Pregnancy and the Risk of Spontaneous Coronary Artery Dissection

Abstract

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.

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

“…Patients with pregnancy-associated SCAD were younger, were more likely to present with ST-segment–elevation MI (50% versus 36%; P =0.013) and left main and multivessel dissections, had poorer LV function immediately and at follow-up, and were less likely to have concurrent FMD. 86 In a recent literature review of 120 pregnancy-associated SCAD cases by Havakuk et al, 96 73% of women were postpartum and 76% presented with ST-segment–elevation MI. Maternal complications were common: cardiogenic shock in 24%, ventricular fibrillation requiring defibrillation in 16%, mechanical support in 28%, and an in-hospital mortality rate of 4%.…”

“…86,96 Management of SCAD in the pregnant or peripartum patient requires a multidisciplinary team approach 195,196 from cardiology and obstetric services that incorporates management for the mother in combination with considerations for fetal well-being. Recommendations for pregnancy follow-up and delivery after SCAD have been reviewed elsewhere and depend on both maternal and fetal status with the goals of limiting maternal hemodynamic demand and close fetal monitoring.…”

“…One of the 8 patients experienced recurrent SCAD after delivery, presenting with ST-segment–elevation MI and ultimately requiring CABG because of unsuccessful PCI. 242 Given the potential risk of recurrent SCAD in a subsequent pregnancy and the accumulating evidence that pregnancy-associated SCAD can result in worse outcomes, 85,90,96 clinicians should carefully counsel any patient contemplating pregnancy of the potential risk. Included in the consideration are risks associated with medication use, functional status, and concomitant myocardial or valvular dysfunction.…”

Mode of Delivery for a Term Patient with Spontaneous Coronary Artery Dissection

“…There appears to be a consensus in the literature that conservative medical management is the most appropriate mode of treatment for clinically stable patients 4,[11][12][13]17 . In contrast to this, there is very little data on the best mode of delivery for patients who have suffered from SCAD during the pregnancy.…”

Ischaemic heart disease and pregnancy

“…Registry data have shown SCAD disproportionately affects younger women9 and maybe the common mechanism for pregnancy-associated MI. In a series of 120 women with SCAD in pregnancy, Havakuk et al showed that three-quarters of women presented with ST elevation, STEMI, with almost two-thirds having an anterior infarct 10. Rarer underlying causes for AMI in pregnancy also need to be considered such as chronic inflammatory conditions like lupus, or thrombotic causes like antiphospholipid syndrome.…”