JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Postpartum Coronary Arterial Spasm
Sameh Askandar, MD, David Flatt, MD, Daniela Rosu, MD, Rami N. Khouzam, MD
Background: Acute coronary syndrome (ACS) during postpartum period is rare. In the current manuscript we present a case of a postpartumpatient who developed ACS attributed to coronary vasospasm in the absence of vasocontrictive medication or smoking. This condition resolved with intracoronary injection of nitroglycerine and verapamil. Case: A 26-year-oldwoman, postpartumday five, presentedwith a sudden onset of chest pain and an acute ST-segment elevation on ECG. Coronary artery catheterization showed multiple areas of spasm, which was relieved by intracoronary injection of nitroglycerine and verapamil. Post-catheterization hospital stay was uneventful and the patient was discharged in a stable condition. Conclusions: Early diagnosis and treatment of ACS in the peripartum period is crucial. Vasospastic coronary disease should be included in the differential diagnosis of peripartum chest pain. Nitrates are still considered the best treatment option with or without calcium channel blockers for both recurrence and prevention.
INTRODUCTION
Pregnancy and the peripartum state create a hormonal milieu that increases the incidence of a variety of cardiovascular pathologies with acute cardiomyopathy and coronary dissection considered to be the most commonly known. We report a rare case of coronary arterial spasm, including spasm of the left main, presenting as acute coronary syndrome. We also describe several potential pathophysiological explanations and etiologies for this rare but potentially life threatening condition. Additionally, we suggest different management strategies of peripartum coronary vasospastic disease and we provide a review of the literature.
valvular abnormality, and a minimal pericardial effusion. Cardiac catheterization revealed normal coronary arteries. Based on this presentation, myo-pericarditis was initially suspected. The patient was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and her pain diminished. She was discharged home. Three days later, the patient presented to the hospital with another episode of severe chest pain (10/10), an elevated serum troponin level of 19ng/ml, and electrocardiographic changes suggestive of acute inferior ST-segment elevation myocardial infarction (STEMI) (Figure 2). Coronary arteriography revealed new diffuse arterial spasm, including spasm of the distal left main (Figure 3). Diffuse spasm was relieved by a combination of high doses of intracoronary nitroglycerin, 600 micrograms (mcg) in total, and verapamil, 900 mcg in total (Figure 4). An intra-aortic balloon pump (IABP) was placed for 48 hours to increase coronary perfusion via improved diastolic coronary filling. The patient was also started on intravenous nitroglycerin and nicardipine drips for 48 hours. Oral medications initiated as an inpatient and continued at discharge included: diltiazem, nitroglycerin, L-arginine, Aspirin, clopidogrel, and a statin. She was discharged home in a stable condition, and remained both stable and asymptomatic until seen at her two month follow-up visit.
CASE PRESENTATION
A 26-year-old African American woman, G5P5, with morbid obesity (BMI=35.2), but no significant medical or previous cardiac history, presented one week postpartumwith squeezing chest pain (7/10) radiating to both shoulders. Family history was positive for premature coronary artery disease manifested as myocardial infarction in her father at the age of 31. The patient denied any history of tobacco, alcohol, cocaine, or other illicit drug use. On initial physical examination, her blood pressure (BP) in the right arm was 163/100 mmHg, and in the left arm was 160/98 mmHg. Her heart rate was regular at 73 beats per minute (bpm). She was alert and oriented. Heart sounds were normal. Physical exam was otherwise unremarkable. An initial troponin level was 8 ng/ml (N: 0.00-0.045). BNP 379 pg/ mL (N: 0.00-100). ECG showed inverted T waves in levels V1 and V2, (Figure1). Echocardiography revealed normal left ventricular systolic anddiastolic functionwithanejection fractionof 55%, no
DISCUSSION
The incidence of ischemic heart disease is low in women in the reproductive age. This risk increases by three-fold to four- fold during pregnancy. Coronary dissection accounts for up to 33% of myocardial infarctions in the postpartum period, and atherosclerotic disease with coronary thrombosis is the culprit
J La State Med Soc VOL 169 JULY/AUGUST 2017 101
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