Diagnostic challenges in identifying myocardial infarction due to coronary vasospasm in pregnancy complicated by partial HELLP syndrome: a case report

Background Although a prevalence of acute myocardial infarction (AMI) is rare in young females regardless of pregnancy, coronary vasospasm (CVS) and spontaneous coronary artery dissection (SCAD) could be observed. Physiologic and hormonal changes during pregnancy, as well as inflammation and vasoreactivity secondary to autoimmune diseases could contribute to CVS or SCAD. Case summary We present a 39-year-old woman with systemic lupus erythematosus, antiphospholipid syndrome, and partial hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome who developed chest discomfort. Initially the on-call physicians considered that this was attributed to demand ischemia secondary to obstetric complications. Due to non-reassuring fetal heart tracings and the development of partial HELLP syndrome, she underwent an emergency cesarean section and her chest discomfort resolved following delivery. However, she developed chest pain again. Electrocardiography showed ST-segment depression in the inferior, anterior, and lateral leads, and cardiac troponin I increased to 5,452 pg/mL. Echocardiography demonstrated normal left ventricular ejection fraction of 60%. SCAD was excluded by coronary angiography and CVS-induced AMI was diagnosed through acetylcholine provocation testing. Following the administration of diltiazem 100 mg twice daily and enalapril 2.5 mg once daily, both of which are considered safe during breastfeeding, the patient and her newborn have done well. Discussion At the time the patient developed chest pain, identifying the cause of the symptom was challenging due to multiple concomitant underlying diseases such as HELLP syndrome and autoimmune diseases. A multidisciplinary approach, along with the timely use of diagnostic tools, are essential for accurate diagnosis and management.