Pregnancy-related Spontaneous Coronary Artery Dissection: Two Case Reports and a Comprehensive Review of Literature

Abstract

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, particularly seen in women during pregnancy or in the puerperium. It has a high acute phase mortality. The etiology is uncertain. Hormonal changes during pregnancy, hemodynamic stress and changes in the autoimmune status have been considered as possible etiological factors. A timely diagnosis and institution of appropriate treatment is important for a successful outcome. There is no consensus of opinion for optimal treatment. Conservative management, coronary artery bypass graft surgery, and percutaneous coronary intervention, all have been described in the literature as possible therapeutic options. Spontaneous coronary artery dissection should be considered as a differential in any young woman presenting with chest pain associated with pregnancy. We report two cases of pregnancy-associated spontaneous coronary artery dissection, both successfully managed, along with a comprehensive review of the previously published literature.

Keywords: Acute coronary syndrome; pregnancy-associated coronary artery dissection; pregnancy-related myocardial infarction; spontaneous coronary artery dissection.

ECG 1

ECG of case 1 showing ST elevation across the antero-lateral leads with reciprocal ST depression in the inferior leads

Figure 1

Angiography (right anterior oblique cranial projection) of the left anterior descending artery. (a) Initial angiogram demonstrating total occlusion of the proximal left anterior descending artery (arrow); (b) In the same projection as in A, after deployment of a stent in the proximal left anterior descending artery (arrow). Thrombolysis in myocardial infarction (TIMI) III flow was demonstrated. LAD – Left anterior descending artery; LCx - Left circumflex artery

ECG 2

ECG of Case 2 showing ST elevation in the antero-lateral leads.

Figure 2

Angiography of the left anterior descending artery; (a) Initial angiogram (left anterior oblique caudal projection) showing dissection of the anterior descending artery from the ostium to the first diagonal (arrow); (b) Repeat angiogram (left anterior oblique cranial projection) after one week (arrow); (c) After three months (left anterior oblique caudal projection) (arrow). LAD – Left anterior descending artery; LCx – Left circumflex artery