Background-Because of the rarity of this condition, information on pregnancy-associated spontaneous coronary artery dissection is limited. We reviewed a large number of contemporary pregnancy-associated spontaneous coronary artery dissection cases in an attempt to define the clinical characteristics and provide management recommendations. Methods and Results-A literature search for cases of pregnancy-associated spontaneous coronary artery dissection reported between 2000 and 2015 included 120 cases; 75% presented with ST-segment-elevation myocardial infarction, and 80% had anterior myocardial infarction. Left anterior descending coronary artery was involved in 72% of cases, left main segment in 36%, and 40% had multivessel spontaneous coronary artery dissection. Ejection fraction was reduced to <40% in 44% of cases. Percutaneous coronary intervention was successful in only 50% of cases. Coronary artery bypass surgery was performed in 44 cases because of complex anatomy, hemodynamic instability, or failed percutaneous coronary intervention. Maternal complications included cardiogenic shock (24%), mechanical support (28%), urgent percutaneous coronary intervention (28%), urgent coronary artery bypass surgery (27.5%), maternal mortality (4%), and fetal mortality (2.5%). During follow-up for 305±111 days, there was a high incidence of symptoms because of persistent or new spontaneous coronary artery dissections, and 5 women needed heart transplantation or ventricular assist device implantation. Conclusions-Pregnancy-associated spontaneous coronary artery dissection is commonly associated with left anterior descending, left main, and multivessel involvement, which leads to a high incidence of reduced ejection fraction, and lifethreatening maternal and fetal complications. Percutaneous coronary intervention is associated with low success rate and high likelihood of complications, and coronary artery bypass surgery is often required. Recurrent ischemic events because of persistent or new spontaneous coronary artery dissection are common during long-term follow-up. (Circ Cardiovasc Interv. 2017;10:e004941.

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1695T he incidence of coronary artery disease (CAD) in women of child-bearing age is low, and acute myocardial infarction (AMI) is uncommon.1,2 Pregnancy, however, has been shown to increase the risk of AMI ≈3-fold compared with the risk in nonpregnant women of similar age. [2][3][4][5] Although previous studies have provided some data related to the incidence of pregnancyassociated MI (PAMI), clinical characteristics, risk factors, and outcome 1,2,4 more information is needed on the mechanisms of AMI, the efficacy and safety of standard therapy, and the applicability of guideline recommendations designed for the general AMI population, to women with PAMI.The aim of this study was therefore to review contemporary data on PAMI in an attempt to provide recommendations for the management of this condition. MethodsA literature search for cases with AMI related to pregnancy was performed using PubMed and Google Scholar. References from these studies were cross-checked to obtain additional studies that may have been missed by the original search.All original articles were obtained online or by interlibrary communication. Articles published in languages other than English were translated by medical translators. A total of 134 cases published in the literature from 2006 to 2011 not included in a previous review 4 were included in this study. In addition, 7 cases presented at the First International Congress on Cardiac Problems in Pregnancy in 2010 (Valencia, Spain) and 9 patients treated or consulted by the authors were also included in the analysis. Recommendations were made on the basis of available clinical information, with the understanding that the cases published in the literature and reviewed by us do not represent all the patients who developed PAMI during the period of the study and that reporting may therefore be incomplete and biased. ResultsOne hundred fifty patients with PAMI were included in the study (Table 1). The age ranged from 17 to 52 years; the mean age was 34±6 years; 75% of the patients were >30 years of age; and 43% were >35 years. Reported risk factors for CAD included smoking in 25% of the patients, dyslipidemia in 20%, hypertension in 15%, and diabetes mellitus and a family history of CAD in 9% each.The type and timing of AMI are shown in Figure 1. Data on the type of AMI were available in 139 of the patients. Of these, 105 (75%) presented with ST-segment-elevation MI (STEMI) and the rest with non-STEMI (NSTEMI). The majority of the patients developed AMI during either the third trimester of pregnancy (STEMI, 25%; NSTEMI, 32%) or the postpartum period (STEMI, 45%; NSTEMI, 55%). The myocardial infarct involved the anterior wall of the left ventricle (LV) in 69% of the patients, the inferior wall in 27%, and the lateral wall in 4%. Table 2 shows the mechanisms of AMI. Coronary angiography was performed in 129 patients and demonstrated coronary dissection (CD) in 56 patients (43%), atherosclerotic disease in 27%, a clot without angiographic evidence for atherosclerotic disease in 22 patients (1...

We performed a prospective, randomized, double-blind, crossover study to compare the efficacy and safety of vasodilation with the calcium entry blocker nifedipine with that of isosorbide dinitrate (ISDN)

Women with the syndrome should be counseled before conception about the risks of pregnancy to both mother and fetus. Because preconceptual dilatation of the ascending aorta seems to be an important predictor for aortic dissection, it should be excluded before pregnancy. Transesophageal echocardiography seems to be preferable for noninvasive assessment of aortic dilatation before and during pregnancy. Prophylactic use of beta-blockers may be useful in preventing aortic dilatation. Surgery should be considered during gestation in patients with progressive aortic dilatation when or before the aortic root reaches 5.5 cm. Because of the potential risk of ionizing radiation to the fetus, noninvasive methods such as transesophageal echocardiography and magnetic resonance imaging are preferred to contrast aortography for the diagnosis of aortic dissection during pregnancy. Vaginal delivery can be done in patients with the Marfan syndrome who do not have cardiovascular system abnormalities. In patients with aortic dilatation, aortic dissection, or other important cardiac abnormalities, cesarean section should be the preferred method of delivery.

In patients with chronic heart failure due to left ventricular systolic dysfunction, the concomitant use of oral hydralazine prevents early development of nitrate tolerance and results in a persistent nitrate-mediated hemodynamic effect on systemic and pulmonary artery and left ventricular filling pressures. These data may support the concurrent use of hydralazine in patients with heart failure treated with organic nitrates.

Background— A “renal dose” of dopamine is often used to increase renal blood flow; however, data on the magnitude of effect and site of action in patients with heart failure are scarce. Methods and Results— Renal effects of intravenous dopamine (1, 2, 3, 5, and 10 μg · kg −1 · min −1 ) were evaluated in 13 patients with chronic heart failure. Renal blood flow was calculated from renal artery cross-sectional area measured with intravascular ultrasound and renal blood flow velocity-time integral measured by the intravascular Doppler technique. Cross-sectional area increased and was significantly higher than baseline (0.30±0.04 cm 2 ) at 5 μg · kg −1 · min −1 (0.36±0.05 cm 2 ) and 10 μg · kg −1 · min −1 (0.38±0.06 cm 2 ). The velocity-time integral was significantly higher than baseline (22±3 cm) at doses of 3 and 5 μg · kg −1 · min −1 (both 31±4 cm). Renal blood flow increased, whereas renal vascular resistance decreased, reaching statistical significance at 2 μg · kg −1 · min −1 through 10 μg · kg −1 · min −1 . Cardiac output gradually increased, reaching statistical significance at doses of 5 and 10 μg · kg −1 · min −1 (5.5±0.5 and 6.1±0.7 versus 4.5±5.2 L/min at baseline), but the increase in renal blood flow appeared proportionately larger than corresponding increases in cardiac output. Conclusions— Dopamine is associated with an increase in renal blood flow in patients with heart failure. This effect is due to dilation of both the large conductance and small resistance renal blood vessels. Further evaluation of the efficacy and safety of dopamine for improvement of renal function in hospitalized patients with heart failure is warranted.

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