Postpartum spontaneous coronary, vertebral, and mesenteric artery dissections: a case report

Spence et al. Journal of Medical Case Reports Postpartum spontaneous coronary, vertebral, and mesenteric artery dissections: a case report Sean Spence 0 1 Maneesh Sud 0 1 Ravi Bajaj 0 1 Anna Zavodni 1 2 Sharron Sandhu 1 3 Mina Madan 0 1 0 Division of Cardiology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto , Toronto, Ontario , Canada 1 Sunnybrook Health Sciences Centre , 2075 Bayview Ave., Room D3 80, Toronto, Ontario M4N 3M5 , Canada 2 Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto , Toronto, Ontario , Canada 3 Division of Rheumatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto , Toronto, Ontario , Canada Background: Spontaneous coronary artery dissection is a rare cause of myocardial infarction that must always be considered on a clinician's differential diagnosis, particularly in patients <50-years old with a paucity of typical vascular risk factors. Case presentation: We describe a case of a 33-year-old white woman, 3 weeks postpartum, presenting with retrosternal chest and back pain, neck pain and stiffness, and intermittent headaches. Subsequent workup revealed concurrent spontaneous dissections in three separate medium-sized arterial beds. Conclusions: She was successfully managed in a conservative fashion, highlighting that percutaneous or surgical revascularization can often be foregone in favor of conservative medical therapy. Coronary artery dissection; Acute myocardial infarction; Vertebral artery dissection; Gender Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (MI). It is being increasingly recognized as a non-atherosclerotic etiology for MI in patients <50-years old, predominantly women <50-years old [ 1 ]. SCAD is currently thought to have a complex multifactorial etiology with associations to atherosclerosis, the peripartum period, multiparity, menopause, oral contraceptive use, connective tissue disease, trauma, psychophysical stress, vascular malformations, cocaine use, vasculitis, fibromuscular dysplasia, polycystic kidney disease, and certain medications [ 2 ]. Although three case reports have been published for concurrent spontaneous coronary and vertebral artery dissections (VADs), we present, to the best of our knowledge, the first case of postpartum multivessel coronary, cerebral, and mesenteric artery dissection [ 3–5 ]. The only risk factor present in these other cases was the postpartum state, and two of the three patients presented with symptoms of headache and angina. With this unusual case we highlight the importance of a systematic approach to diagnosis and management, once SCAD is suspected. Case presentation A 33-year-old white woman (G2P2), with previously repaired sinus venosus atrial septal defect (ASD), underwent emergency coronary angiography for an ST-elevation myocardial infarction (STEMI) 3 weeks postpartum. She had no traditional risk factors for coronary artery disease, both her pregnancies were uneventful, and there was no significant family history or past medical history aside from the aforementioned ASD. She endorsed a 1 to 2week history of intermittent nonexertional chest, back, and neck pain, neck stiffness, and headaches. On the day of admission, she presented to another hospital with severe persistent chest and back pain. Her presenting electrocardiogram (ECG) showed a sinus rhythm with anterior and inferior ST-segment elevation and reciprocal ST-segment depression in the lateral leads. Her creatine kinase was 1018 U/L and high-sensitivity troponin T was 1828 ng/L. Upon arrival at our cardiac catheterization laboratory, her chest discomfort was resolving, and a repeat ECG showed slight persistence of © 2016 Spence et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. ST elevation inferiorly, and T wave inversions across the precordial leads (Fig. 1). She was noted to be hypertensive at 145/99 (equal in both arms). Immediate bedside echocardiography demonstrated normal aortic root dimensions, and absence of ascending aortic dissection or aortic insufficiency. Her overall left ventricular (LV) function was preserved. Coronary angiography revealed normal right coronary and left main arteries. There was abrupt tapering with significant stenosis noted in her mid-left anterior descending (LAD) artery and the second obtuse marginal branch (OM2) of (...truncated)