⚠️ Overview

SCAD is a tear in the wall of a coronary artery that primarily affects young, otherwise healthy women. It accounts for 25-35% of acute coronary syndromes in women under 50.

• Contrast staining of arterial wall
• Multiple radiolucent lumens
• Long smooth stenosis (>20mm)
• Abrupt change in vessel caliber

• Medical management: Beta-blockers, aspirin, consider ACE inhibitors
• Avoid: Thrombolytics (can extend dissection)
• PCI: Only if ongoing ischemia or hemodynamic instability
• Cardiac rehabilitation with modified protocols
• Long-term follow-up: Annual imaging recommended

⚠️ Overview

Takotsubo cardiomyopathy, also known as "broken heart syndrome," is characterized by temporary left ventricular dysfunction following emotional or physical stress. 90% of cases occur in postmenopausal women.

1. Transient left ventricular wall motion abnormalities extending beyond a single coronary distribution
2. Absence of obstructive coronary disease or acute plaque rupture
3. New ECG abnormalities (ST elevation and/or T-wave inversion) or modest elevation in cardiac troponin
4. Absence of pheochromocytoma or myocarditis

• Supportive care, hemodynamic monitoring
• ACE inhibitors or ARBs for LV dysfunction
• Beta-blockers (use cautiously if cardiogenic shock)
• Anticoagulation if LV thrombus present

• Most patients recover fully within weeks to months
• Consider continuing ACE-I/ARB and beta-blocker for 3-12 months
• Psychological support and stress management
• Recurrence rate: 10% at 5 years

⚠️ Overview

Preeclampsia is a pregnancy complication characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks gestation. It increases lifetime cardiovascular disease risk 2-4 fold.

• Proteinuria: ≥300 mg/24hr or protein/creatinine ratio ≥0.3
• Thrombocytopenia: Platelets <100,000/μL
• Renal insufficiency: Creatinine >1.1 mg/dL or doubling of creatinine
• Liver involvement: Elevated transaminases (2x normal)
• Pulmonary edema
• Cerebral or visual symptoms

• BP control: Labetalol, nifedipine, methyldopa (avoid ACE-I/ARBs)
• Seizure prophylaxis: Magnesium sulfate if severe features
• Monitoring: BP q4h, daily labs if severe, fetal monitoring
• Delivery timing: 34-37 weeks based on severity

• Continue MgSO4 24-48h postpartum if severe features
• BP monitoring for 72h minimum, up to 2 weeks
• Long-term CVD risk counseling
• Annual cardiovascular risk assessment recommended

⚠️ Overview

PPCM is heart failure occurring in the last month of pregnancy or within 5 months postpartum in the absence of other identifiable causes. Incidence: 1 in 1,000-4,000 live births in the US.

1. Heart failure in last month of pregnancy or within 5 months postpartum
2. Left ventricular ejection fraction (LVEF) <45%
3. Left ventricular end-diastolic dimension >2.7 cm/m² BSA
4. No other identifiable cause of heart failure

• Diuretics: Furosemide (safe in pregnancy)
• Beta-blockers: Metoprolol, carvedilol
• Hydralazine + nitrates: Alternative to ACE-I
• Anticoagulation: If LVEF <30% or LV thrombus
• Avoid: ACE-I, ARBs, aldosterone antagonists during pregnancy

• Standard HF therapy: ACE-I/ARBs, beta-blockers, diuretics
• Bromocriptine: Consider 2.5mg BID x 2-8 weeks (emerging evidence)
• Advanced therapies: Consider VAD or transplant if refractory
• Contraception: Avoid future pregnancy until full recovery

• Full recovery (LVEF >50%): 50-60% within 6 months
• Persistent dysfunction: 25-30%
• Mortality: 5-15% (higher in developing countries)
• Recurrence risk: Very high (30-50%) in subsequent pregnancies, especially if incomplete recovery

⚠️ Overview

CMD (also called microvascular angina or Cardiac Syndrome X) is chest pain with evidence of myocardial ischemia but no obstructive coronary artery disease on angiography. More common in women, accounting for up to 50% of women with angina and non-obstructive CAD.

• Symptoms: Angina or angina equivalent
• Evidence of ischemia: Abnormal stress test, ECG changes
• No obstructive CAD: Angiography showing <50% stenosis
• Objective CMD: Invasive testing (CFR, IMR) or PET showing impaired flow reserve

• Coronary flow reserve (CFR): <2.0 abnormal (adenosine stress)
• Index of microcirculatory resistance (IMR): >25 abnormal
• PET myocardial perfusion: Reduced perfusion reserve

• First-line: Beta-blockers, calcium channel blockers (especially if vasospastic component)
• ACE inhibitors/ARBs: Improve endothelial function
• Statins: Even with normal cholesterol (anti-inflammatory effects)
• Ranolazine: May improve symptoms
• Aspirin: Standard antiplatelet therapy

• Exercise training (supervised cardiac rehabilitation)
• Weight loss if overweight
• Diabetes control
• Stress management

⚠️ Overview

FMD is a non-atherosclerotic, non-inflammatory vascular disease that primarily affects medium-sized arteries. It most commonly involves renal and cerebrovascular arteries, but can affect any arterial bed. 90% of patients are women. Strong association with SCAD (30-50% of SCAD patients have FMD).

• "String of beads": Classic multifocal FMD (85-90% of cases)
• Focal FMD: Single stenosis, tubular stenosis
• Preferred modalities: CT angiography, MR angiography, catheter angiography

• All SCAD patients should be screened for FMD (head-to-pelvis imaging)
• Young women with hypertension or stroke should be evaluated for FMD
• First-degree relatives may warrant screening

• Antiplatelet therapy: Aspirin recommended
• Hypertension control: ACE-I, ARBs, or calcium channel blockers
• Statin: Consider even if normal cholesterol

• Angioplasty: For symptomatic renal FMD with resistant hypertension
• Avoid stenting: Higher risk of complications
• Surgical revascularization: Rarely needed