Menstrual Chest Pain in Women With History of Spontaneous Coronary Artery Dissection

Abstract

Spontaneous coronary artery dissection (SCAD) is an important etiology of myocardial infarction (MI) and sudden cardiac death in young women (1). Previously considered rare, substantial improvement in SCAD diagnosis and awareness has facilitated research of this disease. Many women with a history of SCAD have recurrent chest pain despite lack of demonstrable ischemia or coronary obstruction. Herein, we report the hypothesis-generating finding of women who experience chest pain that predictably occurs or worsens synchronous with menstruation. The objective was to describe the observation and treatment of cyclic chest pain associated with menstruation (catamenial chest pain) in SCAD.The Mayo Clinic Institutional Review Board approved the study. We reviewed the records of patients in the Mayo Clinic SCAD Registry enrolled from 2012 to 2016 and identified those who voluntarily described chest pain associated with menstruation. These patients were contacted by telephone and participated in a focused survey.A total of 11 women were identified (Table 1). Four had experienced post-partum SCAD, 2 had fibromuscular dysplasia, and 1 had Ehlers-Danlos syndrome type IV. Most (7 of 11, 64%) presented with ST-segment elevation MI at time of SCAD; 1 presented in cardiac arrest. The majority (7 of 11, 64%) had left anterior descending coronary artery SCAD.All women described onset of chest pain just prior to menstruation, usually 1 to 2 days before onset of bleeding. Symptoms persisted into menses in 4 (36%). Two women (18%) had coronary artery obstruction on coronary angiography (CA) (1 with persistent dissection and another with instent stenosis); these patients' catamenial chest pain persisted despite revascularization and negative subsequent stress studies. Six women (55%) had negative stress tests, 2 of whom had patent coronaries upon imaging. Of these, patient #5 had chronic troponin I elevations in the absence of electrocardiogram changes or left ventricular wall motion abnormalities. Two (18%) underwent CA without a preceding stress test with the finding of patent coronaries; another woman (9%) had an unremarkable coronary computed tomography angiography.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

“…Premenopausal women may report chest pain at variable but predictable times of their menstrual cycle. 241 One hypothesis is that this is a result of enhanced coronary vasomotion and abnormal endothelial function or persistent microvascular dysfunction. Clinically, some of these patients respond to empirical use of long-acting nitrates or calcium channel blockers, either daily or during days of the month when they are predictably symptomatic.…”

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Review of the Current Position

“…Spontaneous coronary dissection refers to spontaneous tearing of the intima of the coronary artery under the condition of nonhuman factors, and hematoma formation when blood enters the middle or subintima of the coronary artery, which leads to sharp narrowing of the lumen and serious obstruction of the blood flow, manifesting as acute coronary syndrome (ACS). Spontaneous coronary dissection often occurs in young women [29]. Such patients do not have obstructive lesions on CAG and are diagnosed as MINOCA.…”

Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management

“…After either conservative or revascularisation management, it is imperative to monitor the patient closely for early detection of ischaemic relapses. Recurrent atypical chest pain episodes are common after the SCAD event and can last long after discharge in some patients 21 91 92. After-event chest pain is frequently not accompanied by new angiographic findings.…”

“…As previously mentioned, chest pain with non-demonstrable ischaemia may appear, persist or be cyclic, even related to menstruation (catamenial chest pain) 21 91 92. This can result very disconcerting and frustrating for patients.…”