Peripartum Chest Pain Should Prompt Cardiac Evaluation [23E]

• Published in: Obstetrics and gynecology (New York. 1953) Vol. 133 Suppl 1; no. 1; p. 57S
• Main Authors: Hasan, Abida, Hill, Michael, Massad, Malek, Shroff, Adhir, DiGiovanni, Laura M, Briller, Joan
• Format: Journal Article
• Language: English
• Published: by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved 01.05.2019
• ISSN: 0029-7844; 1873-233X
• DOI: 10.1097/01.AOG.0000559015.73284.be

INTRODUCTION:Cardiovascular disease is a leading cause of maternal morbidity and mortality. Women are at 3 to 4 fold higher risk acute myocardial infarction (AMI) during pregnancy and post-partum (PP). Spontaneous coronary artery dissection (SCAD) is the most common cause of AMI typically presenting within 6 weeks PP. Diagnosis can be missed given low suspicion for ischemic etiologies in young women with chest discomfort. METHODS:A 29-year-old G2P2002 without cardiac risk factors, who provided consent for presentation, underwent uncomplicated vaginal birth after cesarean at 39 weeks. Delivery and immediate PP course were uncomplicated. She was discharged PP day 2. On PP day 22, she self-presented to ED with substernal chest pain (CP) reporting that she had called EMS with prior CP episodes days 5 and 15 PP and was told CP was due to anxiety. EKG suggested ischemia and troponins were elevated. She received sublingual nitroglycerin, aspirin, beta-blocker, and heparin. Coronary angiography demonstrated 60-70% left main coronary artery stenosis, 90% distal left anterior descending artery stenosis, and 100% occlusion of left circumflex artery raising concern for underlying SCAD. While SCAD can often be managed conservatively, she continued to have symptoms with rising biomarkers despite medical therapy, and underwent coronary bypass surgery on PP day 25. Diagnosis of SCAD was confirmed intraoperatively. CONCLUSION:Peripartum women with SCAD may be missed because of young age and few risk factors for atherosclerosis. This case illustrates the imperative of maintaining a high index of suspicion for ischemic disease when women present with CP during pregnancy or PP.