Abstract 4143728: Pregnancy-Associated Spontaneous Coronary Artery Dissection in the Antepartum Period: Navigating Clinical Uncertainties

Description of Case: A 35-year-old G2P1 female with history of drug and tobacco use presented to the emergency department at 25 weeks of gestation with chest pain in the setting of a recent upper respiratory infection. Her vital signs and electrocardiogram (EKG) were normal; however, HS-troponin was elevated at 398 ng/L (normal <5.0 ng/L). An echocardiogram revealed a left ventricular ejection fraction (LVEF) of 55-60% and apical hypokinesis (Figure 1). The initial differential diagnosis included viral myocarditis (supported by elevated inflammatory markers), spontaneous coronary artery dissection (SCAD), and distal atherosclerotic coronary artery disease. Given her hemodynamic stability and preserved LVEF, the risk of invasive angiography outweighed the benefits. She was discharged with medical management and follow-up with maternal-fetal medicine and cardio-obstetric specialists. She underwent planned cesarean delivery at week 37 of gestation. The following day, coronary computed tomography angiography (CCTA) revealed severe stenosis of the mid-left anterior descending (LAD) artery (Figure 2A). Hours later, she had recurrence of chest pain without EKG changes, and HS-troponin increased to 7,000 ng/L. The decision was made to proceed with invasive coronary angiography, which confirmed SCAD in the mid-LAD (Figure 2B). Revascularization was not pursued given her hemodynamic stability, and she was managed conservatively. Discussion: Pregnancy-associated SCAD (PSCAD) is the leading cause of myocardial infarction during pregnancy. The presented case highlights the unique challenges associated with diagnosis and management of antepartum PSCAD, emphasizing the need for a high index of suspicion in pregnant women presenting with chest pain. In PSCAD patients, invasive angiography has been associated with an increased risk of iatrogenic dissections and may pose risks to the fetus, limiting utility. Non-invasive imaging such as CCTA may be considered in clinically stable patients; but there is limited data evaluating the diagnostic accuracy of CCTA in SCAD. Further research is needed to elucidate optimal diagnostic and therapeutic strategies tailored to pregnant women with PSCAD, and to better understand long-term implications of this condition on maternal and fetal outcomes. Given the complexities and unique challenges of managing PSCAD, advancing understanding and developing more specific guidelines is crucial to improving care for these patients.