An Unusual Presentation of Postpartum Spontaneous Coronary Artery Dissection

Abstract

The postpartum population is one with a unique physiologic profile that predisposes these patients to rare and often life-threatening conditions. Herein, we discuss a case of a 37-year-old, multiparous female who presented to the emergency department with vague chest discomfort 14 days after delivering her sixth child via vaginal delivery. The patient was found to have elevated cardiac biomarkers and was ultimately diagnosed with pregnancy-related spontaneous coronary artery dissection (P-SCAD). This case report discusses the evaluation, pathophysiology, workup, and management of P-SCAD.

Pregnancy-Associated Spontaneous Coronary Artery Dissection in Women: A Literature Review

“…These assertions are supported by the findings yielded by a number of SCAD/pregnancy-focused studies, including Saw et al's 3 prospective multicenter SCAD review across Canada, where P-SCAD patients experiencing acute MI were found to be more likely to have fewer risk factors than NP-SCAD patients. 12 , 13 , 17 , 20 , 33 Because these results pertain to mostly Caucasian women, it is worth noting that they are corroborated by the findings yielded by Clare et al's 25 more ethnically diverse study. Thus, although race does not appear to influence the identification of P-SCAD, accurate representation of diverse populations in SCAD registries is warranted.…”

“… 35 The authors challenge the prevalent view that hormones (such as contraceptives and hormone replacement therapy) and changes in hormone levels during birth are risk factors for SCAD because SCAD incidence is low compared with the widespread application of those hormones. Likewise , Saw et al 37 and Alterie et al 33 posit that other stressors and arteriopathies can contribute to the emergence of SCAD, given that psychological and physical precipitating stressors have been identified as risk factors. 11 …”

“…P-SCAD patients are also more likely to present with ST-elevation MI than non-ST-elevation MI patients and their ST values tend to be higher than in NP-SCAD cases. 13 Because greater prevalence of left main dissections as well as vertebral dissections results in more extensive injury, 12 , 13 , 15 , 20 , 33 which can lead to vascular spasms, P-SCAD patients require careful observation and timely treatment. 1 , 38 …”

“…Because P-SCAD most frequently occurs during the last semester and the first week following delivery, 28 women deemed at risk should be given extensive care during this period and should be monitored by both cardiologist and obstetrician, as noted by Yip et al 8 However, given that in many cases P-SCAD may not cause any complaints, as noted by Alterie et al, 33 identifying patients who require this level of care may be challenging and would require close examination of patient history. 15 Given that P-SCAD has been shown to be predominantly present in women of various childbearing ages, Tweet et al's 14 uniquely focused 2020 study of the relationship between SCAD recurrence and pregnancy should be expanded.…”

Care of the Postpartum Patient in the Emergency Department: A Systematic Review with Implications for Maternal Mortality

“…42,43 Implementation of postpartum clinics or home visits did not tend to have an effect, [44][45][46] although women at risk for depression who self-excluded from home visits were more likely to visit an ED. 47 Of the 108 case reports (►Supplementary Table S1, available in the online version), 37% dealt with cardiovascular disease, including aortic dissection, 48 peripartum cardiomyopathy, 15,[49][50][51][52][53][54][55][56] spontaneous coronary artery dissection, 48,[57][58][59][60][61][62][63][64][65][66][67][68] and ST-elevation myocardial infarction. 62,63,[69][70][71] The cardiovascular category also had the highest number of cases that were associated with maternal mortality (n ¼ 3).…”