‘Hearing hooves, finding zebras’: the differential diagnosis of cardiac arrest precipitated by chest pain in the postpartum woman

We describe the case of a 3-week postpartum 27-year-old woman who presented with chest pain to the emergency department shortly before developing cardiac arrest with refractory ventricular fibrillation. She was initially misdiagnosed and treated for presumed pulmonary embolism (PE) with thrombolysis. A total of 14 direct current cardioversion shocks were given and return of spontaneous circulation (ROSC) was achieved post thrombolysis. Subsequent CT pulmonary angiography excluded PE. A post-ROSC ECG demonstrated anterolateral ST elevation and she was transferred to the local cardiac unit for angiography. This revealed extensive dissection of the left anterior descending artery (LAD) with proximal occlusion. The diagnosis therefore was pregnancy-associated spontaneous artery dissection, a type of acute coronary syndrome. She received percutaneous intervention to her LAD with five drug-eluting stents. The patient survived and was discharged 5 days later. Her ventricular function is now grossly impaired, and had the correct diagnosis been arrived at sooner, this loss of function would have been less severe.