Pregnancy-Associated SCAD Is Often More Severe Yet Still Conservatively Managed

NEW ORLEANS — Women with pregnancy-associated spontaneous coronary artery dissection (P-SCAD) had a more severe presentation than those with SCAD who were not pregnant (NP-SCAD), according to a cohort study.

Based on prospectively collected data from the iSCAD registry, those with P-SCAD had lower rates of fibromuscular dysplasia than women with NP-SCAD (31% vs 45%, P=0.01) but similar levels of extracoronary abnormalities, reported Agnes Koczo, MD, of the University of Pittsburgh Medical Center, and colleagues. The data were presented at the American College of Cardiology annual meeting and simultaneously published in JAMA Cardiology.

Women with P-SCAD tended to have more severe SCAD phenotypes than those with NP-SCAD, including higher incidence of ST-segment elevation myocardial infarction (STEMI, 18.6% vs 5.5%, P<0.001), multivessel segment involvement (31% vs 17%, P=0.004), left ventricular ejection fraction (LVEF) lower than 40% (27% vs 7%, P=0.006), and in-hospital major adverse cardiac events (10% vs 5%, P=0.03). Plus, those with P-SCAD experienced less LVEF recovery by 1-year follow-up, with recovery defined as LVEF ≥50% on follow-up echocardiogram within 1 year of follow-up, the authors said.

Three-quarters of both groups were primarily medically managed and did not undergo percutaneous coronary intervention (PCI). The authors reported that a significantly lower proportion of those with P-SCAD received in-hospital anticoagulation versus those with NP-SCAD (74% vs 87%, P=0.001), but that rates of in-hospital single- and dual-antiplatelet therapy use was similar in the two groups.

Among the roughly one-fourth who did undergo PCI, “there were no PCI-related complications in the group with P-SCAD (vessel perforation, side branch loss, no-reflow, abrupt vessel closure, thrombus formation, SCAD extension, or edge dissection),” Koczo’s group said.

“Our study builds on prior data that women with P-SCAD often have more severe presentation,” Koczo told MedPage Today. “Despite this, there were no differences in approach to treatment, with both groups receiving predominantly conservative treatment.”

Authors noted that P-SCAD, a cause of nonatherosclerotic MI, is “a highly morbid condition for which there are limited data to guide pregnancy counseling.”

The analysis found that women with P-SCAD also were significantly more likely to have used assisted reproductive technology (ART, 26% vs 12% in NP-SCAD group, P<0.001), to have pre-eclampsia (25% vs 13%, P=0.001), and to have been pregnant with more than five gestations (13% vs 7%, P=0.02).

Maryam Tarsa, MD, MAS, of the University of California San Diego, noted that P-SCAD is poorly understood and that research specifically looking at the risk of devastating cardiac events during the pregnancy and postpartum periods is desperately needed. Tarsa said that she appreciated that this study’s P-SCAD group included women up until a year postpartum.

“The study highlights the importance of hormonal shifts not only during pregnancy or immediately postpartum but up to a year as the woman’s body is undergoing significant changes and adjusting to new stresses including breast feeding, contraception, and family dynamics,” Tarsa, who was not involved in the study, told MedPage Today. She added that it also calls attention to the importance of baseline cardiac screening, which should start prior to pregnancy, especially for patients interested in ART.

The authors analyzed data from 2019-2024 from the prospective registry that collects patient-facing survey data and investigator-corroborated clinical and imaging data in the U.S. and Australia. Adults women included in the analysis had a SCAD diagnosis not iatrogenic or related to atherosclerosis that was confirmed by coronary angiography; had any history of pregnancy; and answered a baseline questionnaire.

In all, there were 907 participants (n=98 with P-SCAD; n=809 with NP-SCAD) with a median age 52.0 at enrollment and 49.2 at first SCAD event. The median age at first SCAD event was younger in the P-SCAD group than the NP-SCAD group (36.7 vs 50.7).

Most of the cohort were white (87.4%) and not Hispanic or Latino (94.9%); 7.8% were Black or African American, 5.1% were Hispanic or Latino, 2.0% were Asian, 1.5% were multiracial, 0.5% were American Indian or Alaska Native, and 0.3% were Native Hawaiian or other Pacific Islander.

“One important takeaway is that all patients with SCAD, whether associated with pregnancy or not, should have comprehensive vascular imaging performed given the equal prevalence of vascular abnormalities between the P-SCAD and NP-SCAD groups,” Koczo said.

Study limitations included patients’ self-reporting information on reproductive health features and mental health surveys, the possibility of missing data, and that the acute coronary syndrome categorization was selected by sites. Koczo said her group hopes to continue research characterizing how fluctuating hormones affect SCAD events.