Re: spontaneous coronary artery dissection

Posted By CCF CARDIO MD - MTR on November 16, 1998 at 17:31:03:

In Reply to: spontaneous coronary artery dissection posted by Carol Jennings on November 15, 1998 at 09:56:38:

My 31 year old daughter had a spontaneous dissection of the right coronary artery 11 days after the birth of her 2nd child.  She has 5 stints in her right artery.   Do you have any infomation on this subject?  RE:
long term prognosis, possibility of it happening again, survivors, etc.
Anyone with info please write to ***@****

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Dear Carol, thank you for your question. There is limited information on this subject, since coronary artery dissection rarely occurs in pregnant women.  But, I was able to find a few references in medical journals on this subject that I've included with my response.  You can get copies of these articles at a nearby medical library.  Generally, coronary dissection in pregnant women is thought to be caused by a variety of factors: hormonal changes, hypertension, the hemodynamic stress of pregnancy, and certain connective tissue disorders that can alter the composition of the arterial wall to make it more susceptible to dissection.  Thus, your daughters' physicians may consider investigating a connective tissue disorder.  I really can't comment on long-term prognosis and the likelihood of a recurrence since there is limited information available on this subject.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies. Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.   The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.
Unique Identifier
98245306
Authors
Bucciarelli E.  Fratini D.  Gilardi G.  Affronti G.
Institution
Institute of Anatomic Pathology and Histology, University of Perugia, Italy.
Title
Spontaneous dissecting aneurysm of coronary artery in a pregnant woman at term.
Source
Pathology, Research & Practice.  194(2):137-9, 1998.
Abstract
We describe a case of spontaneous dissecting aneurysm of the circumflex coronary artery in a 44-year-old primigravida at term with no vascular risk factors. Spontaneous coronary artery dissection is a very rare condition with a greater prevalence in women, postpartum in particular. The left anterior descending artery is the most frequently affected. Histologically, the most common finding is a hematoma occupying the outer third of the media, resulting in complete compression of the true lumen. Arterial wall changes during pregnancy together with hemodynamic factors, a lytic action of protease released from eosinophils, and intimal tears are the main hypotheses considered to explain the etiology of spontaneous coronary artery dissection.
Unique Identifier
97251256
Authors
Klutstein MW.  Tzivoni D.  Bitran D.  Mendzelevski B.  Ilan M.  Almagor Y.
Institution
Department of Cardiology, Jesselson Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel.
Title
Treatment of spontaneous coronary artery dissection: report of three cases [see comments].
Source
Catheterization & Cardiovascular Diagnosis.  40(4):372-6, 1997 Apr.
Abstract
Spontaneous coronary artery dissection is an extremely rare cause of myocardial infarction. It has been reported mainly in young women during or after pregnancy. The prognosis and treatment of coronary dissection are not clear. We report three cases of spontaneous coronary artery dissection in young women. One of them was pregnant and one was 2 weeks after delivery. The dissection involved the left anterior descending artery (LAD) in two cases and the left main coronary artery in one case. There was no evidence of atherosclerosis on angiography or intracoronary ultrasound in any of the patients. Two of the women were treated by stent implantation with excellent results. This is the first known report of successful coronary stenting of spontaneous coronary artery dissection. The pregnant woman was not a candidate for stent implantation and underwent implantation of the left internal mammary to the LAD without cardiopulmonary bypass. She completed her pregnancy uneventfully.
Unique Identifier
97007546
Authors
Roth A.  Elkayam U.
Institution
Tel-Aviv Medical Center, Israel.
Title
Acute myocardial infarction associated with pregnancy. [Review] [194 refs]
Source
Annals of Internal Medicine.  125(9):751-62, 1996 Nov 1.
PURPOSE: To review available information on the epidemiology, cause, diagnosis, prognosis, and treatment of acute myocardial infarction during pregnancy or in the early postpartum period and to develop guidelines for the management of this condition. DATA SOURCES: MEDLINE and Index Medicus searches and a manual search of bibliographies from reviewed articles. STUDY SELECTION: Published reports of well-documented acute myocardial infarction during pregnancy or the early postpartum period or potentially relevant information. DATA EXTRACTION: 125 well-documented cases of myocardial infarction were identified. DATA SYNTHESIS: The highest incidence seems to occur in the third trimester and in multigravidas older than 33 years of age. Acute myocardial infarction during pregnancy is most commonly located in the anterior wall. The maternal death rate was 21%; death occurred most often at the time of acute myocardial infarction or within 2 weeks of the infarction and was usually related to labor and delivery. Most fetal deaths were associated with maternal deaths. Coronary artery morphology was studied in 54% of described patients. Coronary atherosclerosis with or without intracoronary thrombus was found in 43% of patients, coronary thrombus without atherosclerotic disease in 21%, coronary dissection in 16%, and normal coronary arteries in 29%. CONCLUSIONS: Acute myocardial infarction during pregnancy or the early postpartum period is rare but may be associated with high risk. Although atherosclerosis can be documented in many cases, coronary dissection and arteries that are normal on angiography are common, especially in acute myocardial infarction occurring in the peripartum or postpartum period. Early diagnosis is often hindered by the normal changes of pregnancy and low level of suspicion. Management should follow the usual principles of care for acute myocardial infarction. However, selection of diagnostic and therapeutic approaches may be greatly influenced by fetal safety. [References: 194]
Unique Identifier
96332210
Authors
Badui E.  Enciso R.
Institution
Division of Cardiology, Hospital de Especialidades Centro Medico, La Raza, Mexico, D.F.
Title
Acute myocardial infarction during pregnancy and puerperium: a review [see comments]. [Review] [128 refs]
Source
Angiology.  47(8):739-56, 1996 Aug.
Abstract
The purpose of this review is to analyze the possible parameters that lead to the development of what is a rare event--acute myocardial infarction (AMI) during pregnancy and puerperium. Through the Index Medicus, 109 publications on the subject were obtained. Since the first well-documented case by Katz in 1922, 136 patients have been reported, and from these reports the following data have been gathered: the average age was 32.1 years. This event is more frequent during the third trimester and puerperium of the first and second pregnancies. In 42.6% of the patients no coronary risk factors were observed, but when present, hypertension and cigarette smoking were the most common. The anterior wall along or in combination with any other anatomic area was affected in 73% of cases. Coronary angiograms, when taken, appeared normal in 47%. The maternal mortality rate was 26/136 (19.1%) and was higher during the third trimester, labor, and puerperium. Eight patients (8/26) (30.7%) had sudden death. In 5 of these, (62.5%) coronary thrombosis was found. In 18/26 deaths, an autopsy was performed; 9/18 (50%) had coronary thrombus formation and in 7/18 (39%) variable degrees of atherosclerosis were detected. On the other hand, the fetal mortality rate was 16.9%; however, in only 52% was death coincidental with that of the mother. Coronary artery spasm associated with a probable hypercoagulability state was the most likely mechanism in the majority of these patients, followed by atherosclerotic heart disease and coronary dissection-the last being secondary most likely to hormonal changes. During the AMI these patients should be studied by a medical team composed of a cardiologist, gynecologist, and anesthesiologist. A complete cardiologic work-up should be made to decide individually about further pregnancies. [References: 128]
Unique Identifier
95255320
Authors
Bac DJ.  Lotgering FK.  Verkaaik AP.  Deckers JW.
Institution
Thoraxcenter, Erasmus University, The Netherlands.
Title
Spontaneous coronary artery dissection during pregnancy and post partum.
Source
European Heart Journal.  16(1):136-8, 1995 Jan.
Abstract
This report describes a 35-year-old 40 week pregnant woman who was hospitalized with a diagnosis of acute anteroseptal myocardial infarction. She sustained another, infero-posterior, infarction 4 days later. Coronary arteriography performed after successful Cesearean section displayed primary dissections of the right as well as both left coronary arteries. Her subsequent clinical course was uneventful with medical therapy. This patient is the first non-surgically treated survivor of peripartal spontaneous coronary artery dissection with a myocardial infarction prior to delivery.