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Jason DarrahPGY-3
Internal Medicine ResidencyGundersen Lutheran Medical Foundation
La Crosse, WI
34 Year Old Caucasian Female
2 Months Postpartum
Retrosternal Chest Pain
Radiation Into Left Arm
Pain Between Her Shoulder Blades
Associated N/V, Diaphoresis
No Known Cardiac Risk Factors
Family History of RBBB
Meds: Probiotics, Prenatal Vitamins
Non Smoker
Hypertensive
Exam Was Unremarkable
EKG: ST elevations in I, II, aVL + RBBB
Troponin I and CKMB WNL
Hospital Day 3: “Heartburn”
Troponin Increased
Repeat Angiogram
Stent placed to 1st Diagonal – Small Plaque
Lipoprotein Analysis• Total 180, LDL 90, HDL 66, Trig 63• Lp(a) 107 mg/dL (<30 mg/dL)
Rare Cause of Acute MI
Women > Men • Peripartum
LAD – 60-80%, RCA - Men
1. Peripartum
2. Atherosclerotic
3. Idiopathic
4. Other Causes• Connective Tissue
Disease, SLE, Cocaine, Vigorous Exercise, Coronary Spasms
Sudden Cardiac Death
Acute Coronary Syndrome
Asymptomatic Unstable Angina
EKG Changes, Increased Cardiac
Markers
Intimal Tear
Rupture of the Vasa Vasorum
Heart. 2010; 96:803
Adventitia
External
elastica
Intim
a
Internal
elastica
Media
Vasa vasorum?
Eosinophils?
Clot False lumen
Increased Hemodynamic Stress
Hormonal Effects on Arterial Wall
Periadventitial Infiltrate of Eosinophils
Heart 1996;75:453
Coronary Angiography • Intimal “Flap”
Intravascular Ultrasound (IVUS)
Optical Coherence Tomography (OCT)
JACC. 2012; 59:1075.
Medical • Heparin/LMWH, ASA, Plavix, BB, Nitrates
Emergent Angiography PCI
CABG
Consider Fibrinolytic Therapy
Prognosis is Good
One Case Report Published
Implicated in Aortic Dissection
Independent Risk Factor for CAD
Journal of Cardiovascular Medicine 2011; 12:446-451
Rare cause of ACS
Women – Peripartum
Angiography
Questions?
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Tomography. Journal of the American College of Cardiology. 2012, 59:1073-9.
2. Adlam, D., et al. Management of Spontaneous Coronary Artery Dissection in the Primary
Percutaneous Coronary Intervention Era. The Journal of Invasive Cardiology. 2010, 22:549-553.
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Ischaemia and Sudden Death. Heart. 1996, 75:451-454.
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Therapy. Catheterization and Cardiovascular Diagnosis. 1994, 33:157-160.
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Dissection. The American Journal of Cardiology. 1989, 64:471-474
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and a Review of the Literature. American Journal of Therapeutics. 2012, 19:62-65.
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Report and Review of the Literature. Cardiology in Review. 2004, 12:3-9.
8. Patrignani, A., et al. Spontaneous Coronary Artery Dissection and Elevated Levels of
Lipoprotein(a) in a Young Man: A Causal Association? Journal of Cardiovascular Medicine.
2011, 12:446-451.
9. Shamloo, B.K., et al. Spontaneous Coronary Artery Dissection: Aggressive vs. Conservative
Therapy. The Journal of Invasive Cardiology. 2010, 22:222-228.
10. Vrints, Christian JM. Spontaneous Coronary Artery Dissection. Heart. 2010, 96:801-808.
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Young Women Treated with Thrombolytics. Catheterization and Cardiovascular Interventions.
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