Reassuring Data—and Some Lessons—From Pregnancy-Related SCAD Registry

Many women who survive pregnancy-associated spontaneous coronary artery dissection (SCAD) fare well even with conservative management and, if they choose to do so, are able to safely have additional children, a new analysis of European registry data confirms.

The research letter, published online recently in Circulation, adds clarity to what’s known about the clinical presentation, management, and outcomes of this rare but potentially catastrophic event.

David Adlam, DPhil (Glenfield Hospital, Leicester, England), a senior author of the study, told TCTMD that the data offer lessons for practice. Pregnancy-associated SCAD, they found, is “overwhelmingly a postpartum disease,” where the risk peaks in the first month after pregnancy then remains elevated for months, he explained. “That’s important for healthcare professionals to recognize: . . . It’s that new mom with chest pain that you need to be really [attuned] to thinking about this condition.”

In the years following their SCAD, one-third of the women became pregnant and most of these pregnancies were successful.

The study, which included 82 patients who developed SCAD over a time span of nearly 37 years, also bolsters the notion that SCAD can be more severe in the setting of pregnancy than it would be otherwise. Despite this, most patients were managed conservatively, with the idea of “trying to do as little as you can,” Adlam said. “If you can coax these patients carefully, manage them carefully, through that acute phase, then that’s probably the right thing to do in a lot of cases.”

Marysia S. Tweet, MD (Mayo Clinic College of Medicine, Rochester, MN), said the results are largely consistent with what’s been observed by prior studies. That in itself is valuable, she commented to TCTMD. “It just helps us realize we’re all on the right track, because if it was largely different, I’d start wondering where we were missing a beat. Especially when you’re dealing with a lot of small studies, if they’re being reproduced, that helps us be more confident when we’re caring for and counseling patients. It helps direct the research if we think we’re on the right path.”

If you can coax these patients carefully, manage them carefully, through that acute phase, then that’s probably the right thing to do in a lot of cases. David Adlam

Led by Nathan Chan, MBBS, and Diluka Premawardhana, MBBS, with Adlam and Matthew Cauldwell, MD, as senior authors (all Glenfield Hospital), the researchers gathered data on patients tracked by European SCAD registries for events that occurred between 1984 and 2021. Among them, 82 had survived pregnancy-related SCAD (median age 36 years; 85% white). In all cases, SCAD was confirmed on invasive angiography, either during pregnancy or within 1 year of delivery, miscarriage, or termination.

The vast majority were never/former smokers (94%), while 22% had a family history of coronary artery disease. Just 16% had extracoronary arteriopathies, 13% had dyslipidemia, 5% had diabetes, and 2% had prior stroke.

The riskiest time for SCAD was in the first month after delivery. Only five of the women experienced SCAD during pregnancy itself. Afterward, two of them gave birth vaginally and three by cesarean section.

Nearly half of the women with pregnancy-related SCAD presented with STEMI. For 38%, their event involved proximal coronary segments, while in 19% of women it was multivessel and in 57% it was multisegment.

Most (56%) were managed conservatively without revascularization. Around a third underwent PCI and 12% were referred for CABG. Stented patients required a median of three stents, most often in the LAD. Forty percent of the PCI-treated group had complications, which included six iatrogenic dissections, three hematoma extensions, one distal occlusion, and one failed PCI leading to CABG.

The researchers also used the MBRRACE-UK audit of maternal deaths to obtain data on an additional 13 patients who experienced pregnancy-related SCAD—three during pregnancy and three postpartum—but didn’t survive. Twelve of the 13 had an out-of-hospital cardiac arrest, though only three had symptoms prior to that arrest. Importantly, Chan et al note, these data show that “most deaths in [pregnancy-associated] SCAD result from sudden fatal arrhythmia with little apparent opportunity for medical intervention.”

Adlam said this analysis provides a unique vantage point: “Usually in medicine we focus on survivors, but that of course means we’re not able to learn the lessons from people who don’t survive. We were very focused on trying to say: is there anything we could have done to save these unfortunate cases which didn’t survive?

“What we found was that the overwhelming majority of these patients had cardiac arrests out of hospital, so they had a sudden, catastrophic presentation without actually getting to the hospital,” he continued, adding that this provides some reassurance that SCAD therapies, when given, are working.

For Tweet, the data on female patients who didn’t present to the hospital before their fatal SCAD highlights the need for better recognition of the complication. “You still wonder how many of these patients maybe had symptoms but ignored them or were delayed [in] seeking help,” she said. This emphasizes the “importance of educating women and making sure that they know to reach out if something isn’t feeling right in the postpartum period, and also educating our medical teams [to] consider SCAD in the differential when patients present with symptoms.”

Overall, she added, “SCAD patients, if they’re diagnosed and treated, tend to do well.” However, there’s a wide spectrum of how well they recover after surviving their event, both when it comes to the degree of cardiac damage and to the possible fallout for mental health, said Tweet.

SCAD patients, if they’re diagnosed and treated, tend to do well. Marysia S. Tweet

Ultimately, 28 of the 82 SCAD survivors became pregnant again after their event, for a total of 37 pregnancies. Three patients opted for medical termination due to concerns about risk, while seven of the pregnancies resulted in spontaneous miscarriage. The rate of pregnancy-associated MACCE was 8%, which included one acute MI thought to be due to recurrent SCAD and two angiographically confirmed SCAD recurrences. None were fatal for the female patients or their babies.

Adlam pointed out that these data dovetail with those from a 2020 Mayo Clinic study, led by Tweet, that supports the idea that many women can safely have children even after SCAD.

The risk of recurrence is “not a trivial risk. It’s not a risk we can currently mitigate, but it’s something that some . . . may decide is a risk that they are prepared to take in order to have a family,” he explained. “At least now, . . . we can actually go to patients with some numbers and some information about what we feel the likely risk is, to help them form an opinion.”

Going forward, Adlam says, there’s additional room for hope when it comes to treating SCAD. “Here is a disease that’s crying out for us to understand how female sex hormones and vascular biology and pathobiology are linked,” he explained. “If we can work out what the problem is, we may already have [hormone-based] therapies that can try to do something about it.”