Pregnancy-associated Spontaneous Coronary Artery Dissection Research Articles

Spontaneous Coronary Artery Dissection Outcomes Among Pregnant Versus Non-Pregnant Women.

Abstract Aims Spontaneous coronary artery dissection (SCAD) has become increasingly recognized. It accounts for <1-4% of acute coronary syndrome presentations. Overall, however, it makes up over 40% of pregnancy-associated myocardial infarction. Furthermore, pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is described to have a greater degree of clinical manifestations, including left ventricular dysfunction, shock, and left main or multivessel involvement. The findings are disconcerting, though many studies evaluating P-SCAD are based on case series data or are single centre studies. Methods and results The aim of this study was to evaluate a larger national dataset to evaluate the outcomes of SCAD and specifically P-SCAD in an attempt to better characterize the severity and clinical nature of this condition. To conduct this study, we analysed the National Readmission Database from January 2016 to December 2020. Propensity matching was done using the Greedy 1:1 method. Multivariate logistics and time-to-event Cox regression analysis models were built by including all confounders significantly associated with the outcome on univariable analysis with a cut-off P-value of 0.2. In multivariate regression analysis, P-SCAD patients had a non-propensity matched odds ratio (OR) of 0.21 (0.3-1.54, P = 0.123) of dying and a propensity matched OR of 0.11 (0.02-0.61, P = 0.012) of dying. Thirty-day readmission rate for P-SCAD was 15.8% (n = 93) and for non-pregnant spontaneous coronary artery dissection (NP-SCAD) was 11.2% (n = 2286); non-propensity matched OR for readmission for PSCAD patients was 1.68 (1.24-2.29, P = 0.001) and propensity matched OR was 3.39 (1.93-5.97, P < 0.001). Conclusion Among hospitalized patient, P–SCAD was associated with similar clinical outcomes and reduced incidence of death when compared with NP–SCAD, though had higher rates of 30–day readmission. Larger–scale observational data will be needed to ascertain the true incidence of cardiovascular complications as it relates to P–SCAD.

Concurrent spontaneous coronary dissection and reversible cerebral vasoconstriction syndrome during postnatal care.

Pregnancy-associated spontaneous coronary artery dissection (SCAD) and reversible cerebral vasoconstriction syndrome (RCVS) are rare conditions that may occur during pregnancy and the postpartum period. The coexistence of both diseases may pose a risk to patients, potentially resulting in a variety of complications and clinical manifestations. This is considered the first case of a patient who successfully recovered from a critical condition in the postpartum period, with contemporaneous SCAD and RCVS. A 33-year-old female with no known medical history was referred to the emergency department after experiencing cardiac arrest, which occurred 1 week after giving birth to her third child. She complained of sudden anterior squeezing chest pain, accompanied by a headache, and eventually collapsed due to ventricular fibrillation with seizure. She was successfully resuscitated after receiving basic life support. She showed an alert mentality and did not experience any further seizure events or additional neurological symptoms. Although vital sign remained stable, the level of highly sensitive troponin I was significantly elevated. Electrocardiography revealed sinus rhythm with T-wave inversion at V1-4, while chest computed tomography (CT) demonstrated severe aspiration pneumonia. The patient was admitted to the intensive care unit due to a high requirement of O2 supply. A consultation with the neurologic department and a brain magnetic resonance angiography (MRA) were conducted for the thunderclap headache. The brain MRA demonstrated stenosis in the basilar artery, the right M2 segment, and bilateral A1 segments, along with sulcal hyperintensity on post-contrast fluid-attenuated inversion recovery (FLAIR) suggesting blood-brain barrier breakdown due to vasoconstriction. Formal echocardiography showed regional wall motion abnormality in the left anterior descending artery (LAD) territory. After the improvement of pneumonia, a coronary angiography was performed, revealing diffuse luminal narrowing from the mid to distal LAD due to a long segmental, extensive dissection. We decided to maintain the medical therapy. A follow-up coronary CT angiography performed 6months later revealed complete remission of the dissected coronary vessel, and a brain MRA checked 3months later showed resolved vasoconstriction of the relevant cerebral vessels. The physicians must be aware of pregnancy-associated complications in certain patients. Clear diagnoses and proper treatments are required in pregnant patients who may be exposed to multiple acute conditions, in order to reduce complications and achieve favorable outcomes.

Spontaneous Coronary Artery Dissection (SCAD) from an Interventionalist Perspective.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome (ACS), particularly among women < 50years of age. Here, we aim to review the pathogenesis of SCAD, discuss SCAD as an initial manifestation of systemic arterial disease, and highlight invasive strategies as well as unique challenges in the care of women with SCAD. A paradigm shift has occurred in the care of SCAD patients in the past decade as recommendations for conservative management have become widespread. Invasive interventions are reserved for patients with hemodynamic compromise or active ischemia due to increased periprocedural complications and failure rates. Certain patient populations have been identified for larger territory infarcts and proximal disease including patients with known connective tissue disease, premenopausal women, and patients with pregnancy-associated SCAD (P-SCAD). Current recommended management of SCAD is conservative. Despite a growing awareness of SCAD and its known association with systemic arteriopathies in women, evidence-based data remains scarce. Future studies focused on identifying genetic factors, optimal medical therapy after SCAD, and techniques to minimize interventional complications are needed.

The role of coronary computed tomography angiography in pregnancy-associated myocardial infarction

Pregnancy-associated coronary artery dissection is one of the critical causes of myocardial infarction in young females. The challenges in the diagnosis and follow-up of pregnancy-associated myocardial infarction prompted us to highlight the potential role of coronary computed angiography in managing this life-threatening medical condition. We describe a case of a 29-year-old female with sudden onset chest discomfort one-week postpartum. She presented to the hospital with an ST-elevation myocardial infarction and was urgently taken to the cath lab for PCI and stent placement. Thirteen months later, with intermittent chest discomfort, an coronary computed tomography was done, demonstrating evidence of SCAD and aneurysm formation in the left main coronary artery and left circumflex coronary artery. Repeat cardiac catheterization confirmed the same diagnosis. Given her refractory chest discomfort and the chance of aneurysm rupture decision was made to proceed with a three-vessel CABG. At 3-month and 1-year followup visits, the patient is doing well and remains pain-free. In this case presentation, we aim to highlight the potential role of Coronary Computed tomography angiography in the diagnosis and follow-up of pregnancy-associated spontaneous coronary artery dissection, given the high accuracy and non invasiveness of this diagnostic modality in the context of the high prevalence of spontaneous coronary artery dissection in symptomatic or asymptomatic pregnancy-associated myocardial infarction.

Management of spontaneous coronary artery dissection: Trends over time.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome. Guidance regarding the optimal management of patients with SCAD has been published over the past 10 years, but the impact on clinical practice has not been evaluated. The present study aims to examine if approaches to invasive management, medical therapy, and vascular imaging have changed over time. This is a retrospective cohort study of 157 patients treated for SCAD between 2005 and 2019 at an academic health system in Philadelphia, Pennsylvania. We aimed to examine change in management over time, including rates of coronary revascularization, discharge medications, and vascular imaging. Conservative management of SCAD increased over time from 35% before 2013 to 89% in 2019, p < 0.001. Revascularization was associated with younger age, pregnancy-associated SCAD, and lesions of the left main artery, left anterior descending artery, and multiple vessels, p < 0.05 for all. Partial imaging for extracoronary vascular abnormalities ranged from 33% before 2013 to 71% in 2018, p = 0.146. The rate of comprehensive vascular imaging (cross-sectional head to pelvis imaging) remained low in all time categories (10-18%) and did not change over time. Patients who underwent comprehensive imaging were more likely to be diagnosed with fibromuscular dysplasia (FMD) compared to those with partial imaging (63% vs 15%, p < 0.001). Management of spontaneous coronary artery dissection has changed over time. More patients are being managed conservatively and undergo screening for extracoronary vascular abnormalities such as FMD. Future efforts should focus on improving rates of comprehensive vascular screening.

Pregnancy-Associated Spontaneous Coronary Artery Dissection: A Case Report and the Lessons from Practice

Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is one of the fatal conditions that most commonly causes pregnancy-associated myocardial infarction. We herein report a case of P-SCAD in a 26-year-old multigravida woman, who complained of angina postpartum with raised cardiac biomarkers and transient ST-segment elevation on electrocardiograms. We emphasize the importance of a high degree of suspicion in the diagnosis of P-SCAD, together with the common presentation, the management approach, and its psychological impacts on the patients.

Abstract 12376: Coronary Artery Bypass Graft Surgery in Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome. While most patients are managed conservatively, some patients may require percutaneous or surgical revascularization. Limited data exist on SCAD patients referred for coronary artery bypass graft (CABG) surgery. Hypothesis: Examine the clinical characteristics, management, and outcomes of SCAD patients referred for CABG. Methods: Retrospective study of patients enrolled in the Mayo Clinic SCAD Registry between 2010-2020 who underwent CABG during the initial management of acute SCAD episode. Results: Among the 81 patients with SCAD referred for CABG, 3 (4%) were men, mean age was 40.6 +/- 8.4 years; the majority were white (91%), and 24 (30%) had pregnancy-associated SCAD (P-SCAD). The most common presenting symptom was chest pain 80 (99%); 57 (70%) presented with ST elevation myocardial infarction (STEMI), and 21 (26%) presented with non-ST elevation MI. Multivessel dissection occurred in 40 (49%), left anterior descending artery (LAD) involvement occurred in 66 (81%) and left main (LM) in 32 (40%). Left ventricular ejection fraction was &lt;50% in 40 patients (49%) at time of initial SCAD. The most common reasons for CABG were the presence of high-risk anatomy (56%), hemodynamic instability/active ischemia (7%), failed PCI (9%), and other/unknown (12%). Most patients received venous plus arterial bypass grafts 42 (52%), saphenous vein grafts in 20 (25%), and left internal mammary artery in 17 (21%). Screening for underlying arteriopathy was performed in 50 (62%) of whom 29 (36%) had fibromuscular dysplasia. Recurrent SCAD occurred in 10 (12%) after an average of 6.2 +/- 5 years after initial SCAD. Of those with recurrent SCAD, none required repeat surgical revascularization and 6 required percutaneous intervention (PCI). There were no deaths. Conclusions: Patients undergoing CABG for SCAD commonly present with STEMI, LM, or multivessel dissection, and failed percutaneous intervention attempts. In addition, CABG for P-SCAD was more frequent than expected and may relate to the increased prevalence of multivessel dissection. CABG was associated with low mortality, but recurrent SCAD may still occur.

Implantable cardioverter-defibrillator in patients with spontaneous coronary artery dissection presenting with sudden cardiac arrest.

The role of secondary prevention implantable cardioverter-defibrillator (ICD) remains uncertain in spontaneous coronary artery dissection (SCAD) patients presenting with sudden cardiac arrest (SCA). We aimed at assessing the outcomes following SCA and the role of ICD therapy in SCAD. The meta-analysis was performed using a meta-package for R version 4.0/RStudio version 1.2 and the Freeman-Tukey double arcsine method to establish the variance of raw proportions. Outcomes measured included-(1) incidence of ICD implantation, (2) appropriate and inappropriate ICD therapy, (3) recurrence of SCAD and SCA, and (4) all-cause mortality. Five studies, including 139 SCAD patients with SCA met study inclusion criteria. The mean age was 47.3 ± 12.8 years, mean left ventricular ejection fraction 43.8 ± 10.8%, 88% were female (12% had pregnancy-associated SCAD. Causes of SCA included ventricular arrhythmia (97.9%, n = 136) and pulseless electrical activity (2.1%, n = 3). Overall, 20% patients (95% confidence interval [CI]: 7.1%-36.6%, I2 = 68%) received ICD, of which 1.2% (95% CI: 0%-15.8%, I2 = 0%) and 1% (95% CI: 0%-15.3%, I2 = 0%) patients received appropriate and inappropriate ICD therapies, respectively, during follow-up period (4.1 ± 3.3 years). Incidence of recurrent SCAD was 9% (95% CI: 2.85%-17.5%, I2 = 25%), and recurrent SCA was 3.85% patients (95% CI: 0.65%-8.7%, I2 = 0%; one patient with appropriate ICD therapy). The pooled incidence of all-cause mortality was 6.2% (95% CI: 0.6%-15.1%, I2 = 44%). Although ICD therapy is beneficial in patients (all comers) presenting with cardiac arrest; the risk-benefit ratio of secondary prevention ICD arrest remains unclear. Patient-centered shared decision-making and risk-benefit ratio assessment should be performed before consideration for ICD implantation.

Pregnancy After Spontaneous Coronary Artery Dissection (SCAD): a 2020 Update

Spontaneous coronary artery dissection (SCAD) is a disease which affects a predominantly female and relatively young population, some of whom have not yet completed their reproductive lives. SCAD has traditionally been considered a contraindication to future pregnancy due to concerns about the risk of recurrence and the high-risk phenotype associated with pregnancy-associated SCAD (P-SCAD). This review summarizes recent advancements in the understanding of pregnancy and reproductive health after SCAD. Although traditionally under-recognized and underdiagnosed, the importance of SCAD as a unique clinical entity is now recognized in a growing number of expert guidelines and consensus documents which provide advice on the management of pregnancy. Recent data, although insufficient to alter current management recommendations, offers hope that the recurrence rate in subsequent pregnancies may be lower than previously believed. Pregnancy and reproductive health for women after SCAD is a complex area with relatively limited data to guide management decisions. At present, there is insufficient data to challenge the traditional assumption that subsequent pregnancy should be avoided. Where pregnancy is pursued, thoughtful multidisciplinary management in expert women’s heart health centres is vital. Going forward, increased experience in the management of all aspects of reproductive health in these women will hopefully provide data to allow more accurate understanding of risks and optimal management in this population.

Association of Pregnancy With Recurrence of Spontaneous Coronary Artery Dissection Among Women With Prior Coronary Artery Dissection

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.

The pregnancy-associated spontaneous coronary artery dissection in a young woman with a novel missense mutation in NOTCH1: a case report

BackgroundSpontaneous coronary artery dissection (SCAD) is frequently reported as a disorder that primarily affects women without risk factors for cardiovascular disease. Although it has been recognized as one of the genetically mediated vascular disorders, the genetic pathogenesis of SCAD remains obscure to date.Case presentationIn this report, we presented a rare case of pregnancy-associated SCAD in a young woman that occurred in multiple coronary arteries within a short period. The initial conservative management and then intravascular ultrasound-guided primary percutaneous coronary intervention (PCI) were adopted to achieve optimal results of revascularization in affected coronary arteries and avoid potential risks for PCI-associated complications. We further performed the whole-exome sequencing and Sanger sequencing and, for the first time, reported a novel heterozygous missense variant, c.4574 C > T (p.Arg1438Cys), in the NOTCH1 gene. This variant has never been documented in the medical literature and was predicted as being potentially damaging or disease-causing variant.ConclusionsWe described a rare case of recurrent SCAD in a young woman after baby delivery. The initial conservative management and PCI with multiple stent implantations were successfully implemented to achieve optimal results of revascularization in coronary arteries. We, for the first time, identified a novel missense variant in the NOTCH1 gene, which appears to be a potential predisposing factor for artery fragility.

Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy.

Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.

Characteristics and outcomes of patients with spontaneous coronary artery dissection who suffered sudden cardiac arrest.

Spontaneous coronary artery dissection (SCAD) can cause life-threatening ventricular arrhythmias, but the characteristics and outcomes of this population are not well characterized. We sought to determine the characteristics and outcomes of patients with SCAD who suffered sudden cardiac arrest, whether treated with or without an implantable cardioverter-defibrillator (ICD). Retrospective cohort study of patients diagnosed with SCAD between 2006 and 2016. Eleven of 208 SCAD patients suffered sudden cardiac arrest (5.3%). Those who suffered cardiac arrest were more likely to have pregnancy-associated SCAD (27.3% vs 7.1%, p = 0.018). They were more likely to have left main (18.2% vs 1.0%, p = 0.01) or proximal coronary vessel involvement (36.4% vs 8.1%, p = 0.002), and with left ventricular ejection fraction of < 50% (45.5% vs 13.2%, p = 0.013). Percutaneous coronary intervention was more commonly performed in patients who suffered cardiac arrest (54.6% vs 8.6%, p < 0.001). Left main or proximal LAD involvement increased the odds of cardiac arrest by over 6-fold (OR 6.2, 95% CI 1.2-32.9, p = 0.03). Eight of the 11 patients suffered VT/VF arrest, of which one was treated with an ICD and one with a wearable cardioverter-defibrillator. Of these, no shocks were reported at follow-up and no ventricular arrhythmic events were reported in those not receiving defibrillator treatment. Sudden cardiac arrest in SCAD patients is associated with left main or proximal coronary lesions. Secondary prevention ICD did not show benefit in this cohort. Future larger studies are needed to determine the role of ICD therapy in SCAD patients who suffer cardiac arrest.

TO INTERVENE OR NOT: A CASE OF MULTI-VESSEL SPONTANEOUS CORONARY ARTERY DISSECTION

Spontaneous coronary artery dissection (SCAD) has been increasingly recognized as a common pathologic mechanism of acute coronary syndromes in the absence of coronary atherosclerosis and vessel trauma. Pregnancy-associated SCAD, compared to non-pregnancy associated SCAD, carries a worse prognosis.

Spontaneous Coronary Artery Dissection: an Overview.

Spontaneous coronary artery dissection (SCAD) is a non-inflammatory, non-atherosclerotic cause of acute myocardial infarction (AMI) that, by definition, is not iatrogenic or due to trauma. It is a condition that predominantly affects pre- or perimenopausal women without the traditional risk factors for cardiovascular disease. PURPOSE OF REVIEW: In this review, we will discuss the epidemiology, diagnosis, and management of this condition, with an emphasis on the ongoing research needed to better understand how to care for patients with SCAD. RECENT FINDINGS: There is a paucity of data related to this condition. However, an American Heart Association consensus statement has recently been released that provides helpful insight. There has also been better characterization of pregnancy-associated SCAD. We have learned much about SCAD over the last decade and greatly increased the identification of this condition by first responders and physicians through research and patient advocacy. However, there is much we still do not know about this condition, and further research, using larger numbers of patients, is greatly needed to better understand this condition.

Evolving management and improving outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD): a systematic review

BackgroundPregnancy-associated spontaneous coronary artery dissection (P-SCAD) is defined as SCAD occurring during pregnancy or within 3months 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. MethodsCase 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. ResultsThe only significant demographic change in women experiencing P-SCAD over the last 50years was an increasing proportion of primigravidas (p=0.02). Management and outcomes, however, have altered significantly. Emergent angiography (p<0.0001), reduced thrombolysis (p=0.006) and increasingly conservative or percutaneous management (p<0.0001) are associated with dramatic reductions in maternal mortality (85% in earliest reports to 4% in the last decade, p<0.0001) and foetal mortality (50% in earliest reports to 0.0% in the last decade, p=0.023). ConclusionThis 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.

Spontaneous Coronary Artery Dissection and Pregnancy.

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic, non-traumatic cause of coronary artery dissection. SCAD is the most common cause of myocardial infarction in pregnancy or the postpartum period and results in significant cardiovascular morbidity and mortality in the pregnant population. It is important to consider pregnancy-associated spontaneous coronary artery dissection (PASCAD) high on the differential for a pregnant woman who presents with symptoms consistent with acute coronary syndrome. Management of these patients requires a thoughtful, multidisciplinary approach, with consideration of conservative management if possible. Counseling regarding future pregnancies is also critical and requires compassionate care. Given our limited understanding of SCAD, including PASCAD, more data and research are needed to help guide diagnosis, management, and determination of prognosis.

Spontaneous Coronary Artery Dissection Associated With Pregnancy

BackgroundSpontaneous coronary artery dissection (SCAD) is the most common cause of pregnancy-associated myocardial infarction and remains poorly characterized. ObjectivesThis study sought to assess presentation, clinical factors, and outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD) compared with spontaneous coronary artery dissection not associated with pregnancy (NP-SCAD). MethodsA Mayo Clinic registry was established in 2010 to include comprehensive retrospective and prospective SCAD data. Records were reviewed to identify women who were pregnant or ≤12 weeks postpartum at time of SCAD. Complete records were available for 323 women; 54 women met criteria for P-SCAD (4 during pregnancy) and they were compared with 269 women with NP-SCAD. ResultsMost events occurred within the first month postpartum (35 of 50). Compared with NP-SCAD, P-SCAD patients more frequently presented with ST-segment elevation myocardial infarction (57% vs. 36%; p = 0.009), left main or multivessel SCAD (24% vs. 5%; p < 0.0001; and 33% vs. 14%; p = 0.0027, respectively), and left ventricular function ≤35% (26% vs. 10%; p = 0.0071). Among women with imaging of other vascular territories, P-SCAD was less likely with a diagnosis of fibromuscular dysplasia and extracoronary vascular abnormalities (42% vs. 64%; p = 0.047; and 46% vs. 77%; p = 0.0032, respectively). Compared with U.S. birth data, women with P-SCAD were more often multiparous (p = 0.0167), had a history of infertility therapies (p = 0.0004), and had pre-eclampsia (p = 0.001). On long-term follow-up (median 2.3 years) recurrent SCAD occurred in 51 patients, with no difference in the Kaplan Meier 5-year recurrence rates (10% vs. 23%; p = 0.18). ConclusionsP-SCAD patients had more acute presentations and high-risk features than women with NP-SCAD did. The highest frequency of P-SCAD occurred during the first postpartum month and P-SCAD patients less often had extracoronary vascular abnormalities. Hormonal, hemodynamic variations, and yet-undefined mechanisms might be significant contributors to P-SCAD. (The “Virtual” Multicenter Spontaneous Coronary Artery Dissection [SCAD] Registry [SCAD]; NCT01429727; Genetic Investigations in Spontaneous Coronary Artery Dissection [SCAD]; NCT01427179)

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases.

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. 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. 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 life-threatening 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.

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

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 fetal mortality rate. Aim: We undertook a structured systematic review of P-SCAD demographics, management and maternal and fetal 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 = 0.03). Management and outcomes, however, have altered significantly. Emergent angiography (p < 0.0001), reduced thrombolysis (p = 0.006) and increasingly conservative or percutaneous management (p < 0.0001) are associated with dramatic reductions in maternal mortality (85% in earliest reports to 4% in the last decade, p < 0.0001) and fetal 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 fetal survival rates continue to improve.