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Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in otherwise healthy young and middle-aged patients without cardiovascular risk factors. Herein, is reported a multiparous (5 pregnancies, 5 deliveries) 45-year-old woman without cardiovascular risk factors who presented to the emergency room, 3 months after her last delivery, for oppressive retrosternal chest pain irradiating in the left arm. Electrocardiogram demonstrated negative T waves from V2–V6, I, II and avL. High sensitivity troponins were elevated at 293 ng/L Æ 1345 ng/L. Coronary angiogram demonstrated left main SCAD (type 2) with extension to the distal left anterior descending artery (LAD) and the proximal circumflex artery (LCx). The right coronary artery demonstrated no signs of SCAD (Fig. 1A–C). The patient did not present a trigger factor for SCAD. Echocardiography showed moderate left ventricular dysfunction (ejection fraction 45–50%), with apical akinesia and infero-septal hypokinesia. In the presence of conserved antegrade flow, conservative treatment was performed, and the patient was started on dual antiplatelet therapy by means of acetylsalicylic acid 100 mg/d and clopidogrel 75 mg/d. Heart failure therapy with angiotensin-converting enzyme inhibitors and beta-blockers was initiated. Forty-eight hours after the initial angiogram the patient presented recurrent retrosternal chest pain. Electrocardiogram showed negative T waves from V2–V6, as well as in leads II, III and avF and troponins were elevated at 477 g Æ 3775 ng/L, confirming recurrent MI. Repeat coronary angiogram demonstrated the previously seen spontaneous coronary artery dissections (type 2) with progression of the dissection of the circumflex artery to the distal segment of the vessel, associated with occlusion of the distal LCx (Fig. 1D–F). In the absence of hemodynamic instability, it was decided to treat the LCx dissection conservatively. Clinical evolution was favourable at 6 month follow-up. On echocardiography persistence of apical akinesia was visualized, with a slight left ventricular dysfunction (ejection fraction 50%). Control angiogram demonstrated complete healing of the left main, left circumflex artery and left anterior descending artery (Fig. 1G–I). Peripartum associated SCAD represent a high-risk subset of patients, is associated with high-risk clinical presentation and increased cardiovascular morbidity.

cardiology journal

Recurrent myocardial infarction caused by peripartum left main spontaneous coronary artery dissection, extending to the left anterior descending artery and left circumflex artery