Zusammenfassung
Wir berichten über eine 22-jährige Frau mit postpartaler Koronardissektionen des Ramus interventricularis anterior und des Intermediärastes. Die Patientin wurde rein medikamentös mit Aspirin, Clopidogrel und einem Betablocker behandelt. Eine Kontroll-Angiografie 20 Monate später zeigte ein angiografisch vollständiges Abheilen beider Dissektionen. Das kardiovaskuläre Risikoprofil der Patientin bestand neben einem milden Nikotinabusus aus deutlich erhöhten Werten für das totale und das low-densitylipoprotein Cholesterin, welche sich nach der Schwangerschaft ohne jedigliche medikamentöse Cholesterin-modifizierende Therapie fast normalisierten, was die Frage aufwirft, ob die Schwangerschafts-assoziierte Hypercholesterinämie in der Pathogenese der Schwangerschaft-assoziierten spontanen Koronardissektion (pregnancy-associated spontaneous coronary artery dissection; P-SCAD) eine Rolle spielt.
In einer systematischen Literaturanalyse identifizierten wir 16 Frauen [medianes Alter 34 (31–36,5) Jahre] mit P-SCAD, bei denen eine Kontroll-Angiografie durchgeführt worden war. Die meisten (69%) P-SCAD-Fälle ereigneten sich in der Postpartalzeit [mediane Zeit nach Entbindung 13 (7–21) Tage]. Zehn der 16 (63%) Patientinnen wurden rein medikamentös (Betablocker, Plättchenhemmer) behandelt, wobei angiografisch in 5 Fällen (31% aller Patientinnen) ein komplettes Abheilen der Dissektionen dokumentiert werden konnte, während die Dissektionen bei 5 Patientinnen persistierten oder sogar fortgeschritten waren. Achtzig Prozent der medikamentös behandelten Frauen hatten bei der Follow-up-Untersuchung keine Ischämie-verdächtigen Symptome. In 5/16 Fällen wurde primär eine perkutane koronare Intervention (percutaneous coronary intervention; PCI) durchgeführt. Drei Patientinnen mussten sich einer aortokoronaren Bypass-Operation unterziehen, dies als primäre Therapie in einem Fall und als sekundäre Therapie in zwei Fällen (persistierende Dissektion und Ischämie-typische Beschwerden nach medikamentöser Therapie bzw. PCI ohne Stent-Implantation).
Zusammenfassend kann gesagt werden, dass eine rein medikamentöse Therapie (Aspirin, Clopidogrel, Betablocker) bei ungefähr einem Drittel der Patientinnen mit P-SCAD zu einem sehr guten klinischen und angiografischen Resultat führt.
Summary
We report on a 22- year-old woman with postpartum dissection of the left anterior descending artery and the intermediate branch. The patient was treated with acetylsalicylic acid (ASA), clopidogrel, and betablocker only. Coronary angiography performed 20 months later revealed complete resolution of the dissection sites. The patient’s cardiovascular risk factors included mild smoking and high total cholesterol and low-density-lipoprotein-cholesterol levels, which showed a marked fall after pregnancy without pharmacological cholesterol-modifying therapy raising the question whether pregnancy-related hypercholesterolemia contributed to the pathogenesis of pregnancy-associated spontaneous coronary artery dissection (P-SCAD).
In a systematic review of the literature, 16 women [median age 34 (31–36.5) years] with P-SCAD and angiographic follow-up were identified. The majority (69%) of P-SCAD cases occurred postpartum [median time after delivery: 13 (7–21) days]. In 10/16 (63%) patients medical treatment including betablocker and antiplatelet therapy was given leading to complete resolution of the dissection in 5 of them (31% of all patients) at follow-up, whereas in the other 5 patients the dissections were persisting or even progressive. Of the medically treated patients, 80% were free of symptoms suggestive for ischemia at follow-up. In 5/16 patients percutaneous coronary intervention (PCI) was performed as first-line therapy. Three patients underwent coronary artery bypass grafting, which was performed primarily in one patient, and secondarily in two patients with persisting dissections and ongoing ischemic symptoms after previous medical treatment or PCI without stenting, respectively. In conclusion, medical treatment including ASA, clopidogrel and betablocker therapy results in an excellent clinical and angiographic result in approximately one third of patients with P-SCAD.
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*Address from January 2006: Division of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
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Maeder*, M., Ammann, P., Drack, G. et al. Pregnancy-associated spontaneous coronary artery dissection: impact of medical treatment. ZS Kardiologie 94, 829–835 (2005). https://doi.org/10.1007/s00392-005-0302-6
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DOI: https://doi.org/10.1007/s00392-005-0302-6