A 23‐year‐old Caucasian woman, gravid 2 para 3, without any significant past medical history, was discharged home after a cesarean section delivery of healthy twins. The patient had no risk factors for coronary artery disease, family history of sudden death or any other systemic illnesses. On the fourth day post partum, she awakened with midsternal heaviness associated with shortness of breath and diaphoresis, which disappeared spontaneously after an hour. On the Sixth day postpartum, she again had chest pressure/discomfort which she likened to “an elephant sitting on my chest.” She then presented to the emergency room, where her electrocardiogram was normal, but troponin was markedly elevated to 32. An echocardiogram showed apical, septal, and inferior hypokinesia. Emergent cardiac catheterization revealed spontaneous spiral dissection in the distal LAD causing 95% stenosis in mid distal LAD. Successful PTCA/Stent of the mid and distal LAD was performed. She was discharged on day 2 post‐stenting in stable condition.
Spontaneous coronary artery dissections (SCAD), though an infrequent event, is seen most commonly in women especially in the postpartum period. The occurrence is often fatal, with most of the diagnoses being established postmortem. The majority of these dissections involve the proximal or mid‐LAD. While no specific etiology has been defined to explain this phenomenon, several causes have been implicated such as hormonal changes, abnormal collagen metabolism, hemodynamic stresses related to preganancy, primary rupture of the vasa vasorum into the medial wall, and eosinophilic angitis. The most common histologic findings consist of a dissection, often in the outer third of the media and the adventitia with a large hematoma compressing the true lumen. Medical management, percutaneous coronary angioplasty, stent placement, surgical bypass, ventricular assist devices, and heart transplant in few selected cases comprise the successful management modalities.
SCAD are a rare cause of myocardial infarction. They have been reported in late pregnancy and in the puerperium phase. This event carries a very high mortality rate for both mother and fetus and early diagnosis can be life saving