Case summary: we report a case of a young women presenting with chest pain in the post-partum period. Her clinical appearance was that of a myocardial infarction, and angiography was indicative of a Type 2 SCAD. The patients had persistent chest pain, reduced left ventricular function, and critical left anterior descending artery stenosis. Percutaneous coronary intervention was done with caution. Shared decision-making with the patient helped guide the medical treatment plan and follow-up.
Case presentation: A woman in her 40s presented to the emergency department following 4 h of acute chest pain. The pain was described as severe pressure on the chest and radiated to the left arm. The patient was 2 weeks following the birth of a healthy daughter (gravity 6, parity 3, caesarean section 3, spontaneous abortion 3). The pregnancy was uncomplicated. She had an elective caesarean section due to previous caesarean section with her first pregnancy (breech presentation). This was performed at week 38 + 3. However, during admission following the caesarean section, the patient was noted to have elevated blood pressure and proteinuria and was treated with magnesium intravenously for pre-eclampsia. She was discharged with no further medication and was currently breastfeeding her child. She was not on any other chronic medications, no past medical history, with no known allergies. She did not smoke, and her lipid profile 4 years prior revealed LDL blood level of 78 mg/dL. Her initial vital signs were blood pressure 145/80 mmHg, heart rate 95 b.p.m., normal oxygen saturation, and no fever. She was not in haemodynamic compromise or respiratory distress. The heart and lung examination were without abnormal findings.
The electrocardiogram (Figure 1) showed sinus rhythm, normal axis, narrow QRS complex with T waves inversion in the anterior leads, and Type 2 Wellens sign in leads V4–V5 with QTC 462 ms (Bazett formula). There was no recording or symptoms of an arrhythmia on telemetry monitoring in the emergency room.
A focused echocardiogram in the emergency department showed reduced left ventricular dysfunction (ejection fraction estimated to be 40%) with hypokinesia of the mid and apical segments mostly of the anterior wall in the four-chamber and two-chamber views, with no valvular lesions and no pericardial effusion (see Supplementary material online, Video S1) Blood results reported an elevated troponin T 1633 ng/L (normal value < 13 ng/L), NT ProBNP 1046 pg/mL (normal value < 125 pg/mL), creatinine kinase 1451 U/L, creatinine of 0.6 mg/dL (glomerular filtration rate according to MDRD 133.5 mL/min/1.73m2 ) (normal value:
0.51–0.95 mg/dL), AST 116 U/L (normal values < 31 U/L), no electrolyte abnormalities, haemoglobin 14 g/dL (normal values: 12–16 g/dL), and platelets 431 K/mcL (normal values: 150–450 K/μL). Due to ongoing chest pain, the patient was taken urgently to the catheterization laboratory. Angiography showed critical stenosis of 99% of the middle left anterior descending artery with TIMI flow score of 3 (Figures 2 and 3 and Supplementary material online, Video S2). This lesion was tapered and indicative of spontaneous Type 2 coronary artery dissection (SCAD). No other coronary lesions were noted with smooth contour of the coronary arteries otherwise. Due to the clinical presentation of ongoing chest pain, abnormal electrocardiogram, and reduced left ventricular function, percutaneous coronary intervention was pursued. This was done with a 5 French 3.0 EBU engagement catheter, careful wiring of the coronary artery using a floppy wire (RUNTHROUGH NS Floppy, Terumo, Japan) and direct stenting with a single long EluNIR™ ridaforolimus drug eluting stent (Medinol, Tel Aviv, Israel, 2.75 mm diameter × 28 mm length) with a good angiographic result and optimal distal angiographic flow (Figure 4). The patient had immediate clinical improvement and was transferred for observation in the coronary care unit. She was given a loading dose of aspirin (300 mg) and clopidogrel (600 mg).
Her echocardiogram the following day showed a reduced ejection fraction of 40% with anterior-apical dyskinesia and no valvular abnormalities. She was found to be hypertensive during her admission with 24 h albuminuria of 838 md/day and was started on Enalapril 5MG BD following a nephrology and gynaecology consultation. Bisoprolol 2.5MG QD was added due to her left ventricular dysfunction. LDL results were 144 mg/dL, and a statin (atorvastatin 80 mg) was initiated.
A shared decision-making discussion was done with the patient about the recommendations and relative lack of data on antiplatelet drugs and effects of drugs from drug eluting stents (DESs) in breastmilk. The patient decided to avoid the potential risk on her child from the drugs and to stop breastfeeding. Her antiplatelet regimen was then changed to dual antiplatelet with ticagrelor (90 mg twice daily) and aspirin (100 mg once daily).
Follow-up: One month following her admission, the patient continues to feel well. She was referred for magnetic resonance angiography of extra-coronary vasculature (renal and cervico-ephalic) for screening for fibromuscular dysplasia (FMD). The FMD is an arteriopathy with a high prevalence amongst patients with SCAD. Patients with SCAD should be screened
for associated risk factors such as arteriopathies (including FMD), connective tissue diseases, and systemic inflammatory conditions.2 She was referred to our outpatient cardiac rehabilitation programmed. Left ventricular function improved to an ejection fraction of 50% on repeat echocardiography at one month follow-up and further heart failure medications, such as SGLT2 inhibitors and mineralocorticoid receptor antagonists, were not initiated. At latest follow-up (3 months post-delivery), mother and baby are both doing well. We have discussed that our recommendation is a detailed pre-conception multidisciplinary discussion prior to any further pregnancy.