Abstract
Spontaneous coronary artery dissection (SCAD) is a notable cause of acute coronary syndrome in women of childbearing age. To test the hypothesis that pregnancy after SCAD is associated with recurrent SCAD. Three study designs were implemented: a case series of women with pregnancy after SCAD; a nested case-control study comparing patients with recurrent SCAD to matched controls without recurrent SCAD; and a cohort study. Women with SCAD who were of childbearing potential and enrolled into the Mayo Clinic SCAD Registry from August 30, 2011, to April 4, 2019, were included in the study. Patients with coronary dissections associated with iatrogenesis, trauma, or atherosclerosis were not enrolled. Pregnancy after SCAD. The primary outcome was SCAD recurrence, defined as an acute coronary syndrome or cardiac arrest due to new SCAD. Other demographic measures collected included age, year of SCAD occurrence, and comorbidities. The cohort included 636 women of childbearing potential. Twenty-three of those women had a total of 32 pregnancies after SCAD. The median (interquartile range) age of women with pregnancy after SCAD was 38 years (34-40 years), and 20 (87%) were White. In the nested case-control study, 92 cases of recurrent SCAD were matched to 158 controls. There was no significant difference in exposure to subsequent pregnancies in the women with recurrent SCAD as compared with matched controls (2 of 92 [2%] vs 13 of 158 [8%]; P = .06). In the overall cohort of 636 patients, recurrent SCAD was present in 122 patients with a Kaplan-Meier 5-year SCAD recurrence estimate of 14.8%. The Cox analysis showed no significant association between subsequent pregnancy and SCAD recurrence with a nonsignificant hazard ratio of 0.38 (95% CI, 0.09-1.6) when controlling for age at first SCAD, year of first SCAD, and fibromuscular dysplasia. This study found that most women tolerated pregnancy and lactation after SCAD without evidence for increased risk of SCAD recurrence when compared with women with a history of SCAD who did not experience pregnancy. Although this study is reassuring and indicates complex contributors to SCAD recurrence, the results need to be interpreted prudently because of study selection bias and the small total number of women who became pregnant after SCAD. The notable hemodynamic changes that occur with pregnancy and severe presentation of pregnancy-associated SCAD are reasons for concern when considering pregnancy after SCAD.
Highlights
The Cox analysis showed no significant association between subsequent pregnancy and Spontaneous coronary artery dissection (SCAD) recurrence with a nonsignificant hazard ratio of 0.38 when controlling for age at first SCAD, year of first SCAD, and fibromuscular dysplasia
This study found that most women tolerated pregnancy and lactation after SCAD without evidence for increased risk of SCAD recurrence when compared with women with a history of SCAD who did not experience pregnancy
Meaning This study found no evidence for increased risk of SCAD recurrence among women who became pregnant after SCAD, but results are limited by the small total number of women with normal left ventricular ejection fraction at time of subsequent pregnancy and should be interpreted with caution
Summary
Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome that occurs in women of childbearing age. It is the cause of ST-elevation myocardial infarction (MI) in 1 of 5 women younger than age 50 years and a foremost cause of heart attack among pregnant women. Acute SCAD causes MI or sudden cardiac death due to obstruction by a coronary artery wall hematoma alone or a hematoma and an intimal-medial tear. Enhanced awareness and technological improvements in the catheterization laboratory have facilitated the diagnosis of SCAD, which for some patients has been previously overlooked.More than 80% of patients with SCAD are women with a mean age of 42 to 52 years at the time of SCAD occurrence. Most patients with a history of SCAD do not have the traditional risk factors, such as tobacco use, hyperlipidemia, diabetes, or a sedentary lifestyle. Approximately one-third of patients have a history of hypertension. Most patients have abnormalities in the peripheral arteries, such as fibromuscular dysplasia (FMD), aneurysms, and dissections. Only a small proportion of patients have an inherited connective tissue disease (5%-8%) or family members with SCAD (1%). Despite the observation based on follow-up imaging that most coronary dissections heal, the morbidity of SCAD is substantial, with an estimated 30-day rate of major adverse cardiac events of 8.8%8 and 10-year estimated rate of major adverse cardiac events as high as 47%.6 Much of the long-term risk is related to SCAD recurrence, which occurs in 12% to 29% of patients. SCAD recurrence is defined as an MI or cardiac arrest due to SCAD in another, usually different, coronary artery. Risk factors for SCAD recurrence and effective prevention strategies are unknown and remain a principal concern for patients and clinicians.. Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome that occurs in women of childbearing age.. Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome that occurs in women of childbearing age.1,2 It is the cause of ST-elevation myocardial infarction (MI) in 1 of 5 women younger than age 50 years and a foremost cause of heart attack among pregnant women.. Most patients with a history of SCAD do not have the traditional risk factors, such as tobacco use, hyperlipidemia, diabetes, or a sedentary lifestyle.. Much of the long-term risk is related to SCAD recurrence, which occurs in 12% to 29% of patients.. Risk factors for SCAD recurrence and effective prevention strategies are unknown and remain a principal concern for patients and clinicians.
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