Treatment
Options available:
Medical management
Stenting
CABG
Treatment
QuickTime™ and a decompressor
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Indications for medical treatment: (1/3 of patients fall into this category)
Unimpaired coronary flow
Single vessel disease
No ongoing symptoms or hemodynamic instability
50% of patients will show complete angiographic healing
Maeder et al. Z Kardiol
2005;94:829-835
Treatment
Medical treatment includes:
ASA
Clopidogrel
? GP IIb/IIIa inhibitors
Beta blockers
Not enough data on Thrombolysis
Not recommended in P-SCAD
A relative contraindication in pregnant pts w/ AMI
Roth et al. J am Coll Cardiol
Treatment
Stenting
CABG
Review:
95 patients with AMI during or following pregnancy
10 women underwent CABG
7 due to coronary dissection
1 patient died
1 intrauterine fetal death
Patients need to be monitored for several days
Tongi et al. Am J Med 1999;107:407-8 Roth et al. J am Coll Cardiol 2008;52:171-180
Labor And Delivery
Elective C-section
Avoids long stressful labor
Better control of time or delivery
Allows the presence of an appropriate team
Review of 103 patients:
10 patients had a C- section
Lower than the average rate of C-sections in the general population (30%)
Vaginal Delivery
Eliminates the risk of
Anesthesia
HD fluctuations
Blood loss
Infection
Respiratory complications
Damage to pelvic organs
Safe in the stable patient
Need to reduce cardiac work load/O2 demand
May use Nitro, BB, CCB
Roth et al. J am Coll Cardiol
2008;52:171-180
DISCOVERY
DISection of COronary
Arteries: Veneto and Emilia
RegistrY
Multicenter prospective registry with a case control group
Spontaneous dissections of coronary arteries and acute coronary syndromes
Aimed at:
Assessing the role of SCAD in the pathogenesis of ACS
Identifying the role of different therapeutic strategies
Fontanelli et al. J Cardiovasc Med
Prognosis
50% experience sudden death
Among those that survive to present to hospital:
Low in-hospital mortality (~3%)
95% 2 year survival rate (De Maio et al.)
Vanzetto et al. Eur J CT Surgery 2009;35:
Prognosis
Multivariate predictors of death:
Female sex (OR 4)
Absence of early treatment (OR 36)
Non-peripartum SCAD amongst women
Kamineni et al. Cardiology in Review 2002;1
Prognosis: Peri-Partum
SCAD
Follow-up angiographies in medically treated patients:
50% resolution of dissection at 90 days
85% event-free survival at 30 months
No published cases of patients with subsequent pregnancies
Prior AMI:
Moderate risk category for future pregnancies (5- 15% maternal mortality rate)
Recommendation:
Against future pregnancies in SCAD patients
European Heart Journal 2003;24:761-
Return to Case
Pain free on medical therapy
Troponin I rose to 26
Repeat cath showed improved angiographic appearance of pLAD with hematoma causing 40% obstruction
Recommended:
No PCI
Plavix for 1 month, ASA for life
CTA in 1 month
CTA: no residual flap or thrombus, slight reduction in diameter of pLAD
Echocardiogram (1 month): normal LVEF