Postpartum dissection of the left main coronary artery

Peripartum coronary artery dissection is rare, but it is an increasingly recognized risk to women of childbearing age. Literature reviews reveal that about 80% of the population with spontaneous coronary artery dissections (SCAD) are female, and approximately 25-33% of cases occurred while the woman was pregnant or in the peripartum phase. Most cases have presented within 2 weeks of delivery. The left anterior descending is the most commonly affected vessel. The etiology is poorly understood, but many reports suggest that SCAD occurs as a result of protease release secondary to an eosinophilic vasculitis resulting in vessel lysis. Many investigators have examined the correlation between peripartum SCAD and estrogen levels; however, case studies have shown conflicting results regarding estrogen levels as the putative causative factor. Optimal treatment remains controversial. Presently, stenting appears to be best employed in the patients who have single-vessel dissection not involving the left main coronary artery (LMCA). Surgical revascularization via coronary artery bypass graft remains the optimal therapy in patients whose dissection involves the LMCA, in patients with concurrent multivessel dissection, and in patients with disease refractory to medical management. It is important to consider coronary artery dissection in the differential of any young woman who presents with signs or symptoms consistent with acute coronary syndrome, particularly if she is peripartum. Furthermore, once suspected, it is imperative that a definitive diagnostic study, that is, coronary angiography, be completed prior to the initiation of treatment whenever possible.