Post-partum SCAD with ongoing ischaemia — case discussion

Presentation

Practice case (not a real patient). A 34-year-old woman, 5 days after an uncomplicated vaginal delivery and not breastfeeding, presents with severe central chest pain. Her ECG shows anterior ST-segment elevation and troponin is rising.^[7][5] She has no cardiovascular risk factors and no previous cardiac history.^[5]

Step 1 — What are you thinking?

Discussion:

• ESC 2023: SCAD is the most common cause of AMI in pregnancy, tending to occur mainly in late pregnancy or the early post-partum period.^[2]
• ESC 2025 pregnancy: pregnancy-associated SCAD is the single most frequent cause of ACS during pregnancy and post-partum (43%); it may occur at any time during or after pregnancy, although >70% occur early post-partum, most commonly within the first week.^[7]
• The Fifth UDMI says SCAD should be considered particularly in women under 50 years and in pregnancy or the post-partum period.^[1]
• Pregnant women with SCAD tend to present more severely than women with non-SCAD ACS (ESC 2025 pregnancy), and AHA 2018 notes that women with pregnancy-associated SCAD seem to have a poorer prognosis than women with SCAD unrelated to pregnancy.^[7][5]

Step 2 — Angiography

Discussion:

• Once SCAD is suspected, AHA 2018 advises coronary angiography as early as feasible, especially in STEMI.^[5]
• The catheter is part of the risk: ESC ACCA 2018 advises a meticulous co-axial technique and avoidance of aggressive or deeply engaging guiding catheters because of secondary iatrogenic dissection.^[6]
• Angiography shows a proximal left anterior descending dissection with reduced antegrade flow. Her pain and ST-segment elevation persist, and the territory at risk is large.^[2][7]

Step 3 — Does she need revascularisation?

Discussion:

• Yes. ESC 2023 recommends PCI in spontaneous coronary artery dissection only for patients with symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow (Class I, Level C), and she meets all three.^[2]
• NHFA/CSANZ 2025 also says to consider selective revascularisation in SCAD with haemodynamic instability and/or ongoing ischaemia (weak recommendation, very low certainty).^[10]
• ESC 2025 pregnancy adds that if SCAD involves the left main or proximal vessels, CABG may be considered depending on technical considerations and local expertise, and a multidisciplinary team should decide between PCI and CABG.^[7]

Step 4 — Doing PCI safely

Discussion:

• If there is any uncertainty, confirm that the guidewire is in the true lumen before intervening, because stenting into the false lumen can have serious consequences (ESC ACCA 2018).^[6]
• ESC 2023 lists strategies that may be useful: minimal plain balloon angioplasty to restore flow followed by a conservative strategy, targeted stenting to seal the proximal and distal ends of the dissection, and/or extended stent lengths to prevent haematoma propagation.^[2]
• Where stents are deployed, second-generation drug-eluting stents are advised (ESC ACCA 2018).^[6]
• Thrombolysis is contraindicated in acute SCAD (ESC ACCA 2018).^[6]

Step 5 — Drugs after PCI

Discussion:

• After stenting, ESC ACCA 2018 says DAPT for 12 months and then prolonged or lifelong monotherapy, usually aspirin, in line with ACS guidelines; AHA 2018 says standard guideline-based antiplatelet therapy after PCI.^[6][5]
• ESC ACCA 2018 says an assessment of LV systolic function is mandatory after SCAD, as after MI of other causes, to guide medical and potentially device therapy.^[6]
• AHA 2018: β-blockers should be considered with LV dysfunction, arrhythmias or hypertension; ACE inhibitors or ARBs when MI is complicated by LV systolic dysfunction, with a warning about teratogenicity for women of reproductive age.^[5]
• Statins are not recommended routinely after SCAD unless there is a conventional indication (AHA 2018).^[5]
• If prolonged, severe menorrhagia develops while antiplatelet therapy is mandated after stenting, ESC ACCA 2018 says a levonorgestrel-releasing intrauterine system or endometrial ablation may be considered, and AHA 2018 says NSAIDs and tranexamic acid should generally be avoided in women with SCAD.^[6][5]

Step 6 — Before she goes home

Discussion:

• Screen for associated arteriopathy: a complete vascular examination, with vascular imaging from the brain to pelvis considered (AHA 2018).^[5]
• Refer for cardiac rehabilitation, tailored to her ejection fraction, age and goals (AHA 2018).^[5]
• Counsel her carefully about recurrence in a future pregnancy (ESC 2025 pregnancy); ESC ACCA 2018 considers any planned or unplanned pregnancy high risk.^[7][6]
• Avoiding hormonal contraception where possible may be a reasonable strategy (ESC ACCA 2018).^[6]
• Anxiety and depression are common after SCAD, especially after peripartum SCAD (AHA 2018).^[5]