This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dimitrios Dougenis Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Koniari, I. Articles by Dougenis, D. Search for Related Content PubMed PubMed Citation Articles by Koniari, I. Articles by Dougenis, D. Related Collections Related Article

eComment: Spontaneous coronary artery dissection: a fatal cause of myocardial infarction in pregnancy

Department of Cardiothoracic Surgery, University Hospital of Patras, 22500 Rion Patras, Greece

Acute ventricular rupture due to myocardial infarction during postpartum period

Acute myocardial infarction (AMI) is uncommon under the 40 years of age, especially among women as you mention in your very elucidating case report [1]. Primary non-traumatic spontaneous coronary artery dissection (SCAD) is an uncommon cause of AMI seen in young, apparently healthy women, without overt cardiovascular risk factors. Approximately one in four female patients with spontaneous coronary artery dissection is in the peripartum period, most commonly in the third trimester of pregnancy or in the early postpartum period [2].

Patients with SCAD are traditionally divided into three subsets: young women in peripartum period or taking oral contraceptives, patients with underlying CAD and an idiopathic group. Idiopathic SCAD occurs in patients without risk factors for coronary artery disease and underlying pregnancy. The prognosis of SCAD is generally poor and a great number of cases are diagnosed at necroscopy [3]. Especially, it has been most commonly described in middle-aged, otherwise healthy women in the peripartum period or under oral contraceptive use, with no coronary atherosclerosis and no apparent risk factors for atherosclerosis. In this patient group, which constitutes the largest single subset of SCAD cases, weakening of arterial wall due to progesterone, rupture and hemorrhage of vasa vasorum and hemodynamic effects of pregnancy have been proposed as underlying mechanisms [4].

In general, this disease is associated with high mortality, about 50% at presentation. There is an 85% survival rate for patients who survive the acute phase. Sudden death without preceding myocardial ischaemia is a frequent mode of presentation. The overall mortality in those patients who do present with myocardial infarction exceeds 70%. This is why it is usually recognized at post-mortem examination [2].

Immediate coronary angiography is essential to establish an early diagnosis and allow a therapeutic decision. Therapy should depend on the persistence of myocardial ischaemia, the area at risk and the number of vessels involved. Stenting is the considered therapy in case of a well-localized dissected lesion in a single vessel not involving the left main stem. In case of multivessel or left main stem involvement, surgical revascularization seems the most controlled strategy, although the anastomosis of the graft on a dissected coronary artery is hazardous [2].

Finally, it is notable that relaxin plays a possible vasoprotective role in pre-eclampsia. Recently, evidence suggests that soluble growth factor receptor fms-like tyrosine kinase 1, asymmetric dimethyl arginine and autoantibodies are involved in the pathophysiology of pre-eclampsia, leading to inactivation of circulating pro-angiogenic factors, inhibition of endothelial NO biosynthesis and stimulation of angiotensin receptors [5]. Consequently, as relaxin can increase renal vasodilation and hyperfiltration, reduce myogenic activity of small renal arteries through activation of the endothelin B-receptor NO pathway and stimulate endothelial NO generation [5], it appears to be a promising agent to counteract the pathogenesis of preeclampsia, preventing further the ‘cascade of potential myocardial ischaemia’ in pregnancy.

	References

Top References

 

1. Topal AE, Eren MN. Acute ventricular rupture due to myocardial infarction during postpartum period. Interact CardioVasc Thorac Surg 2009;8:565–567.[Abstract/Free Full Text]
2. Van den Branden BJ, Bruggelin WA, Corbeij HM, Dunselman PH. Spontaneous coronary artery dissection in the postpartum period. Neth Heart J 2008;16:412–414.[Medline]
3. Iyisoy A, Agac MT, Celik T, Jata B. Spontaneous dissection of left main coronary artery associated with hypertensive crisis: a probable fatal complication detected by intravascular ultrasound. Int J Cardiol 2008 Aug 13, [Epub ahead of print].
4. Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature. Eur J Cardiothorac Surg 2001;20:573–576.[Abstract/Free Full Text]
5. Bani D. Relaxin as a natural agent for vascular health. Vasc Health Risk Manag 2008;4:515–524.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dimitrios Dougenis Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Koniari, I. Articles by Dougenis, D. Search for Related Content PubMed PubMed Citation Articles by Koniari, I. Articles by Dougenis, D. Related Collections Related Article