Coronary artery plaque disruption as cause of acute myocardial infarction during cesarean section with spinal anesthesia

A 31-year-old parturient delivered twins at 35 weeks' gestation by cesarean section with spinal anesthesia. Following anesthesia induction, hypotensio n and bradycardia occurred, and were immediately treated with theodrenaline plus cafedrin (Akrinor) and atropine. Blood pressure and heart rate increa sed to 180/100 mmHg and 140 beats per minute, respectively. Several minutes later, the patient developed a myocardial infarction (MI) that she survive d after intensive care treatment without sequelae. Although the coronary an giography showed normal coronary vessels, an intravascular ultrasound study demonstrated an atheroma in the left main coronary artery with ruptured fi brous cap. Laboratory screening for risk factors of coronary artery disease (CAD) showed hypercholesterinemia, increased factor VII activity, and hype rfibrogenemia. Angiographically normal coronary vessels are frequently foun d in pregnant patients who suffered MI. In these patients, coronary spasms have been discussed as the major mechanism of disease. Our case demonstrate s that a significant CAD may be present despite angiographically normal fin dings. Plaque rupture was triggered by hypertension and led to MI as the fi rst symptom of disease. On the basis of these findings, we believe that MI during pregnancy is more often caused by plaque rupture than may be expecte d, according to the current literature. (C) 2000 by Elsevier Science Inc.