Spontaneous coronary artery dissection is a rare and often fatal cause of ischemic heart disease occurring predominantly in young or middle-aged, otherwise healthy patients. The cause of and the optimal management approach for this challenging condition are still being debated [1-4]. To our knowledge, about 200 cases of spontaneous coronary artery dissection have been reported in the world literature. Sixty-eight percent of the reported cases occurred in women, and 30% of these patients were peripartum or puerperal. We describe the second case of postpartum coronary dissection successfully treated by intracoronary stenting; the first case was recently reported elsewhere [2].

A 31-year-old woman was admitted with a diagnosis of acute anterior myocardial infarction 4 days after an uncomplicated spontaneous vaginal delivery. She was a heavy smoker. Because her symptoms had started more than 18 hours before admission, thrombolytic therapy was avoided. The patient was given aspirin and intravenous nitroglycerin, metoprolol, and heparin. When she was discharged 6 days later, she was asymptomatic. However, she later developed recurrent, atypical angina pectoris, and cardiac catheterization was done. Coronary angiography revealed a longitudinal dissection of the proximal left anterior descending artery (Figure 1). Subsequently, an intracoronary stent was successfully implanted, and the patient's condition stabilized. The patient was discharged and continued to receive aspirin and ticlopidine. At a follow-up visit 5 months after stenting, the patient remained asymptomatic.

View larger version (122K): [in this window] [in a new window]   Figure 1. Angiogram before intervention shows extensive dissection (arrows) in proximal left anterior descending coronary artery.

Physicians must maintain a high index of suspicion for ischemic heart disease when evaluating peripartum or puerperal women with acute chest pain. Confirmation of acute myocardial infarction in this setting should prompt a diligent search for a possible coronary dissection. In the absence of severe left ventricular impairment, symptomatic patients with single-vessel dissection not involving the left main coronary artery could benefit from primary coronary stenting to decrease the chance of sudden death, reinfarction, and arrhythmia.