Unveiling an insidious diagnosis and its implications for clinical practice: Individual patient data systematic review of pregnancy-associated spontaneous coronary artery dissection

Background: Pregnancy-Associated Spontaneous Coronary Artery Dissection (P-SCAD) is the most common cause of myocardial infarction in pregnancy and postpartum. Aim of this systematic review is to provide a descriptive picture of P-SCAD presentation, clinical course, management and outcomes.

Methods: International databases were systematically screened up to November 2023 and all published P-SCAD case reports/series identified; additionally, we gathered four original cases, establishing a new database for the derived cohort.

Results: 253 studies (215 case reports, 38 case series) were included for the analysis, enrolling 316 patients admitted between 1952 and 2023. Median age was 34 (SD 5) years old, 64 (20.4 %) were prepartum, 249 (79.6 %) postpartum. Most common presentation was ST-elevation myocardial infarction (72.6 %). Cardiac arrest and cardiogenic shock occurred in 18.4 % and 16.1 %, respectively. Multivessel dissection was present in 45.2 % of cases, with left anterior descending artery being most frequently affected (74.4 %). Initial therapeutic strategy was medical therapy in 54.8 % while upfront revascularization was performed in 45.2 % of cases. Excluding autoptic studies, mortality rate was 4.1 %, without significant differences between pre and postpartum SCAD (p-value 0.6) or according to initial therapeutic approach (p-value 0.5). Recurrences after index event were registered in 74 patients (23.4 %), being more common after medical treatment than in case of immediate revascularization (30.8 versus 18.3 %, p-value 0.02).

Conclusions: P-SCAD is a complex clinical scenario: timely diagnosis is difficult, therapeutic management not well-defined, rate of recurrences not negligible. Additional observational studies and dedicated registries are necessary to enhance the management of this rare but severe condition.