am J Cardiol 1989;64:471–4. [5] Dhawan R, Singh G, Fesniak H. Spontaneous coronary artery dissection: the clinical spectrum. Angiology Jan–Feb 2002;53(1):89–93.