A young woman with dyspnea

A 35-year-old Sri Lankan woman (gravida 3, para 3, abortus 0) presented to the Jewish General Hospital (Montreal, Quebec) with shortness of breath and diffuse swelling. She was five months postpartum of her most recent delivery, which was complicated by pre-eclampsia and gestational diabetes. She described a three-week history of progressive exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. There was no history of recent viral illness, and the patient had no traditional risk factors for coronary artery disease. A physical examination, laboratory results and echocardiography were typical for heart failure. A presumptive diagnosis of peripartum cardiomyopathy was made. To initiate a transplant referral, coronary angiography was performed. Six discrete atherosclerotic lesions were found, notably left main equivalent disease. A diagnosis of ischemic cardiomyopathy was made, and the patient was referred for high-risk coronary artery bypass surgery and transplant. The present case illustrates the excess burden of coronary artery disease borne in south Asian patient populations.