Immunosuppressive therapy for peripartum-type spontaneous coronary artery dissection: case report and review

A 35-year-old postpartum woman presented with myocardial infarction (MI) due to spontaneous coronary artery dissection (SCAD). In addition to conventional medical therapy, she was treated with immunosuppressive agents (prednisone and cytoxan) because of five noncontiguous coronary dissections, surgical inoperability, and postinfarction angina. Repeat angiography 94 days later demonstrated angiographically normal vessels.

A literature review of 42 additional cases of peripartum SCAD was performed, and the results were compared with this patient.

Mortality was 48.8% (21/43). Sudden cardiac death was the initial presentation in 27.9% (12/43) of cases. The left coronary artery was involved in 78.6% (44/56) of dissections with left main segment dissection in 10 cases. In women who survived > 24 h post infarction, recurrent MI, usually due to a second coronary dissection, occurred in 20.8% (5/24). Histopathologic studies have often shown periadventitial inflammation (80%, 16/20), in which eosinophils predominate (68.8%, 11/16), and may be linked to the medial degeneration often found in these cases.

The common observation of eosinophilic periadventitial inflammation suggests a role in the pathophysiology of this rare, yet serious condition. Aggressive immunosuppressive therapy in this case of multivessel dissection resulted in spontaneous angiographic healing of all lesions.