Diagnostic challenges in identifying myocardial infarction due to coronary vasospasm in pregnancy complicated by...

Although a prevalence of acute myocardial infarction (AMI) is rare in young females regardless of pregnancy, coronary vasospasm (CVS) and spontaneous coronary artery dissection (SCAD) could be observed. Physiologic and hormonal changes during pregnancy, as well as inflammation and vasoreactivity secondary to autoimmune diseases could contribute to CVS or SCAD.

We present a 39-year-old woman with systemic lupus erythematosus, antiphospholipid syndrome, and partial haemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome who developed chest discomfort. Initially, the on-call physicians considered that this was attributed to demand ischaemia secondary to obstetric complications. Due to non-reassuring foetal heart tracings and the development of partial HELLP syndrome, she underwent an emergency caesarean section and her chest discomfort resolved following delivery. However, she developed chest pain again. Electrocardiography showed ST-segment depression in the inferior, anterior, and lateral leads, and cardiac troponin I increased to 5452 pg/mL. Echocardiography demonstrated normal left ventricular ejection fraction of 60%. Spontaneous coronary artery dissection was excluded by coronary angiography and CVS-induced AMI was diagnosed through acetylcholine provocation testing. Following the administration of diltiazem 100 mg twice daily and enalapril 2.5 mg once daily, both of which are considered safe during breastfeeding, the patient and her newborn have done well.

At the time the patient developed chest pain, identifying the cause of the symptom was challenging due to multiple concomitant underlying diseases such as HELLP syndrome and autoimmune diseases. A multidisciplinary approach, along with the timely use of diagnostic tools, is essential for accurate diagnosis and management.