自发性冠状动脉夹层与妊娠相关。

Spontaneous Coronary Artery Dissection Associated With Pregnancy.

机构信息

Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota.

出版信息

J Am Coll Cardiol. 2017 Jul 25;70(4):426-435. doi: 10.1016/j.jacc.2017.05.055.

DOI:10.1016/j.jacc.2017.05.055

PMID:28728686

Abstract

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is the most common cause of pregnancy-associated myocardial infarction and remains poorly characterized.

OBJECTIVES

This study sought to assess presentation, clinical factors, and outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD) compared with spontaneous coronary artery dissection not associated with pregnancy (NP-SCAD).

METHODS

A Mayo Clinic registry was established in 2010 to include comprehensive retrospective and prospective SCAD data. Records were reviewed to identify women who were pregnant or ≤12 weeks postpartum at time of SCAD. Complete records were available for 323 women; 54 women met criteria for P-SCAD (4 during pregnancy) and they were compared with 269 women with NP-SCAD.

RESULTS

Most events occurred within the first month postpartum (35 of 50). Compared with NP-SCAD, P-SCAD patients more frequently presented with ST-segment elevation myocardial infarction (57% vs. 36%; p = 0.009), left main or multivessel SCAD (24% vs. 5%; p < 0.0001; and 33% vs. 14%; p = 0.0027, respectively), and left ventricular function ≤35% (26% vs. 10%; p = 0.0071). Among women with imaging of other vascular territories, P-SCAD was less likely with a diagnosis of fibromuscular dysplasia and extracoronary vascular abnormalities (42% vs. 64%; p = 0.047; and 46% vs. 77%; p = 0.0032, respectively). Compared with U.S. birth data, women with P-SCAD were more often multiparous (p = 0.0167), had a history of infertility therapies (p = 0.0004), and had pre-eclampsia (p = 0.001). On long-term follow-up (median 2.3 years) recurrent SCAD occurred in 51 patients, with no difference in the Kaplan Meier 5-year recurrence rates (10% vs. 23%; p = 0.18).

CONCLUSIONS

P-SCAD patients had more acute presentations and high-risk features than women with NP-SCAD did. The highest frequency of P-SCAD occurred during the first postpartum month and P-SCAD patients less often had extracoronary vascular abnormalities. Hormonal, hemodynamic variations, and yet-undefined mechanisms might be significant contributors to P-SCAD. (The "Virtual" Multicenter Spontaneous Coronary Artery Dissection [SCAD] Registry [SCAD]; NCT01429727; Genetic Investigations in Spontaneous Coronary Artery Dissection [SCAD]; NCT01427179).

摘要

背景

自发性冠状动脉夹层（SCAD）是妊娠相关心肌梗死的最常见原因，但其特征仍描述不清。

目的

本研究旨在评估妊娠相关自发性冠状动脉夹层（P-SCAD）与非妊娠相关自发性冠状动脉夹层（NP-SCAD）的临床表现、临床特征和结局。

方法

2010 年建立了梅奥诊所注册中心，以纳入全面的回顾性和前瞻性 SCAD 数据。回顾记录以确定在 SCAD 发生时处于妊娠或产后≤12 周的女性。323 名女性的完整记录可用；54 名女性符合 P-SCAD 标准（4 名在妊娠期间），并与 269 名 NP-SCAD 女性进行比较。

结果

大多数事件发生在产后第一个月（35 例中有 50 例）。与 NP-SCAD 相比，P-SCAD 患者更常出现 ST 段抬高型心肌梗死（57% vs. 36%；p=0.009）、左主干或多支血管 SCAD（24% vs. 5%；p<0.0001；和 33% vs. 14%；p=0.0027）和左心室功能≤35%（26% vs. 10%；p=0.0071）。在对其他血管区域进行影像学检查的女性中，P-SCAD 较少伴有纤维肌性发育不良和冠状动脉外血管异常（42% vs. 64%；p=0.047；和 46% vs. 77%；p=0.0032）。与美国出生数据相比，P-SCAD 女性更常为多产妇（p=0.0167）、有不孕治疗史（p=0.0004）和子痫前期（p=0.001）。在长期随访（中位 2.3 年）中，51 名患者出现复发性 SCAD，Kaplan-Meier 5 年复发率无差异（10% vs. 23%；p=0.18）。

结论

与 NP-SCAD 女性相比，P-SCAD 患者的临床表现更为急性，且具有更高的高危特征。P-SCAD 发生的最高频率发生在产后第一个月，P-SCAD 患者较少有冠状动脉外血管异常。激素、血流动力学变化和尚未明确的机制可能是 P-SCAD 的重要因素。（“虚拟”多中心自发性冠状动脉夹层（SCAD）登记处[SCAD]；NCT01429727；自发性冠状动脉夹层（SCAD）的遗传研究；NCT01427179）。