Young woman postpartum presenting with recurrent chest pain and ST elevation

Introduction: Acute coronary syndromes (ACS) in pregnant women are rare (3-6 per 100 000 deliveries) and generally related to well-established risk factors such as smoking, hypertension, dyslipidemia, older age, diabetes mellitus and family history of coronary artery disease. Most often, ACS is due to spontaneous isolated coronary artery dissection. However, with the rise in maternal age and high-risk women who become pregnant, the incidence in pregnancy-related ACS is expected to increase.
Case presentation: We present the case of a 38-year-old woman, who was referred to our Emergency Department for recurrent intense chest pain and ST segment elevation with onset at rest and of approximately 20 minutes duration. She had had a cesarean delivery a week prior to presentation and developed 3 days post-partum unstable angina treated by PCI and pharmacologically active stent implantation at the distal LAD level in another center. On admission, the EKG showed sinus rhythm and newly diagnosed ST segment elevation in the inferior leads, as well as persistent ST elevation in the anterior leads. She underwent emergent coronary angiography, which revealed diffuse stenosis in the mid-LAD, extending into the lateral branches with normal reflow the distal segment, suggestive for intimal flap dissection, and a similar aspect in the mid-RCA segment extending into the posterior descending artery (PDA). IVUS was considered, however, due to high suggestive angiographic appearance for SCAD and increased risk of dissection extension, it was not performed.
Subsequently, the patient was monitored in the co-ronary care unit, where she underwent medical treatment with DAPT (she was switched from ticagrelor to clopidogrel), ACEI, beta-blocker, with no recurrent symptoms. She was then transferred to a ward, whe-re she developed chest pain described as constrictive, partially remitted with beta-blocker and sublingual ni-troglycerin. An ECG was done and showed transient ST elevation in the inferior leads. An emergent repeat angiogram was performed, revealing dissection into the proximal segment of the RCA, for which a phar-macologically active stent implantation was performed. No complications followed post-procedurally and the patient remained symptom-free. She was discharged 5 days later.
The echocardiography revealed a left ventricular dysfunction with a 40% ejection fraction and with wall motion abnormalities described in the antero-lateral territory.
Discussion: Spontaneous coronary artery dissections are more prevalent among pregnant women than non-pregnant, with cases reported particularly around delivery and the post-partum period. From a pathophysiological standpoint, this is considered to happend secondary to high progesterone levels that alter the collagen structure within vascular walls.
The diagnostic criteria of ACS during pregnancy or puerperium are similar to those for non-pregnant patients and consist of chest pain, ECG changes and cardiac biomarkers.
Furthermore, maternal mortality is estimated at 5-10% and is highest during the peripartum period. Long term prognosis depends on infarct size and associated comorbidities.
Conclusions: In general, the management of acute myocardial infarction (MI) in pregnant women is similar to that in the general population, including the use of revascularization with percutaneous coronary intervention and stenting or coronary artery bypass graft surgery. However, treatment needs to be individualized, as the needs of the mother and child may conflict.
Spontaneous coronary artery dissection is a rare but important cause of myocardial ischemia and infarction in young, healthy women, without classical atherosclerotic risk factors.
Immediate coronary angiography is essential to establish an early diagnosis and allowing a therapeutic decision, taking in consideration the increased risk of secondary iatrogenic dissection.
In clinically stable patients with maintained coronary flow, a conservative management strategy is pre-ferred because of the increased risk of adverse outcomes with revascularization considering that usually heals completely over a few months
Where angiographic diagnosis of SCAD in uncertain, intracoronary imaging (IVUS, OCT) should be considered.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)