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Brain & Heart

COMMENTARY
Pregnancy-associated coronary artery dissection

(P-SCAD): A crucial differential diagnosis for
chest pain during pregnancy

2†
Muhammad Haris 1† , Amer Hammad *, and Vicky Kumar 3
1 Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, New Jersey,
United States of America
2 Department of Internal Medicine, Englewood Health/Hackensack University Medical Centre,
Englewood, New Jersey, United States of America
3 Department of Internal Medicine, Dow Medical College, Karachi, Sindh, Pakistan

Abstract

Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is a rare but severe
cause of acute coronary syndrome. The clinical presentation of P-SCAD can vary widely,
ranging from asymptomatic cases to cardiac arrest and sudden cardiac death. Chest pain
is the most common presenting symptom, though other symptoms, such as dyspnea,
nausea, vomiting, and palpitations, may also occur. P-SCAD is often underdiagnosed
† These authors contributed equally because patients typically do not fit the profile of those with atherosclerosis and
to this work. myocardial infarction. It predominantly occurs in younger individuals without traditional
*Corresponding author: cardiovascular risk factors. The diagnosis of P-SCAD is commonly made during coronary
Amer Hammad angiography. Therefore, in pregnant and postpartum females presenting with chest pain
(amer.hammad@ehmchealth.org)
or pressure, P-SCAD should be considered in the differential diagnosis, regardless of the
Citation: Haris M, Hammad A, presence of other risk factors such as age, hypertension, or diabetes.
Kumar V. Pregnancy-associated
coronary artery dissection
(P-SCAD): A crucial differential Keywords: Pregnancy-associated spontaneous coronary artery dissection; Acute
diagnosis for chest pain during
pregnancy. Brain & Heart. coronary syndrome
2025;3(1):4722.
doi: 10.36922/bh.4722
Received: August 31, 2024
Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) most commonly
Revised: December 10, 2024 occurs during the third trimester or within the first 30 days after delivery, with a prevalence
Accepted: December 23, 2024 of only 1.18/100,000 pregnancies. It is characterized by coronary artery dissection that is
1
2
Published online: February 19, not caused by trauma or atherosclerosis but by bleeding into the vessel wall. The proposed
2025 pathophysiology is linked to hormonal changes during pregnancy, where increases in
estrogen and progesterone levels impair collagen synthesis, thereby reducing the elasticity of
Copyright: © 2025 Author(s).
3
This is an Open Access article the vessel wall, which is necessary to withstand hemodynamic changes. In addition, estrogen
distributed under the terms of the increases the production of matrix metalloproteinase, which weakens the structural integrity
Creative Commons Attribution of the vasa vasorum in the outermost wall (tunica adventitia). The literature describes two
3
License, permitting distribution,
and reproduction in any medium, primary theories of rupture. The first involves the rupture of the innermost layer (tunica
provided the original work is intima) of the coronary vessel, creating a false lumen that narrows the vessel’s caliber and
properly cited. reduces blood flow. This condition appears as an intimal flap on angiography as the contrast
4
Publisher’s Note: AccScience material tracks into the false lumen. The second theory, known as the “outside-in” hypothesis,
Publishing remains neutral with involves rupture in the vasa vasorum of the outermost vessel layer (tunica adventitia), which
regard to jurisdictional claims in 4
published maps and institutional also creates a false lumen. However, this alteration does not appear as a flap on angiography
affiliations. due to the lack of communication between the true and false lumens (Figure 1).
Volume 3 Issue 1 (2025) 1 doi: 10.36922/bh.4722