Core EKG: Postpartum Acute ST Elevation

EKG Characteristics

• Rate

  150

• Rhythm

  Sinus Tachycardia

• Intervals

  Normal

• Axis

  Left axis deviation

• ST Segments

  ST-elevations in leads I, II, III, aVF, and V2-V5 (infero-laterally), with ST-depressions in aVR

Diagnosis

Spontaneous Coronary Arterial Dissection (SCAD)

Questions

1. What are the appropriate next steps in management and disposition for this patient?

   Given acute chest pain with STE in contiguous leads that meets STEMI Criteria, the next steps include cath lab activation and emergent cardiology consultation with initiation of STEMI care and simultaneous evaluation of alternative diagnoses.

2. What is the differential diagnosis for a young woman without any cardiac risk factors present with symptoms of Acute Coronary Syndrome (ACS)?

   Acute Coronary Syndrome (acute plaque rupture), Spontaneous Coronary Artery Dissection, Coronary Vasospasm, Aortic Dissection, Pericarditis, Cardiomyopathy, Ventricular Aneurysm.

Discussion

Spontaneous Coronary Arterial Dissection (SCAD) occurs after a non-traumatic tear in the coronary artery wall results in separation between arterial wall layers, creating a false lumen and intramural hematoma. As the hematoma expands it causes compression of the true lumen and decreased coronary blood flow, resulting in myocardial infarction.

Pregnancy has been shown to significantly increase the incidence of SCAD. Suggested reasons for this increased risk include elevated progesterone levels during pregnancy, which impairs the synthesis of collagen and decreases the elasticity of arterial walls. Estrogen, also elevated in pregnancy, causes hyper-coagulability, increasing the risk of thrombosis formation within the arterial wall false lumen. Pregnancy also requires increased cardiac output and higher blood volume, causing increased strain on the arterial walls, possibly further provoking the creation of a false lumen.

Epidemiology:

• Pregnancy related SCAD (p-SCAD) accounts for 17% of all SCAD cases.
• p-SCAD is estimated to occur in 1.81 per 100,000 pregnancies.
• p-SCAD carries a mortality rate of 50%, with the rate increasing to 70% in patients who present with myocardial infarctions.

Presentation:

• p-SCAD can occur during pregnancy or during the postpartum period. In the postpartum period, the majority of cases (54%) occurred during the first week of the postpartum period.
• The most common presenting complaint is chest pain (with 93% of patients reporting chest pain)
  Other common complaints are back pain, diaphoresis, nausea, vomiting.
• Most patients (65%) will present without any cardiac risk factors commonly associated with ACS such as hypertension, hyperlipidemia, diabetes, or a smoking history.
• Factors associated with increased risk of p-SCAD are:
  • Older age at first pregnancy (>30 years or age)
  • History of multiple pregnancies
  • Use of fertility treatments
  • Preeclampsia during pregnancy

Workup:

• Troponin levels are elevated in 95% of cases.
• EKGs usually appear as STEMIs or NSTEMIs, however one study reported that up to 33% of cases had normal EKGs at presentation3. A normal EKG should not deter further workup of this diagnosis.
• Gold standard of diagnosis is coronary angiography.

Management:

• There is no current consensus on the optimal treatment for p-SCAD.
• Majority of patients are medically managed with aspirin, beta-blockers, clopidogrel. DAPT may be stopped after angiography confirms the diagnosis.
  90% of SCAD demonstrate angiographic healing after conservative management.
• Thrombolytics are discouraged as they have been associated with an increased risk of adverse outcomes and extension of the coronary dissection or hematoma.
• Percutaneous Coronary Intervention (PCI) and CABG are reserved for critical patients, as neither of these interventions showed a significant benefit, and in fact have shown increased risk of adverse outcomes caused by iatrogenic damage to the already weakened arterial walls.

Disposition:

• Cath lab activation and emergent cardiology consultation for ECG that meets criteria with STEMI
• Admission

Pearls

• Consider cath lab activation in any patient presenting with an acute coronary syndrome and an ECG that meets criteria for STEMI.
• Consider SCAD (and alternative etiologies of STE) as a differential in any young woman presenting with chest pain, especially in the setting of current or recent pregnancy.
• While most EKGs will show findings of a STEMI, EKGs can also be normal at presentation and should not dissuade from further workup of SCAD if clinical suspicion is high.

Sources

1. Muhammad Durrani, DO, MS, “Spontaneous Coronary Artery Dissection (SCAD)”, REBEL EM blog, October 19, 2020.
2. Sheikh AS, O’Sullivan M. Pregnancy-related Spontaneous Coronary Artery Dissection: Two Case Reports and a Comprehensive Review of Literature. Heart Views. 2012 Apr;13(2):53-65. doi: 10.4103/1995-705X.99229. PMID: 22919449; PMCID: PMC3424780.
3. Hayes S, Tweet M, Adlam D, et al. Spontaneous Coronary Artery Dissection. J Am Coll Cardiol. 2020 Aug, 76 (8) 961–984. https://doi.org/10.1016/j.jacc.2020.05.084
4. Katherine Zeven, Pregnancy-Associated Spontaneous Coronary Artery Dissection in Women: A Literature Review. Current Therapeutic Research, Volume 98, 2023, 100697, ISSN 0011-393X. Https://doi.org/10.1016/j.curtheres.2023.100697.
5. Hayes S et al. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018. PMID: 29472380
6. Elkholy KO, Khizar A, Khan A, Hakobyan N, Sahni S. Subacute Stent Thrombosis in a Patient With COVID-19 Despite Adherence to Antiplatelets. Cureus. 2021 Feb 7;13(2):e13194. doi: 10.7759/cureus.13194. PMID: 33717736; PMCID: PMC7942390.
7. Marysia S. Tweet, Sharonne N. Hayes, Elisabeth Codsi, Rajiv Gulati, Carl H. Rose, Patricia J.M. Best. Spontaneous Coronary Artery Dissection Associated With Pregnancy. Journal of the American College of Cardiology, Volume 70, Issue 4, 2017, Pages 426-435. ISSN 0735-1097, https://doi.org/10.1016/j.jacc.2017.05.055.
   Tweet, Marysia S et al. “Spontaneous coronary artery dissection: revascularization versus conservative therapy.” Circulation. Cardiovascular interventions vol. 7,6 (2014): 777-86. doi:10.1161/CIRCINTERVENTIONS.114.001659