Query: peripartum chest pain

title: Peripartum Chest Pain Should Prompt Cardiac Evaluation [23E]

title: Pulmonary thromboembolism presenting with chest pain in a case of peripartum cardiomyopathy.
abstract: Peripartum cardiomyopathy (PPCM) is an idiopathic reduction in left ventricular function, presenting at the peripartum period. The diagnosis is based on echocardiographic features and excluding other causes of heart failure. Similar to any other cause of heart failure, the management of PPCM consists of diuretics, prevention of ventricular remodeling, preventing short and long term complications. Ventricular clots, transient cerebral ischemic attacks, lower extremity thrombosis, kidney and liver infarcts and pulmonary thromboembolism have been previously reported in PPCM cases. Among them, pulmonary thromboembolism is one of the most important complications, as it is also a challenging differential diagnosis of PPCM. We discuss a case of PPCM followed by a diagnosis of pulmonary thromboembolism and briefly review the relevant PPCM literature.

title: Pregnancy associated spontaneous coronary artery dissection (PASCAD) An etiology for chest pain in the young peripartum patient.
abstract: Cardiac emergencies in pregnancy and the postpartum period are rare but often life threatening. An emergency physician's differential diagnosis for chest pain in the peripartum patient often includes serious etiologies such as pulmonary embolism or myocardial infarction (MI) A lesser known but important consideration on the differential for MI is that of a spontaneous coronary artery dissection (SCAD) SCAD is defined as an intramural hematoma within the coronary artery that compresses the true lumen. Expansion by increased pressures may lead to subsequent myocardial ischemia and infarction. This condition is the most common cause of pregnancy associated MI and is reported as the cause of MI in 24% to 35% of all women younger than 50 years. This condition is predominately seen in young healthy females with no traditional risk factors for coronary artery or cardiac disease, and typically in the postpartum period. SCAD in the peripartum period is defined as pregnancy associated spontaneous coronary artery dissection (PASCAD) Abnormal ECG changes, elevated troponins, and regional wall motional abnormalities on echocardiography are all diagnostic findings of SCAD, which can be ultimately confirmed with coronary angiography. Failure to immediately address this condition can lead to acute heart failure, cardiogenic shock, and death. Thrombolytic treatment may be harmful and is not recommended, and percutaneous coronary intervention can result in the iatrogenic propagation of further coronary dissection. As a result, the management for suspected SCAD involves emphasis on urgent transfer and urgent coronary artery angiography to determine appropriate treatment modalities.

title: Peripartum cardiac chest pain and troponin rise.
abstract: The incidence of myocardial ischaemia is increasing in the obstetric population. This has been attributed to several factors including greater maternal age, the increasing incidence of obesity and diabetes, and the growing population of patients with grown up congenital heart disease who now reach adulthood and become pregnant. A number of cases of myocardial ischaemia in pregnant women have been documented, during and after delivery, for which no cause has been established. We present a case of a nulliparous woman who developed cardiac chest pain, bradycardia, hypertension and a raised troponin I after vaginal delivery of twin boys at 36 weeks of gestation. Ischaemic electrocardiogram changes were noted. Detailed investigations demonstrated a normal coronary circulation. A patent foramen ovale was found on bubble echocardiography.

title: Symptoms Chest pain Chest and left axillary pain Chest pain Not known Chest pain Chest and jaw pain Cardiac arrest Chest pain Chest pain Midsternal chest pain
abstract: S pontaneous coronary artery dissection (SCAD) is a nonatherosclerotic disease of the coronary arteries and usually presents as acute coronary syndrome.1,2 The pathogenesis of SCAD involves development of a dissection plane within the coronary artery wall with concurrent intramural hematoma and/or intimal flap, ultimately obstructing flow and causing myocardial ischemia and infarction. Spontaneous coronary artery dissection was previously considered rare, with only individual cases and small case series published.3 5 However, the advent of dedicated online SCAD patient communities and social media communication has led to increased awareness of the condition and robust patient initiated research activity. More recent studies6,7 with advanced intracoronary imaging suggest that 1% to 4% of patients with acute coronary syndrome may have SCAD. More importantly, SCAD may be responsible for one third of the acute coronary syndromes in females younger than 50 years and is the most common cause of peripartum myocardial  9 The emerging recognition that both the treatment and outcomes of SCAD differ from those of acute coronary syndrome caused by atherosclerosis1,10,11 highlights the need to increase awareness and diagnostic acumen among health care professionals. Spontaneous coronary artery dissection occurs most commonly in young women with no or minimal cardiovascular risk factors. The exact pathophysiologic mechanisms associated with SCAD are unclear, but associations with the peripartum period, extreme exercise or emotion, connective tissue disorders, and fibromuscular dysplasia have been reported.1,2,12 Because the estimated 10 year incidence of major adverse cardiovascular events, including death, recurrent SCAD, heart failure, and myocardial infarction after initial SCAD, is high (47%,1 identification of novel risk factors is critical. To our knowledge, the significance of family history in SCAD has not been previously reported.

title: A rare cause of postpartum chest pain.
abstract: We report the case of a 45 year old postpartum female at low risk for coronary artery disease (CAD) who presented with chest pain, a normal electrocardiogram (ECG) and elevation of serial troponin T levels. Coronary angiography revealed dissection of the first obtuse marginal branch of the left circumflex coronary artery. The patient was treated medically and discharged home safely. Spontaneous coronary artery dissection (SCAD) is a rare condition. In the absence of CAD, it is seen most frequently in young females during the peripartum period. Insult from the hemodynamic stresses during pregnancy and labor combined with the underlying pregnancy related arterial wall changes is the proposed mechanism of dissection in this setting. The normal ECG in the presence of an acute myocardial infarction (AMI) in this case also demonstrates the occasional electrically silent ECG that can occur during acute compromise of the left circumflex coronary artery.

title: An interesting case of a twin pregnancy complicated with happy hypoxia, peripartum cardiomyopathy and haemolysis, elevated liver enzymes, low platelet count syndrome during the COVID 19 pandemic situation
abstract: We are reporting a case of a pregnant woman with twin pregnancy and pregnancy induced hypertension who rapidly progressed to hemolysis elevated liver enzymes (HELLP) syndrome without having proteinuria along with features of peripartum cardiomyopathy and also had low oxygen saturation levels (less than 72% though she did not have any complaints of dyspnea, orthopnea, hemoptysis, chest pain, cough or peripheral oedema. She was tested for COVID 19 with real time polymerase chain reaction (RT PCR) on 2 occasions a week apart and was

title: Postpartum psychosis in peripartum cardiomyopathy: a case report
abstract: This case report highlights the rare occurrence of postpartum psychosis in the setting of peripartum cardiomyopathy, which can have rare presentations like arrhythmias and pulmonary edema; and the challenges one should anticipate while managing these conditions together. Caution is advised whenever antipsychotic drugs are to be administered to a patient with a cardiac condition as these drugs potentially increase the risk of arrhythmias and sudden death.  A 35 year old grand multiparous woman who was 1 week into puerperium was admitted with severe difficulty in breathing at rest, chest congestion and pain. She also had easy fatigability, orthopnea, paroxysmal nocturnal dyspnea, edema, tachycardia, tachypnea, irregularly irregular heart rate with a pulse deficit, elevated jugular venous pressure, cardiomegaly, hepatomegaly and pulmonary crepitations. On the sixth day while improving on standard drugs for heart failure, she developed bizarre behavior and confusion. She also had auditory, visual and olfactory hallucinations; violence to the baby and the husband; and refusal to feed and take medication. There was no altered sensorium and the vital signs were normal. She was diagnosed with puerperal psychosis during the management of peripartum cardiomyopathy.  In the rare occurrence of puerperal psychosis in the course of management of peripartum cardiomyopathy one must be acutely aware of the risk of sudden cardiac death occasioned by use of antipsychotics, either directly or due to arrhythmias. Continuous electrocardiogram (ECG) monitoring or use of alternative management modalities is thus highly advised.

title: Three broken vessels in a peripartum patient: a rare case report of spontaneous triple vessel coronary artery dissection
abstract: Spontaneous coronary artery dissection (SCAD) is a frequently underdiagnosed entity that carries a significant risk of morbidity and mortality. Spontaneous coronary artery dissection is increasingly recognized as an important cause of acute coronary syndrome (ACS) and, the majority of SCAD patients are young healthy women.  A 23 year old female G5P4 presented to the emergency room for severe sub sternal chest pain, associated with shortness of breath. Past medical history was significant for pre eclampsia. Initial electrocardiogram was remarkable for ST depressions in V5 V6 with inverted T waves to V1 V2. Troponin I was elevated to 1.13 ng/mL. Two dimensional echo showed reduced left ventricular function with an ejection fraction of 40% Cardiac catheterization showed triple vessel dissection involving the left main trunk extending into mid left anterior descending and dissection extending from ostium of left circumflex artery into large first obtuse marginal branch. She was started on aspirin and heparin. After 48 h she was loaded with clopidogrel. Computed tomography angiography of head, neck, abdomen, and pelvis showed findings compatible with fibromuscular dysplasia. She was haemodynamically stable and symptom free and did not want surgery. She was recommended to continue dual antiplatelet therapy for 12 months and subsequently aspirin and beta blocker only lifelong.  Spontaneous coronary artery dissection is a rare condition which is underdiagnosed. A thorough history and high degree of suspicion is required to diagnose in a timely manner and it should be high on differential in a postpartum female presenting with signs and symptoms of ACS.

title: Recurrent myocardial infarction caused by peripartum left main spontaneous coronary artery dissection, extending to the left anterior descending artery and left circumflex artery.
abstract: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in otherwise healthy young and middle aged patients without cardiovascular risk factors. Herein, is reported a multiparous (5 pregnancies, 5 deliveries) 45 year old woman without cardiovascular risk factors who presented to the emergency room, 3 months after her last delivery, for oppressive retrosternal chest pain irradiating in the left arm. Electrocardiogram demonstrated negative T waves from V2 V6, I, II and avL. High sensitivity troponins were elevated at 293 ng/L AE 1345 ng/L. Coronary angiogram demonstrated left main SCAD (type 2) with extension to the distal left anterior descending artery (LAD) and the proximal circumflex artery (LCx) The right coronary artery demonstrated no signs of SCAD  The patient did not present a trigger factor for SCAD. Echocardiography showed moderate left ventricular dysfunction (ejection fraction 45 50% with apical akinesia and infero septal hypokinesia. In the presence of conserved antegrade flow, conservative treatment was performed, and the patient was started on dual antiplatelet therapy by means of acetylsalicylic acid 100 mg/d and clopidogrel 75 mg/d. Heart failure therapy with angiotensin converting enzyme inhibitors and beta blockers was initiated. Forty eight hours after the initial angiogram the patient presented recurrent retrosternal chest pain. Electrocardiogram showed negative T waves from V2 V6, as well as in leads II, III and avF and troponins were elevated at 477 g AE 3775 ng/L, confirming recurrent MI. Repeat coronary angiogram demonstrated the previously seen spontaneous coronary artery dissections (type 2) with progression of the dissection of the circumflex artery to the distal segment of the vessel, associated with occlusion of the distal LCx  In the absence of hemodynamic instability, it was decided to treat the LCx dissection conservatively. Clinical evolution was favourable at 6 month follow up. On echocardiography persistence of apical akinesia was visualized, with a slight left ventricular dysfunction (ejection fraction 50% Control angiogram demonstrated complete healing of the left main, left circumflex artery and left anterior descending artery  Peripartum associated SCAD represent a high risk subset of patients, is associated with high risk clinical presentation and increased cardiovascular morbidity.