Case Presentation: A 32-year-old female with a history of recent uncomplicated vaginal delivery (3 weeks prior, G7P6A1) was brought in following cardiac arrest. She had been running errands with family when she developed seizure-like activity prior to arresting. Cardiopulmonary resuscitation was not initiated until emergency medical services arrived 15 minutes after the event. Patient arrived at the hospital in ventricular fibrillation, and advanced cardiac life support was performed until return of spontaneous circulation was achieved at 34 minutes. Electrocardiogram revealed a tombstoning pattern with anterolateral ST elevations as well as reciprocal inferior depressions. Patient was taken for left heart catheterization which revealed spontaneous coronary artery dissection of the distal left anterior descending artery. She was loaded with aspirin and clopidogrel, started on heparin, and transferred to the cardiac intensive care unit to initiate post-arrest targeted temperature management. MRI brain revealed diffuse hypoxic ischemic injury. Due to decerebrate posturing, CT head was obtained, showing effacement of bilateral cerebral sulci and basal cisterns concerning for impending herniation. With continual decline in neurologic status, family made the decision to transition patient to comfort care and she ultimately passed away.
Discussion: Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome that accounts for less than 4% of cases. SCAD can be categorized into atherosclerotic and non-atherosclerotic causes, the latter of which more commonly affects young women with low or absent cardiac risk factors. Pregnancy associated SCAD accounts for 5% of SCAD cases and appears to affect the left main coronary artery, left anterior descending artery, or multiple vessels. Conversely, SCAD is the most common cause of pregnancy associated myocardial infarction. Risk factors for pregnancy associated SCAD include multiparity, history of infertility therapy, and pre-eclampsia. Peak incidence is within the first postpartum month. It has been proposed that hormonal changes during pregnancy weaken the endothelium and increase the likelihood of dissection, but hemodynamic changes such as increased cardiac output, heart rate, stroke volume, and myocardial oxygen demand may also contribute. Management includes either conservative measures or percutaneous coronary intervention, however success rates are low and complication rates high, with mortality rates of 50% at the time of presentation.
Conclusions: Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome in the general population, but is the most common cause of pregnancy associated myocardial infarction. Outcomes are heavily dependent on timing and management, therefore SCAD should be considered in any postpartum female presenting with acute chest pain.