i An update to this article is included at the end

Spontaneous coronary artery dissection i”>American Journal of Emergency Medicine (2010) 28, 641.e5-641.e7

Case Report

Spontaneous coronary artery dissection in a Postpartum woman presenting with chest pain

Abstract

Pregnancy-associated spontaneous coronary artery dis- section is a rare but potentially lethal condition presenting as acute coronary syndrome. Forty percent of patients die suddenly or within a few hours of symptom onset. Survivors of the acute phase who subsequently receive proper diagnosis and treatment usually have good prognosis. Proposed etiologies include altered endocrine status, hemodynamic stress, eosinophilic Inflammatory infiltrate, and disruption of vasa vasorum. Definitive diagnosis is made by coronary angiography. Treatment has not been well defined. Strategies include medical management, stenting, and Coronary artery bypass grafting. We report a case of a 32-year-old woman, less than a week postpartum, who developed spontaneous multivessel coronary dissection involving left anterior descending artery and the right coronary artery, leading to Severe systolic dysfunction. She underwent surgical revascu- larization resulting in recovery of the left ventricular function.

A 32-year-old woman, gravida 2 para 2, presented to the emergency department (ED) complaining of chest pain. Five days previously, she underwent uncomplicated cesarean section after a normal Intrauterine pregnancy. Soon after discharge, she developed substernal chest pain, radiating to both arms, which was exacerbated by exertion. On the morning of her presentation, the chest pain became more severe, unrelenting, and associated with shortness of breath, nausea, vomiting, and diaphoresis. She contacted her primary physician and was advised to come to ED.

Upon arrival to the ED, the patent’s pain was relieved with a single dose of sublingual nitroglycerin. Her history did not reveal any significant risk factors for coronary disease. She was mildly overweight. Vital signs included a temperature of 38.3?C, blood pressure of 135/76 mm Hg, heart rate of 60 beats/min, and oxygen saturation of 94% on room air. There was no jugular venous distension. Lungs were clear to auscultation. Cardiac examination revealed normal S1 and S2, and no murmurs, rubs, or gallops. Distal

pulses were equal bilaterally. Abdomen was benign. There was 1 + Pitting edema of both lower extremities.

Initial electrocardiogram did not show ST-segment abnormalities diagnostic of ischemia (Fig. 1). Chest x-ray showed mild bilateral prominence of interstitial markings with slight enlargement of the cardiac silhouette. A computed tomography angiography demonstrated no pulmonary embo- lus. Initial laboratory tests were significant for elevated levels of troponin T at 0.37 ng/mL, creatine kinase at 583 U/L, and creatine kinase-MB at 22.3 ng/mL. A bedside echocardio- gram revealed akinesis of interventricular septum and apex as well as ejection fraction of 45%.

The patient was not taken emergently to the catheteriza- tion laboratory because there was no evidence to support ST- elevation myocardial infarction and her symptoms had resolved. She was started on aspirin, enoxaparin, metoprolol, atorvastatin, and topical nitroglycerin and admitted to Coronary intensive care unit. Subsequent cardiac catheteriza- tion revealed Spontaneous dissection of the proximal left anterior descending artery (LAD), extending into the first diagonal branch and distally (Fig. 2). There was a 99% stenosis of the true lumen of the mid LAD caused by external compression by the hematoma in the false lumen. The dominant right coronary artery appeared angiogra- phically normal; however, there was abrupt ending of distal part of the right posterior descending artery, consistent with spontaneous dissection in that vessel. Faint left-to-right collaterals were observed. The left circumflex artery was angiographically normal. Left ventriculography showed moderately dilated cavity with anterior, apical, and inferior hypokinesis. The left ventricular ejection fraction was 25%. intra-aortic balloon pump was placed in the hope of improving Coronary blood flow. The patient remained asymptomatic and was continued to be managed medically. coronary angiogram, performed 48 hours later, showed persistent dissection of the LAD and extensive dissection of the RCA (Fig. 3). The electrocardiogram demonstrated new

inferior Q waves.

In view of a multivessel dissection and high risk of Hemodynamic compromise, the patient underwent quadruple coronary artery bypass grafting. Her postoperative course was uncomplicated. She was discharged home on post- operative day 3. Follow-up echocardiogram 3 weeks later

0735-6757/$ - see front matter (C) 2010

641.e6 Case Report

Fig. 1 Initial electrocardiogram revealed sinus rhythm, normal QRS axis and voltage, no ST-segment or T-wave abnormalities diagnostic of ischemia, and no Pathologic Q waves.

demonstrated ejection fraction of 50%, and an exercise stress with myocardial perfusion imaging revealed normal perfu- sion. She has since returned to work.

Eighty percent of all spontaneous coronary artery dissections (SCADs) occur in women [1]. A third of these

Fig. 2 Initial coronary angiogram. There is a dissection flap (white arrow) in the LAD with compression of the true lumen of the vessel distal to the origin of the first diagonal branch (black arrow). LM indicates left main coronary artery; LCX, left circumflex artery; D1, first diagonal branch.

occur in pregnancy or postpartum period. A little over a hundred cases have been reported. Most occur postpartum, usually within 2 weeks after delivery [2,3]. Older age and multiparity seem to be risk factors. Proposed etiologies include altered endocrine status, hemodynamic stress, eosinophilic inflammatory infiltrate, and disruption of vasa vasorum. No clear association with coronary artery disease

Fig. 3 Repeat coronary angiogram. There is extensive dissection of the RCA. Dissection flaps are seen in the RCA (white arrows), as well as in the acute marginal branch (black arrow).

Case Report 641.e7

risk factors has been found. Forty percent of pregnancy- associated SCAD cases present with sudden death or die within a few hours of onset of symptoms. Survivors of the acute phase who subsequently receive proper diagnosis and treatment usually have good prognosis [2]. Patients generally present with acute coronary syndrome. Electro- cardiogram often shows evidence of ST-elevation or non- ST-elevation myocardial infarction; however, in some cases, such as ours, it may initially be normal. Cardiac biomarkers may be elevated. Definitive diagnosis is made by coronary angiography.

Management of pregnancy-associated dissections has not been well defined. Stable patients with single-vessel dissection, without progression or hemodynamic compro- mise, and without left main coronary artery involvement or otherwise large area of myocardium in jeopardy could be managed medically [2]. Many of these heal spontaneously. Although no specific medical regimen exists, aspirin, clopidogrel, heparin, ?-blockers, and angiotensin-convert- ing enzyme inhibitors have been used [2-4]. Thrombolytics may cause progression of intramedial hemorrhage, exten- sion of dissection, and further compression of the true lumen [4]. Percutaneous coronary intervention with stenting has been used successfully in selected cases. Coronary artery bypass grafting is usually indicated for patients with left main coronary artery involvement, multivessel dissections, failed medical or percutaneous therapy and evolving dissections with significant hemody- namic compromise [2,3]. In pregnant patients, simulta- neous cesarean section and coronary artery bypass grafting have been performed [5]. cardiac transplantation has successfully been performed in a few cases with severe left ventricular dysfunction [6,7].

Our case illustrates 2 important points. First is that the initial electrocardiogram in patients presenting with peripar- tum SCAD may be normal or nonspecific. Second is that despite initial severe reduction in left ventricular function, a nearly Complete recovery is possible after revascularization. It is important to suspect SCAD in any young female without significant risk factors for coronary artery disease who presents with symptoms of acute coronary syndrome, especially if the woman is postpartum or pregnant. Rapid

diagnosis and proper treatment is essential to avoid disaster and achieve excellent outcome.

Leo Marcoff MD Andra Popescu MD Gilbert A. Leidig MD Anthony W. Clay DO John J. Kelly MD Ehsanur Rahman MD Section of cardiology department of Medicine

Christiana Care Health System Newark, DE 19718, USA

E-mail address: [email protected]

Letitia Price MD Department of Medicine Temple University Hospital Philadelphia, PA 19140, USA

doi:10.1016/j.ajem.2009.09.005

References

1. Rogers IS, Rinaldi MJ, Humphrey CB, et al. Postpartum dissection of the left main coronary artery. Clin Cardiol 2006;29(4):175-8.
2. Koul AK, Hollander G, Moskovits N, et al. Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature. Catheter Cardiovasc Interv 2001;52(1):88-94.
3. Maeder M, Ammann P, Drack G, et al. Pregnancy-associated spontaneous coronary artery dissection: impact of medical treatment. Case report and systematic review. Z Kardiol 2005;94(12):829-35.
4. Mohamed HA, Eshawesh A, Habib N. Spontaneous coronary artery dissection-a case report and review of the literature. Angiology 2002;53(2):205-11.
5. Sherif HM, Nguyen HC, Sarter BH, et al. Spontaneous coronary dissection in late pregnancy: a multidisciplinary approach to manage- ment. Ann Thorac Surg 2008;85(5):1793-4.
6. Curiel P, Spinelli G, Petrella A, et al. Postpartum coronary artery dissection followed by Heart transplantation. Am J Obstet Gynecol 1990;163(2):538-9.
7. Paez M, Buisan F, Herrero E. Spontaneous dissection of the left coronary artery trunk during the postpartum period treated with revascularization surgery, ventricular assistance and a successful heart transplant. Acta Anaesthesiol Scand 2007;51(7):960-1.

Update

American Journal of Emergency Medicine

Volume 28, Issue 8, October 2010, Page 980-981

DOI: https://doi.org/10.1016/j.ajem.2010.07.011

American Journal of Emergency Medicine (2010) 28, 980-981

Errata

In the article “Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy” in the

American Journal of Emergency Medicine 2010;28(3):389.e3-389.e5, there was an error in the byline. The Correct byline is: Baptiste Valle MD

Philippe Frontin MD Vincent Bounes MD Sandrine Charpentier MD

SAMU 31, Pole de Medecine d’Urgence Hopitaux Universitaires

31059 Toulouse cedex 9, France

E-mail address: [email protected]

Vincent Minville MD

Pole d’Anesthesie-Reanimation Hopitaux Universitaires

31059 Toulouse cedex 9, France

Jean-Louis Ducasse MD

SAMU 31, Pole de Medecine d’Urgence Hopitaux Universitaires

31059 Toulouse cedex 9, France

DOI of original article: 10.1016/j.ajem.2009.07.027 doi:10.1016/j.ajem.2010.07.010

In the article, “Spontaneous coronary artery dissection in a postpartum woman presenting with chest pain” Am J Emerg Med 2010; 28(5):641.e5-641.e7, there was an error in order of the byline. The correct byline is:

Leo Marcoff MD Andra Popescu MD Section of Cardiology

Department of Medicine Christiana Care Health System Newark, DE 19718

E-mail address: [email protected]

Letitia Price MD Department of Medicine Temple University Hospital Philadelphia, PA 19140

0735-6757/$ - see front matter (C) 2010

Errata 981

Gilbert A. Leidig MD Anthony W. Clay DO John J. Kelly MD Ehsanur Rahman MD Section of Cardiology Department of Medicine

Christiana Care Health System Newark, DE 19718

DOI of original article: 10.1016/j.ajem.2009.09.005 doi:10.1016/j.ajem.2010.07.011

In the article “Timely identification of bacterial pathogens may reduce inappropriate antibiotic prescription” in the American Journal of Emergency Medicine 2010;28(4):519-520, there was an error in the byline. Dr Jolobe was incorrectly listed as an MD. The correct byline is below.

Oscar M.P. Jolobe MB, ChB

DOI of original article: 10.1016/j.ajem.2010.01.022 doi:10.1016/j.ajem.2010.07.012

In the article “The differential diagnosis includes reversible cerebral vasoconstrictor syndrome” in the American Journal of Emergency Medicine 2010;28(5):637, there was an error in the byline. Dr Jolobe was incorrectly listed as an MD. The correct byline is below.

Oscar M.P. Jolobe MB, ChB

DOI of original article: 10.1016/j.ajem.2010.03.030 doi:10.1016/j.ajem.2010.07.013