Pregnancy-Associated Spontaneous Coronary Artery Dissection

Importance: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction predominantly affecting women. There is a paucity of reproductive health data surrounding pregnancy-associated SCAD (P-SCAD). Objective: To examine detailed reproductive variables as well as demographics, psychosocial, and SCAD-event factors among women with a history of at least 1 prior pregnancy in a large, multicenter registry (iSCAD Registry). Design, Setting, and Participants: This cohort study compared data of women with P-SCAD vs women with non-pregnancy-associated SCAD (NP-SCAD) between the years 2019 and 2024 and rates of certain reproductive health features among the general reproductive-aged population in US states. Differences were analyzed using the Kruskal-Wallis test for continuous variables and χ2 test for categorical variables. Exposures: Pregnancy and SCAD. Main Outcomes and Measures: Patient survey-based clinical and reproductive history variables were collected and corroborated with investigator-extracted clinical and imaging data, including detailed characterization of the SCAD event. Results: Among 907 women (median [IQR] age at enrollment, 52.0 [45.1-59.4] years; median [IQR] age at first SCAD event, 49.2 [42.3-57.1] years) with SCAD and 1 or more pregnancies, 98 had P-SCAD with median (IQR) age of 36.7 (33.7-39.1) years at time of SCAD event. Those with P-SCAD had a lower prevalence of fibromuscular dysplasia (27 of 86 [31%] vs 309 of 681 [45%]; P = .01) but similar rates of extracoronary abnormalities. Greater use of assisted reproductive technology (ART; 25 of 97 [26%] vs 98 of 804 [12%]), greater multigravida with more than 5 gestations (13 of 98 [13%] vs 55 of 809 [7%]), and preeclampsia (24 of 98 [25%] vs 101 of 809 [13%]; P = .001) were reported among women with P-SCAD. Those with P-SCAD had a more severe SCAD phenotype including higher incidence of STEMI (16 of 86 [18.6%] vs 40 of 733 [5.5%]; P < .001), multivessel segment involvement (22 of 70 [31%] vs 101 of 588 [17%]; P = .004), and left ventricular ejection fraction (LVEF) lower than 40% (4 of 15 [27%] vs 6 of 105 [7%]; P = .006). They also experienced less LVEF recovery by 1-year follow-up. The majority (661 of 887 [75%]) of both groups were primarily medically managed. Conclusions and Relevance: From this large, multisite registry, results reveal that women with P-SCAD had greater median ages at gestation, greater history of ART use, and greater instances of multigravida and preeclampsia than women with NP-SCAD and the general reproductive-aged US population. With high percentages of vascular imaging among participants, women with P-SCAD had less fibromuscular dysplasia but similar rates of extracoronary abnormalities including dissection and aneurysms as women with NP-SCAD. In this contemporary cohort, women with P-SCAD continue to represent a higher-risk phenotype with predominantly conservative management; however, they had less LVEF recovery.