DefinePK

Abstract

Background: Spontaneous coronary artery dissection (SCAD) is the most common cause of myocardial infarction in young females, especially during the postpartum period. Medical management is preferred for hemodynamically stable patients as most cases tend to heal over time. However, the decision to pursue revascularization in postpartum SCAD (P-SCAD) presents a clinical dilemma. We present a challenging case that required intervention based on one of the established indications.
Case: A 37-year-old female, Gravida 2 Para 2, presented 8 days after childbirth with postpartum preeclampsia. During hospitalization, she began experiencing chest pain, and EKG revealed anterior ST elevation myocardial infarction. Diagnostic angiography confirmed type II SCAD with total occlusion of the proximal left anterior descending artery (LAD), an Ejection Fraction (EF) of 25%, and anteroapical myocardial hypokinesis. Given her risk factors, a decision was made to treat her conservatively. However, eight hours after admission, she experienced sustained ventricular fibrillation. She was resuscitated and cardioverted back to sinus rhythm. She was emergently taken to the cath lab, and two drug-eluting stents (2.2512, 2.2530) were placed in proximal LAD with good distal flow. She was discharged in stable condition. Five days after discharge, the patient returned with chest pain. An angiogram revealed patent LAD stents with TIMI Grade III distal flow and significant distal LAD spasm, which was treated with nitrates. Her EF was 35%, and she was placed on a LifeVest and treated with guideline-based medical therapy. Forty days later, a repeat LV gram showed her EF had improved to 45%, and the LifeVest was removed. She continues to remain stable.
Conclusion: Revascularization in P-SCAD should be considered for patients with hemodynamic instability, total occlusion of the left main coronary artery or the proximal LAD, cardiogenic shock, sustained ventricular arrhythmia, or those with ongoing ischemia despite medical management.