{"id":44886,"date":"2014-09-08T16:54:32","date_gmt":"2014-09-08T20:54:32","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=discussion&p=44886"},"modified":"2014-09-22T17:05:30","modified_gmt":"2014-09-22T21:05:30","slug":"anteroseptal-mi-and-left-main-dissection-in-a-pregnant-woman","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2014\/09\/08\/anteroseptal-mi-and-left-main-dissection-in-a-pregnant-woman\/","title":{"rendered":"Anteroseptal MI and Left-Main Dissection in a Pregnant Woman"},"content":{"rendered":"

A 25-year-old woman who is gravida 4, para 2 and is 32 weeks pregnant presents to the emergency department with sudden-onset chest pain that started while she was preparing her kids for school in the morning. An electrocardiogram reveals anteroseptal MI with ST-segment elevations in leads V1\u2013V4 and reciprocal depressions in leads II, III, and aVF.<\/p>\n

The patient is immediately taken to the cath lab, where she has a finding of spontaneous distal left-main dissection extending into the left anterior descending artery with TIMI 3 flow.<\/p>\n

After transfer to the hospital\u2019s tertiary care center, the patient becomes free of chest pain on a 10-\u03bcg\/minute nitroglycerin drip, from which she is then weaned in a few hours. ECG shows a >50% reduction in ST-segment changes. The patient is monitored in the CCU. Echocardiography reveals a normal LV ejection fraction with no wall-motion abnormalities.<\/p>\n

Questions:<\/b><\/p>\n

1. What management approach would you choose for this pregnant woman?<\/p>\n

2. Which antiplatelet\/anticoagulation strategies should be used?<\/p>\n

3. What is the most appropriate revascularization strategy? When should it be initiated?<\/p>\n

4. How should delivery of the child be conducted?<\/p>\n

Response:<\/strong><\/p>\n

James Fang, MD<\/a><\/strong><\/p>\n

September 22, 2014<\/p>\n

1. Coronary dissections are generally best managed conservatively. They generally heal with anticoagulation strategies. PCI is often complicated by trying to identify and wire the true lumen; complications are common (see the ACCF\/AHA PCI guidelines).<\/p>\n

2. I would consider using heparin and a short-acting glycoprotein IIb\/IIIa antagonist in order to facilitate delivery.<\/p>\n

3. As noted, coronary dissections are best managed conservatively, given the difficulties in identifying the true lumen with either by PCI or surgery.<\/p>\n

4. I would consider a cesarean delivery to control the hemodynamic situation of the mother. Direct surgical management of the wound allows for careful use of anticoagulants and antiplatelet agents.<\/p>\n

It is also important to screen this woman for fibromuscular dysplasia. Other conditions in the differential diagnosis include Ehlers\u2013Danlos syndrome, giant-cell arteritis, Takayasu\u2019s arteritis, and other true connective-tissue disorders.<\/p>\n","protected":false},"excerpt":{"rendered":"

Harsh Golwala presents our latest case: A 25-year-old woman, 32 weeks pregnant, presents with sudden-onset chest pain. How do you proceed?<\/p>\n","protected":false},"author":952,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[754,781,1314,1449],"class_list":["post-44886","post","type-post","status-publish","format-standard","hentry","category-interventional-cardiology","tag-chest-pain","tag-left-main-disease","tag-myocardial-infarction","tag-pregnancy"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/44886","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/952"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=44886"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/44886\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=44886"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=44886"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=44886"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}