Pregnancy-Related Spontaneous Coronary Artery Dissection

Vijayaraghavan, Ram; Verma, Subodh; Gupta, Nandini; Saw, Jacqueline

doi:10.1161/circulationaha.114.011422

Cited by 145 publications

(134 citation statements)

References 20 publications

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“…Successful procedure was reported in only half of the patients, and there was a high incidence of propagation of the dissection, often leading to CABG surgery or repeat PCI during follow-up for recurrent ischemic symptoms. The risk of coronary interventions during pregnancy or the postpartum period is further emphasized by previous reports by our group and others 5,87,115 of iatrogenic coronary dissection as a result of intracoronary contrast injection or guidewire manipulations leading to severe complications including urgent CABG surgery, severe heart failure with ventricular assist device implantation, and mortality.…”

Section: Percutaneous Interventionmentioning

confidence: 87%

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection

Havakuk

Goland

Mehra

et al. 2017

Circ: Cardiovascular Interventions

145

153

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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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Section: Percutaneous Interventionmentioning

confidence: 87%

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection

Havakuk

Goland

Mehra

et al. 2017

Circ: Cardiovascular Interventions

145

153

View full text Add to dashboard Cite

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“…In their review, Vijayaraghavan recommend optimal medical therapy for all P-SCAD patients in the first instance unless there is left main dissection, ongoing chest pain, electrocardiographic evidence of ischaemia, ventricular arrhythmias or haemodynamic instability. In these patients, PCI should be performed where feasible, with CABGs reserved for patients with left main or multi-vessel dissection [99]. We suggest (Table 4) a standardized approach to assessment and emergent management of P-SCAD patients in the cardiac catheterization laboratory, based upon our review of the literature and personal clinical experience [55,82,86].…”

Section: Management and Outcomesmentioning

confidence: 99%

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

Paratz

Kao

MacIsaac

et al. 2017

Heart, Lung and Circulation

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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...

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“…Fibromuscular dysplasia (FMD) is an inflammatory non-atherosclerotic vascular disease strongly associated with SCAD and should be always investigated [13][14][15][16]. Pregnancy is also considered a condition predisposing to SCAD; this association may be due to the drastic hemodynamic changes and the increase of several hormone levels [17,18]. In particular, progesterone levels elevation alters the fibro-elastic composition and collagen production of the vascular wall, while the increase of estrogen drives a pro-thrombotic state [19,20].…”

Section: Pathogenesismentioning

confidence: 99%

How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

Pepe¹,

Cecere²,

Napodano³

et al. 2017

Interv Cardiol J

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AbstarctSpontaneous coronary artery dissection (SCAD) is a separation of the coronary wall layers, not related to trauma, medical procedures or atherosclerosis. The dissection causes the blood entry in the vascular wall with the consequent formation of a false lumen and intramural hematoma (IMH). Two pathogenetic mechanisms have been proposed to explain SCAD: a "primary" rupture of coronary endothelium or the rupture of the "vasa vasorum". Clinical presentation and severity of manifestations are variable, ranging from complete absence of symptoms to acute coronary syndrome (ACS), cardiogenic shock, cardiac arrest or sudden cardiac death. Despite coronary angiography is the first-line examination, by supplying two-dimensional images of the lumen, it does not always allow an incontrovertible diagnosis of SCAD. New intravascular imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS), have been recently introduced and may be extremely helpful in assessing the coronary wall integrity, thus improving coronary angiography diagnostic accuracy.Because of the lack of large randomized trials comparing different strategies, the optimal treatment of SCAD is still controversial. The first-line approach is conservative and based on medical therapy. Nevertheless, in particular situations an invasive approach is necessary. In the last years, several new strategies have improved the way to perform percutaneous coronary interventions (PCI), such as new generation drug eluting stents (DES), bio-resorbable scaffolds (BRS), sirolimus self-expandable stent (SES), drug eluting balloons (DEB), and cutting balloon. Cardiac artery bypass graft (CABG) is an even more invasive method to restore coronary flow and should be considered in urgent/emergent settings when PCI is not feasible or has failed.Cause the therapeutic approach of SCAD can be substantially different from that of atherosclerotic coronary artery disease, an accurate diagnosis is crucial to set up the best treatment strategy.

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Pregnancy-Related Spontaneous Coronary Artery Dissection

Cited by 145 publications

References 20 publications

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection

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

How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

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