Evolving Management and Improving Outcomes in Pregnancy-Associated Spontaneous Coronary Artery Dissection (P-SCAD) Systematic Review

Abstract

Background: Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is defined as SCAD occurring during pregnancy or within 3 months post-partum. Earlier systematic reviews have suggested a high maternal and foetal mortality rate. We undertook a structured systematic review of P-SCAD demographics, management and maternal and foetal outcomes. Methods: Case study identification was conducted according to PRISMA guidelines, with screening of all published P-SCAD cases not meeting pre-defined exclusion criteria. Of two hundred and seventy-three publications screened, one hundred and thirty-eight cases met inclusion criteria. Cases were allocated to one of three time periods; 1960-85 (twenty cases) reflecting early management of P-SCAD, 1986-2005 (forty-two cases) reflecting recent management, and 2006-16 (seventy-six cases), reflecting contemporary management. Results: The only significant demographic change in women experiencing P-SCAD over the last 50 years was an increasing proportion of primigravidas (p = 0.02). Management and outcomes, however, have altered significantly. Emergent angiography (p b 0.0001), reduced thrombolysis (p = 0.006) and increasingly conservative or percutaneous management (p b 0.0001) are associated with dramatic reductions in maternal mortality (85% in earliest reports to 4% in the last decade, p b 0.0001) and foetal mortality (50% in earliest reports to 0.0% in the last decade, p = 0.023). Conclusion: This systematic review of temporal changes in presentation, management and outcomes of P-SCAD represents the widest range of variables analysed in the largest cohort of P-SCAD patients to date. In the setting of earlier coronary angiography and increasingly conservative management, maternal and foetal survival rates continue to improve. Keywords:Spontaneous coronary dissection Pregnancy Interventional cardiology Case studyA 35-year-old G2P0 woman presented with chest pain and anterior ST elevation at ± 34 weeks and 3 days gestation of an in vitro fertilisation (IVF) pregnancy. She had undergone two cycles of IVF therapy prior to pregnancy, and received a standard regime of hormonal stimulation. After discussion with the treating obstetrician, the cardiac catheterization laboratory was activated, with midwives and an obstetrics registrar on standby for urgent delivery in case of foetal distress or maternal arrest.Radial coronary angiography performed with minimal contrast (70 mL), minimal radiation (skin dose 88 mGy), and abdominal shielding. A spontaneous dissection of our patient's distal left anterior descending artery was found. Due to her haemodynamic stability, the decision was made to treat her conservatively with optimal medical therapy.Our patient commenced aspirin, clopidogrel, metoprolol and a heparin infusion (subsequently changed over to enoxaparin). Her electrocardiogram evolved to show anterior Q waves, and troponin peaked at 40,494 ng/L (normal b 16 ng/L). Echocardiography showed anterior hypokinesis with an ejection fraction (LVEF) of 40%, and spontaneous echo...

Acute Myocardial Infarction in Young Individuals

“…33 Only 4 occurred during pregnancy, and most events occurred within the first month postpartum. 26,28,34,35 The prevalence of myocarditis varies, but a recent meta-analysis reported it in 33% of patients (183 of 556) with MINOCA. 36 The prevalence of myocarditis varies from 2% to 42% in autopsy series 37,38 and 9% to 16% by endomyocardial biopsy in adults with nonischemic dilated cardiomyopathy.…”

Bicoastal Spontaneous Coronary Artery Dissection: A Therapeutic Dilemma

“…When it occurs, P-SCAD is most likely to present in the first week postpartum, subsequently the first month postpartum. 3 6 However, as women of reproductive age are at risk for this particular coronary event, suspicion for the condition should remain high when assessing chest pain even during pregnancy.…”

“… 3 In the general population, coronary intervention is considered in patients who are hemodynamically unstable, have SCAD of the left main coronary artery, or multiple vessel disease. 1 2 3 6 8 The decision to intervene in pregnancy should follow these same principles. Concern for fetal radiation exposure from coronary angiography should not prevent intervention as the total exposure is low and preservation of maternal health is crucial.…”

“…On the other hand, while conservative management does not treat SCAD, the goal is to prevent immediate complications and recurrence. 6 8 Although components of the conservative approach may vary across institutions, blood pressure control has universally been the primary target in patients with SCAD. However, in the case presented, the patient was generally normotensive while being persistently tachycardic.…”

“…3 However, this carries inherent risk for dissection propagation. 6 In the case presented, the patient had a classic presentation of SCAD: typical chest pain in a reproductiveaged woman without cardiovascular risk factors. As she was hemodynamically stable, diagnostic angiography and cardiac interventions were initially deferred in pursuit of conservative management.…”