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Brain & Heart Pregnancy-associated coronary artery disease

Spontaneous coronary artery dissection Pregnancy‑associated spontaneous coronary artery dissection
Coronary artery hematoma and intimal tears narrow the P-SCAD frequently occurs in the 1 month postpartum
st
lumen, thereby limiting blood flow to the myocardium P-SCAD has severe presentation:
- ST-elevation myocardial infarction
- Reduced left ventricular function
- Left main and/or multivessel involvement
P-SCAD versus SCAD:
- P-SCAD has a more severe presentation
- P-SCAD patients have a history of multiple pregnancies
- P-SCAD patients have fewer extracoronary vascular abnormalities
Figure 1. Features of pregnancy-associated spontaneous coronary artery dissection.
Abbreviation: SCAD: Spontaneous coronary artery dissection.
Approximately 1 – 4% of acute coronary syndrome European Society of Cardiology, medical management
(ACS) cases are attributable to SCAD, which predominantly for SCAD should primarily involve beta-blockers and
affects females. P-SCAD accounts for a small percentage angiotensin-converting enzyme inhibitors or angiotensin
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of these cases and typically presents as chest pain, sudden receptor blockers. Furthermore, thrombolysis is
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cardiac death, or ventricular arrhythmias. According to the contraindicated, the duration of dual antiplatelet therapy
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Mayo Registry report by Tweet et al. and a comprehensive remains controversial, and statins should be used if the
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review of P-SCAD cases by Havakuk et al., significant risk patient has hyperlipidemia. 14
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factors for P-SCAD include being over 30 years old, pre-
In conclusion, P-SCAD is a rare but severe condition
eclampsia, and multiparity. Notably, compared to non- that presents with worse ACS outcomes compared
pregnant females with SCAD, P-SCAD patients exhibit
markedly reduced left ventricular function, multivessel to SCAD in non-pregnant individuals. Diagnosis
involvement, ST-elevation myocardial infarction at can be challenging, and the optimal management
presentation with predominant left anterior descending or strategies for SCAD remain unclear. However, based on
left main coronary artery involvement, and a surprisingly observational data, most patients eventually progress
low prevalence of extravascular manifestations, such as from medical management to intervention. Due to the
fibromuscular dysplasia or Marfan syndrome. Preferred life-threatening nature of the condition, P-SCAD should
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treatment for P-SCAD is primarily based on retrospective be included in the differential diagnosis for postpartum
observational data. A recent review summarized cases of females presenting with chest pain. Further research is
P-SCAD and SCAD over the past 15 years in the USA. needed to better understand the pathophysiology, risk
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Among these, fewer P-SCAD cases (42.7%) were treated factors, and long-term outcomes of P-SCAD and to
conservatively, with the majority (32.2%) progressing to develop evidence-based management guidelines for this
revascularization. In contrast, a larger proportion of SCAD condition.
cases (77.2%) were treated conservatively, with only a small Acknowledgments
percentage (2.3%) requiring revascularization. Similarly,
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prospective multicenter studies from the Canadian None.
SCAD registry demonstrated conservative management
in up to 84.3% of SCAD cases, with a 0.8% mortality Funding
rate at 3 years. Another prospective study by Hassan et None.
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al. showed higher rates of major cardiac events both
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in-hospital and at follow-up (3.7 years) post-percutaneous Conflict of interest
coronary intervention (PCI) in SCAD patients. These The authors declare that they have no competing interests.
findings suggest that P-SCAD likely presents with a worse
prognosis than SCAD in non-pregnancy-associated Author contributions
coronary artery disease. Given the risk of progression of
dissection with PCI, some authors have recommended Conceptualization: Muhammad Haris
initial conservative management unless there is significant Writing – original draft: Muhammad Haris, Amer Hammad
chest pain, hemodynamic instability, or substantial left Writing – review & editing: Amer Hammad, Vicky Kumar
main involvement. Emergent coronary artery bypass Ethics approval and consent to participate
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grafting following PCI has been reported in 10 – 12%
of cases. 12,13 According to a recent publication by the Not applicable.

Volume 3 Issue 1 (2025) 2 doi: 10.36922/bh.4722