Chest Pain in Pregnancy: The Big 3: Part 1 Coronary Dissection

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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David G., M.D. -

Color me dubious that a young, let's say freshly post-partum, woman comes in with chest pain and ST segment elevation consistent with acute coronary occlusion and somehow we're supposed to assume this is a dissection that should just be treated medically? Obviously, the only way to diagnose a dissection is in the cath lab, which--I would argue--(like any acute coronary occlusion), is where such a patient belongs. Once there, let the interventionalist decide what to do. My youngest STEMI pt was 27. Weird things happen. It would be indefensible to miss an acute occlusion amenable to stenting that knocks off a good portion of the LV due to relying on what, just over 100 patients ever reported? Obviously, we don't have a large clinical trial that compared intervention with medical management. Let's not over-think this.
David Glaser
Denver

Rebecca B., MD -

David, Thank you for your comment. I definitely don't think you should assume it's a dissection on your own, as I also state in the podcast and as you mention, this diagnosis is made in the cath lab. The treatment would not be our hands but the cardiologist, I reviewed the treatment differences so there is awareness that it's different. Bottom line, as EPs we should diagnose like we would any acute chest pain and get the patient to the cath lab like we do with all patients with AMI on EKG, mobilize the multidisciplinary resources this patient will need, but think about this diagnosis and avoid lytics if in the rare chance you are faced with that choice. - Rebecca Bavolek

Jessica B. -

SCAD happened to me three weeks ago, at 1 am on shift. I am 40 years old. Ran 4 miles before shift that day without symptoms. I had no medical conditions, not pregnant. I was standing at a sweet 90-something year old patient’s bed, explaining to her that she was in complete heart block, when I had had sudden onset of severe chest pain, diaphoresis, dyspnea, and nausea. Asked my charge nurse to do an EKG and it undeniably showed STEMI. Repeated and looked the same. Cardiologist was at bedside from home within 10 minutes. Took me to cath lab within 30 min and I had 100% LAD occlusion with decreased EF. My cardiologist knew it was SCAD right away and reluctantly placed 3 stents. He did not feel there was a choice but to stent. I immediately felt better with reprofusion. I truly believe that if I had not been on shift and had stents placed, the outcome likely would have been different. From what I’ve read, there is still little known about SCAD and its etiologies. Although rare, it is one of the leading causes of MI in (especially females) less than 50 yrs old. It is likely under-diagnosed given that it most frequently occurs in young, healthy patients without risk factors. Although medical management is advised when possible, PCI is sometimes unavoidable if there is hemodynamics instability with ongoing ischemia. Fortunately, we do not need to make this decision as EPs. That’s left to the interventional cardiologist. Our job is to maintain a high level of suspicion and communicate SCAD on our DDx with cardiology on these young and/or pregnant patients with STEMI as they take them to the cath lab. Thanks for covering this topic!

Mel H. -

OMG! And you are right. On our role!

Rebecca B., MD -

Jessica, I'm so glad that you are doing well! Agree, our role is to maintain high suspicion and get these women to the cath lab right away and leave into the hands of the cardiologist. You were in the right hands that day. -Rebecca Bavolek

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