Abstract 4371279: A Rare Combination: Postpartum SCAD With Fibromuscular Dysplasia

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare, underrecognized cause of acute coronary syndrome, responsible for up to 4% of ACS cases, with higher incidence in young females. It can result in myocardial infarction, arrhythmia, or sudden cardiac death. Fibromuscular dysplasia (FMD) is a common nonatherosclerotic arteriopathy found in SCAD patients. Pregnancy-associated SCAD (PASCAD) affects 1.81 per 100,000 pregnancies, according to national inpatient data. Case Presentation: A 38-year-old woman, G3P3, presented 16 days postpartum with chest pain radiating to both arms and transient left monocular vision loss. Troponins rose from 466 to 638 ng/L over 90 minutes. EKG showed ischemic changes. Cardiac catheterization revealed SCAD type 1, 2, and 3 on RPDA and RPLB, OM1, and mid to distal LAD respectively. Echocardiogram showed lateral wall hypokinesis with preserved ejection fraction. CT angiography identified 60% stenosis and subtle beading of the left internal carotid artery, <50% stenosis of the right carotid, and segmental narrowing of the superior mesenteric artery suggestive of FMD. ESR and CRP were elevated but rheumatologic workup was negative. Brain MRI and vascular duplex studies were unremarkable. The patient was treated with nitroglycerin and discharged on aspirin, clopidogrel, metoprolol, rosuvastatin, and amlodipine. Eleven days later, she presented with similar chest pain but no new EKG changes. She declined repeat angiography and opted to continue conservative management with cardiac rehabilitation. Discussion: PASCAD is a rare but important cause of ACS in postpartum women, likely driven by hormonal, hemodynamic, and vascular changes that increase arterial fragility. Coronary angiography is the diagnostic gold standard in symptomatic patients. Conservative medical therapy is preferred over PCI, given risks of stent misplacement and dissection extension. SCAD often resolves spontaneously, though recurrence occurs in ~11% within two years. Associations with pregnancy and FMD are well recognized and FMD is found in up to 86% of SCAD cases. SCAD and FMD share overlapping genetic mechanisms, underscoring the need for vascular screening in postpartum patients. Conclusion: This case highlights the importance of considering SCAD in postpartum women and the role of FMD as a predisposing arteriopathy. Prompt recognition and tailored management are essential to reduce morbidity and avoid invasive procedures when possible.