Kucher, Nils

Lüscher, Thomas F.

Schuler, Pia K.

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CLINICAL VIGNETTE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehn241Online publish-ahead-of-print 2 June 2008Multiple postpartal coronary artery dissections and fibromuscular renalartery dysplasiaPia K. Schuler, Thomas F. Lu¨scher, and Nils Kucher*Cardiovascular Division, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland* Corresponding author. Tel: þ41 44 255 8762, Fax: þ41 44 255 4401, Email: nils.kucher@usz.chA 42-year-old postpartal woman presented 5 months after deliveryof her second child with sudden onset of chest pain following exer-cise. The clinical investigation was unremarkable except for a bloodpressure of 185/110 mmHg and a positive troponin test. Her pastmedical history included controlled arterial hypertension and twoepisodes of a troponin-positive acute coronary syndrome due tospontaneous coronary artery dissection (SCAD) that weretreated conservatively. The first episode was not pregnancy associ-ated and was caused by single SCAD of the posterior descendingcoronary artery. The second episode occurred 2 months afterdelivery of her first child and involved a single SCAD of the inter-mediate branch. During the second episode, a right renal arterystenosis due to fibromuscular dysplasia (FMD) was treated by per-cutaneous transluminal angioplasty (PTA).At present, angiography showed multiple SCAD of the leftanterior descending artery, first diagonal branch, intermediatebranch (Panel A), and the right posterior descending artery (PanelB). In addition, there was restenosis of the right renal artery(Panel D). Despite medical therapy, including aspirin, clopidogrel,unfractionated heparin, transdermal nitrates, and calcium channelblockers, the patient developed anterior ST-elevation myocardial infarction during the next 24 h. Re-angiography revealed progressionof the multiple dissections in the left coronary artery (Panel C). After insertion of an intra-aortic balloon pump, intravenous nitrates,ablactation, and renal artery PTA, the patient recovered and remained event-free during clinical follow-up of 12 months.Spontaneous coronary artery dissection is often pregnancy associated and occurs particularly during the early postpartum period(78%); the LAD is involved in approximately 80% of patients. SCAD is thought to be caused by an altered endocrine status and anincreased haemodynamic strain during pregnancy and the postpartum period. Whether SCAD in our patient was triggered by second-ary hypertension from renal FMD remains unclear. Alternatively, SCAD may be related to FMD; indeed, carotid dissection hasbeen reported in such patients. Urgent coronary angiography is indicated to establish the diagnosis and determine the appropriatetherapeutic approach. Conservative medical therapy may be preferred in stable conditions and can lead to complete healing of thedissected coronary artery. In unstable conditions involving proximal coronary dissections with absent coronary flow, percutaneousor surgical revascularization should be considered.Panel A. Left anterior cranial view showing multiple, rather distally located spontaneous coronary artery dissections of the leftanterior descending artery (left arrow), first diagonal branch (middle arrow), and intermediate branch (right arrow).Panel B. Right anterior oblique view showing dissection of the right posterior descending artery. A dissection membrane is clearlyvisible (arrow).Panel C. Left anterior cranial view showing progression of the dissections of the left anterior descending artery (left arrow), firstdiagonal branch (middle arrow), and intermediate branch (right arrow) during anterior ST-elevation myocardial infarction.Panel D. Digital subtraction angiography showing the typical bead-string changes of fibromuscular renal artery dysplasia. Haemo-dynamic significance of the lesion was confirmed by ultrasound.Published on behalf of the European Society of Cardiology. All rights reserved.& The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org.Clinical vignette 2825

Multiple postpartal coronary artery dissections and fibromuscular renal artery dysplasia

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