Acute myocardial infarction associated with pregnancy

Percutaneous Coronary Intervention in Pregnancy: A Contemporary Review

Percutaneous coronary intervention (PCI) during pregnancy presents unique challenges due to physiological cardiovascular adaptations and concerns regarding maternal and fetal safety. This comprehensive review examines the current understanding of PCI in pregnancy, including pathophysiology, indications, technical considerations, outcomes, and management approaches. Despite being rare, cardiovascular disease remains the leading cause of maternal mortality in developed countries, with acute coronary syndrome increasing in frequency among pregnant women. The management of acute coronary syndrome in pregnancy requires a multidisciplinary approach focusing on maternal safety while minimizing fetal risks. Current evidence supports the use of PCI as the preferred revascularization strategy for appropriate indications during pregnancy, with specific procedural modifications to minimize radiation exposure and optimize medication selection. This review synthesizes contemporary literature to provide evidence-based recommendations for the management of pregnant patients requiring coronary intervention.

Sudden Cardiac Death in Pregnant Women-Literature Review and Autopsy Findings

Cardiovascular diseases increase among pregnant women and complicate 1-4% of pregnancies worldwide. The incidence of maternal deaths due to cardiovascular causes has increased dramatically, rising from 3% three decades ago to 15% in recent years. The aim of this study is to provide a comprehensive overview of the current status of knowledge in sudden maternal death (SMD) described in the literature and to present two cases of autopsy findings in sudden cardiac death in pregnant women. Among the most common causes of sudden maternal deaths are peripartum cardiomyopathies, aortic dissection, acute myocardial infarction, arrhythmias, ischemic heart disease, and coronary artery dissection, and among the less common causes, we list coronary artery dissection, congenital heart diseases, valvulopathies, hypertension, fibroelastosis, and borderline myocarditis. The Centers for Disease Control and Prevention (CDC) reported that over 80% of pregnancy-related deaths were preventable. To reduce the number of maternal deaths caused by cardiovascular diseases, the implementation of specialized multidisciplinary teams has been proposed. Molecular biology techniques are proving their effectiveness in forensic medicine. PCR or DNA sequencing can be utilized in "molecular autopsy", which holds particular value in cases of sudden death where the forensic autopsy is negative but there is a suspicion that death was caused by arrhythmia. Susceptibility genes can be analyzed, such as KCNQ1, KCNH2, KCNE1, and KCNE2, which are involved in long QT syndrome, the RYR2 gene implicated in catecholaminergic polymorphic ventricular tachycardia type 1, or the SCN5A gene associated with Brugada syndrome. Early identification of risk factors involved in sudden maternal death prenatally and during pregnancy is essential. At the same time, genetic determinations and molecular biology techniques are absolutely necessary to prevent the occurrence of sudden deaths among close relatives.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Pregnancy and Postpartum Trends in Self-Measured Blood Pressure and Derived Indices: The BOSHI Study

In this study, we aimed to reveal the trends of self-measured blood pressure (SMBP) and SMBP-derived indices during pregnancy and the postpartum period. The Babies and Their Parents Longitudinal Observation in Suzuki Memorial Hospital in the Intrauterine Period (BOSHI) Study is a prospective cohort study in Japan. Participants were instructed to measure SMBP daily during pregnancy and for 1 month after delivery. Among 237 participants with normotensive blood pressure (BP) during pregnancy and the postpartum period who were analyzed using mixed-effects models for repeated measures, the SMBP was measured, on average, 14.3 times from the day before delivery to 28 days postpartum. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) on the day before delivery were 110.6 ± 1.0 and 68.1 ± 0.8 mmHg (estimate ± standard error). Postpartum BP increased from postpartum Days 3-8 in SBP and from Days 3-22 in DBP, compared to that on the day before delivery. The SBP and DBP were 4.9 and 4.7 mmHg higher on postpartum Days 8 and 7 than the day before pregnancy, respectively. During pregnancy, the pulse rate (PR) showed an inverted U-shaped trend and then sharply increased rapidly until the first postpartum day after delivery. The Shock Index showed a similar trend to that of the PR, decreased from labor until postpartum Day 8, and plateaued thereafter. The double product peaked during labor, remained higher than the prelabor levels for approximately 10 days, and then decreased in the postpartum period.

Obstetric anesthesia considerations in pregnancy-associated myocardial infarction: a focused review

Pregnancy-associated myocardial infarction (PAMI) is a rare but serious complication that can occur either during pregnancy or postpartum. The etiologies of PAMI are atherosclerosis, spontaneous coronary artery dissection, coronary thrombosis, coronary embolism, and coronary vasospasm. Therapy of acute PAMI depends largely on the ECG presentation, hemodynamic stability, and suspected etiology of myocardial infarction. Anesthetic management during delivery in patients with PAMI should consist of early and carefully titrated neuraxial analgesia and anesthesia, maintenance of normal sinus rhythm, preservation of afterload, and monitoring for and avoiding myocardial ischemia. To improve the care of women with PAMI, a multidisciplinary team of cardiologists, maternal fetal medicine specialists, obstetric providers, neonatologists, and anesthesiologists must work collectively to manage these complex patients.

Ischemic Heart Disease in Pregnancy: Current Understanding and Management Strategies

Ischemic heart disease (IHD) during pregnancy poses a rare but significant risk to maternal and fetal health, with global incidence rates ranging from 0.7 to 10 cases per 100,000 pregnancies. This review synthesizes current literature on the epidemiology, pathophysiology, clinical presentation, diagnosis, management, and outcomes of IHD in pregnancy. Pregnancy-related IHD encompasses various conditions, including coronary artery disease, spontaneous coronary artery dissection, myocardial infarction with nonobstructive coronary arteries, coronary embolism, and coronary vasospasm. The pathophysiology is multifactorial, involving hemodynamic changes, hormonal influences, and increased hypercoagulability. Clinical presentation may mimic typical pregnancy symptoms, necessitating a high index of suspicion for timely diagnosis. A multidisciplinary strategy is needed for management, taking into account the hazards to the mother and fetus while also taking drug safety and procedural treatments such coronary artery bypass grafting and percutaneous coronary intervention into account. Careful observation and timely management are necessary for complications such as cardiogenic shock, arrhythmias, and thromboembolic events following myocardial infarction. With advancements in treatment techniques and early discovery, the prognosis has improved, although maternal mortality is still a worry. For the purpose of improving results and directing future research endeavors, knowledge and comprehension of IHD during pregnancy are essential.

Spontaneous Coronary Artery Dissection in the Late Third Trimester of Pregnancy

Acute coronary syndrome due to a non-atherosclerotic, non-traumatic, or iatrogenic-induced spontaneous coronary artery dissection (SCAD) is a rare clinical condition that affects mostly young women of reproductive age. In this case, we present a 36-week-pregnant, 35-year-old G2P1 woman, with no previous medical history, who was admitted to our hospital with premature pre-labor contractions. During her hospitalization, she underwent a coronary artery percutaneous angiography revealing SCAD of the three coronary vessels, after an episode of acute-onset chest pain, tachypnea, EKG alterations, cardiac enzyme elevation, and bilateral pleural effusions. An emergency cesarean delivery was performed and the patient was transferred to the cardiology intensive care unit. Conservative management was decided and the woman was discharged a few days later.

Guidelines for assessing maternal cardiovascular physiology during pregnancy and postpartum

Maternal mortality rates are at an all-time high across the world and are set to increase in subsequent years. Cardiovascular disease is the leading cause of death during pregnancy and postpartum, especially in the United States. Therefore, understanding the physiological changes in the cardiovascular system during normal pregnancy is necessary to understand disease-related pathology. Significant systemic and cardiovascular physiological changes occur during pregnancy that are essential for supporting the maternal-fetal dyad. The physiological impact of pregnancy on the cardiovascular system has been examined in both experimental animal models and in humans. However, there is a continued need in this field of study to provide increased rigor and reproducibility. Therefore, these guidelines aim to provide information regarding best practices and recommendations to accurately and rigorously measure cardiovascular physiology during normal and cardiovascular disease-complicated pregnancies in human and animal models.

Antiplatelet Drugs Use in Pregnancy-Review of the Current Practice and Future Implications

When clinicians opt for antithrombotic therapy to manage or prevent thrombotic complications during pregnancy, it is imperative to consider the unique physiological state of the pregnant woman's body, which can influence the pharmacokinetics of the drug, its ability to traverse the placental barrier, and its potential teratogenic effects on the fetus. While the efficacy and safety of aspirin during pregnancy have been relatively well-established through numerous clinical studies, understanding the effects of newer, more potent antiplatelet agents has primarily stemmed from individual clinical case reports necessitating immediate administration of potent antiplatelet therapy during pregnancy. This review consolidates the collective experiences of clinicians confronting novel thrombotic complications during pregnancy, often requiring the use of dual antiplatelet therapy. The utilization of potent antiplatelet therapy carries inherent risks of bleeding, posing threats to both the pregnant woman and the fetus, as well as the potential for teratogenic effects on the fetus. In the absence of official guidelines regarding the use of potent antiplatelet drugs in pregnancy, a plethora of cases have demonstrated the feasibility of preventing recurrent thrombotic complications, mitigating bleeding risks, and successfully managing pregnancies, frequently culminating in cesarean deliveries, through meticulous selection and dosing of antiplatelet medications.

Ischemic Heart Disease in Women

This review synthesizes the current understanding of ischemic heart disease in women, briefly discussing differences in risk factors, presentation, and treatment. We have underscored the unique clinical phenotype of IHD in women with a higher prevalence of ischemia with non-obstructive coronary arteries. Further research is needed to elucidate the complexities of ischemic heart disease in women, understand the discordance between ischemic burden and clinical symptoms, and optimize treatment strategies.

The Impact of Medical Physical Training and a Structured Personalized Exercise Training Program on Hemodynamic Parameters and Arterial Stiffness in Pregnant Women

INTRODUCTION

In developed countries, heart disease is the primary cause of maternal mortality during pregnancy. Arterial stiffness, an independent risk factor for atherosclerosis and a predictor of cardiovascular complications, can be assessed using the augmentation index (AIx) and pulse wave velocity (PWV). In this prospective study, we aimed to evaluate diverse hemodynamic parameters and arterial stiffness in pregnant women before and after participating in a structured, personalized exercise training program.

MATERIALS AND METHODS

Forty healthy pregnant women, non-smokers, who agreed to participate daily for 12 weeks in a physical exercise training program under the supervision of a team made up of an obstetrician, a cardiologist, and a physiotherapist were included. Anthropometric characteristics, arterial function, and physical activity data were collected from the participants at two different time points: at the beginning of the exercise training program (T0) and at the end, after 12 weeks (T1).

RESULTS

Upon conducting a statistical analysis, it was discovered that there were noteworthy disparities (p = 0.05) in body mass index, brachial AIx, systolic blood pressure, and pulse pressure values between the two time points. The regression analysis for the AIx brachial values and the PWVao values from Trim II (T0) and Trim III (T1) showed major differences between these two time points; the association between the AIx brachial values in the second and third trimesters of pregnancy revealed a strong direct significant correlation (p < 0.001), and the correlation between the PWVao values in the second (T0) and third trimester (T1) of pregnancy was weak and insignificant (p = 0.12).

CONCLUSIONS

The findings of our study indicate that a personalized exercise training program positively impacts the physical and psychological well-being of pregnant women, leading to a reduction in PWV.

Ischemic heart disease in pregnancy: a practical approach to management

Ischemic heart disease is a crucial issue during pregnancy. The term is composed of both preexisting conditions and acute coronary syndrome in pregnancy, including pregnancy-associated myocardial infarction, which can have a significant effect on maternal and fetal outcomes. This review provides a complete guide to managing ischemic heart disease in pregnant women, emphasizing the importance of multidisciplinary care and individualized treatment strategies. Cardiovascular disease, particularly ischemic heart disease, is now the leading cause of maternal mortality worldwide. Pregnancy introduces unique physiological changes that increase the risk of acute myocardial infarction, with pregnancy-associated myocardial infarction cases often associated with factors, such as advanced maternal age, chronic hypertension, and preexisting cardiovascular conditions. This review distinguishes between preexisting ischemic heart disease and pregnancy-associated myocardial infarction. It will emphasize the various etiologies of pregnancy-associated myocardial infarction, including coronary atherosclerosis and plaque rupture presenting as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and other nonatherosclerotic causes, including spontaneous coronary artery dissection, vasospasm, and embolism. Our study discusses the practical management of ischemic heart disease in pregnancy, with a focus on preconception counseling, risk assessment, and tailored antenatal planning for women with preexisting ischemic heart disease. Moreover, this document focuses on the challenges of diagnosing cardiovascular disease, especially when presented with nonclassical risk factors and presentation. It provides insight into the appropriate diagnostic testing methods, such as electrocardiogram, cardiac biomarkers, and echocardiography. In addition, the review covers various treatment strategies, from medical management to more invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft. Special attention is given to medication safety during pregnancy, including anticoagulation, beta-blockers, and antiplatelet agents. The complexities of delivery planning in women with ischemic heart disease are discussed, advocating for a multidisciplinary team-based approach and careful consideration of the timing and mode of delivery. Furthermore, the roles of breastfeeding and postpartum care are explored, emphasizing the long-term benefits and the suitability of various medications during lactation. Lastly, this review provides crucial insights into the management of ischemic heart disease in pregnancy, stressing the need for heightened awareness, prompt diagnosis, and tailored management to optimize maternal and fetal health outcomes.

Acute Myocardial Infarction in Pregnancy

Pregnancy-associated myocardial infarction is an overall uncommon event, but can be associated with significant maternal and fetal morbidity and mortality. In contrast to myocardial infarction in the general nonpregnant population, the mechanism of pregnancy-associated myocardial infarction is most commonly due to nonatherosclerotic mechanisms such as coronary dissection, vasospasm, or thromboembolism. The diagnosis of pregnancy-associated myocardial infarction can be challenging, requiring a high index of suspicion for prompt recognition and management. Furthermore, the management of pregnancy-associated myocardial infarction can be complex due to maternal and fetal considerations and may vary based on the specific underlying mechanism of the myocardial infarction. This review aims to review the recent literature on pregnancy-associated myocardial infarction and summarize the epidemiology, mechanisms, diagnosis, and treatment strategies for this uncommon entity.

Spontaneous coronary artery dissection in women in the generative period: clinical characteristics, treatment, and outcome-a systematic review and meta-analysis

Introduction

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall.

Materials and methods

This systematic review and meta-analysis is reported following the PRISMA guidelines and is registered in the PROSPERO database. A literature search was focused on female patients in generative period (16-55 of age) with acute coronary syndrome (ACS) caused by SCAD, and comparison from that database NP-SCAD (spontaneous coronary artery dissection in non pregnant women) and P-SCAD (spontaneous coronary artery dissection in pregnant women).

Results

14 studies with 2,145 females in the generative period with ACS caused by SCAD were analyzed. The median age was 41 years (33.4-52.3 years). The most common risk factor was previous smoking history in 24.9% cases. The most common clinical presentation of ACS was STEMI in 47.4%. Conservative treatment was reported in 41.1%. PCI was performed in 32.7%, and 3.8% of patients had CABG surgery. LAD was the most frequently affected (50.5%). The prevalence of composite clinical outcomes including mortality, non-fatal MI and recurrent SCAD was 3.3% (95% CI: 1.4-5.1), 37.7% (95% CI: 1.9-73.4) and 15.2% (95% CI: 9.1-21.3) of patients. P-SCAD compared to NP-SCAD patients more frequently had STEMI (OR = 3.16; 95% CI: 2.30-4.34; I2 = 64%); with the left main and LAD more frequently affected [(OR = 14.34; 95% CI: 7.71-26.67; I2 = 54%) and (OR = 1.57; 95% CI: 1.06-2.32; I2 = 23%)]; P-SCAD patients more frequently underwent CABG surgery (OR = 6.29; 95% CI: 4.08-9.70; I2 = 0%). NP-SCAD compared to P-SCAD patients were more frequently treated conservatevly (OR = 0.61; 95% CI: 0.37-0.98; I2 = 0%). In P-SCAD compared to NP-SCAD mortality rates (OR = 1.13; 95% CI: 0.06-21.16; I2 = not applicable) and reccurence of coronary artery dissection (OR = 2.54; 95% CI: 0.97-6.61; I2 = 0%) were not more prevalent.

Conclusion

The results of this meta-analysis indicated that patients with P-SCAD more frequently had STEMI, and events more frequently involved left main and LAD compared to NP-SCAD patients. Women with NP-SCAD were significantly more often treated conservatively compared to P-SCAD patients. P-SCAD compared to NP-SCAD patients did not have significantly higher mortality rates or recurrent coronary dissection.

Trends in cardiovascular complications of pregnancy: A nationwide inpatient sample analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. Physiologic stress of pregnancy can induce several hemodynamic changes that contribute to an increased risk of cardiac complications in the peripartum period. There are ongoing efforts to improve cardiovascular mortality in pregnant patients. Understanding trends in cardiovascular complications during pregnancy may provide insight into improving care for high-risk pregnancies.

METHODS

We retrospectively analyzed data from the National Inpatient Sample (NIS) Database and identified all inpatient hospitalizations for pregnancy and delivery. We then analyzed trends in the rates of cardiac complications in the pregnant patient.

RESULTS

There are concerning increases in trends of cardiac complications and comorbidities in pregnant people including: acute coronary syndrome, spontaneous coronary artery dissection, cardiogenic shock, pulmonary hypertension, chronic congestive heart failure, heart transplant, aortic syndromes, stroke, and pulmonary embolism. While the rates of STEMI have decreased, the incidence of peripartum cardiomyopathy has remained stable.

CONCLUSION

There are concerning increases in certain cardiac complications during pregnancy. This is likely due to increasing age at the time of pregnancy and associated comorbidities.

Common Cardiovascular Diseases in Women

Cardiovascular disease is a leading cause of death for women in the United States. This article encompasses the epidemiology/etiology, clinical presentation, diagnostic assessment, management, and prognosis of some common cardiovascular disorders seen in women with a special focus on pregnancy.

[Acute coronary syndrome provoked by a coronary intramural hematoma]

Background

Intramural coronary hematoma (ICH) is an unusual cause of acute coronary syndrome, and it represents a diagnostic challenge, especially in young patients in which it is not considered among the differential causes of acute myocardial ischemia.

Clinical case

40-year-old female, with type 2 diabetes and no other cardiovascular risk factors, who assisted to the Emergency Room with chest pain. In her first evaluation, electrocardiographic abnormalities, and troponin I elevation were found. A cardiac catheterization was performed, in which a proximal obstruction of the left anterior descending artery was observed, and then an optical coherence tomography (OCT) confirmed the presence of an ICH without a dissection flap. A stent was implanted in the obstruction area, with adequate angiographic outcome. The patient had a satisfactory evolution and was discharged to home without evidence of systolic dysfunction and is free of cardiovascular symptoms at 6-month follow-up.

Conclusions

ICH must be considered within the differential diagnosis of acute myocardial ischemia in young patients, especially females. Intravascular image diagnosis is essential for the adequate diagnosis and treatment. Treatment must be individualized considering the extent of ischemia.

Spontaneous Coronary Arterial Dissection in a Young Female in the Postpartum Period: A Case Report From Sub-Saharan Africa

Spontaneous coronary arterial dissection (SCAD) has become an important cause of acute coronary syndrome (ACS) and sudden cardiac death, particularly in young women, without classic atherosclerotic cardiovascular risk factors. Missed diagnosis is common due to a low index of suspicion in these patients. Here, we present a case of a 29-year-old African female in the postpartum period who presented with a two-week history of heart failure symptoms and acute onset chest pain. An electrocardiogram showed ST-segment elevation myocardial infarction (STEMI) with elevated high-sensitivity troponin T. Echocardiography on admission revealed an ejection fraction of 40% with septal hypokinesia. Coronary angiography showed multivessel dissection with type 1 SCAD in the left circumflex artery and type 2 SCAD in the left anterior descending artery. The patient was managed conservatively, and angiographic healing of SCAD together with normalization of the left ventricular systolic dysfunction was seen after four months. SCAD should always be in the differential diagnosis of any peripartum patient who presents with ACS and lacks the typical atherosclerotic risk factors. Accurate diagnosis and appropriate management are paramount in such cases.

The role of the pregnancy heart team in clinical practice

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

Acute coronary syndrome during pregnancy and postpartum in France: the nationwide CONCEPTION study

BACKGROUND

Cardiovascular diseases, including acute coronary syndromes, are the leading cause of maternal death in many developed countries.

OBJECTIVE

We assessed acute coronary syndrome incidences during pregnancy, peripartum, and postpartum periods. We also compared overall pregnancy (ie, covering all 3 periods) incidence with that found in nonpregnant women of childbearing age.

STUDY DESIGN

All women aged between 15 and 49 years without ischemic heart disease who delivered between 2010 and 2018 in France were included in the CONCEPTION cohort. Data were extracted from the French National Health Insurance Information System database. Acute coronary syndromes were defined according to the International Classification of Diseases, Tenth Revision codes recorded in the principal hospital diagnosis. We used Poisson regression to estimate crude acute coronary syndrome incidences, and tested age-adjusted Poisson models to compare the incidence risk ratio of acute coronary syndrome between pregnant and nonpregnant women, with 95% confidence intervals.

RESULTS

Among 6,298,967 deliveries in France, we observed 225 first-time acute coronary syndrome diagnoses during overall pregnancy (overall pregnancy-related acute coronary syndrome incidence, 4.34/100,000 person-years; 1 case/23,000 pregnancies). In multivariate analysis, independent factors associated with acute coronary syndrome were age, social deprivation, obesity, tobacco use, chronic hypertension, and hypertensive disorders of pregnancy (all P<.05). Among the nonpregnant women aged 15 to 49 years in the general French population, 18,247 cases of acute coronary syndrome (incidence, 16.5/100,000 person-years) occurred throughout the whole study period (>100 million person-years). Compared with the acute coronary syndrome incidence in nonpregnant women, age-adjusted overall pregnancy-related acute coronary syndrome incidence was lower (incidence rate ratio, 0.76; 95% confidence interval, 0.57-0.98; P<.05). Although compared with nonpregnant women, age-adjusted incidence rates were lower during pregnancy, risk was increased during peripartum and postpartum periods.

CONCLUSION

With an incidence of 4.34 per 100,000 person-years, acute coronary syndrome still accounts for a significant proportion of maternal mortality. The peripartum and postpartum periods remain high-risk periods, and greater efforts should be made in terms of acute coronary syndrome prevention, especially because several cardiovascular risk factors are treatable, such as tobacco use and hypertensive disorders of pregnancy.

Impact of Pre-Existing Ischemic Heart Disease on Severe Maternal Morbidity and Mortality During Delivery Hospitalizations

BACKGROUND

The impact of pre-existing ischemic heart disease (IHD) on pregnancy is incompletely described.

OBJECTIVES

The purpose of this study was to compare adverse pregnancy outcomes between those with IHD and those with a cardiac diagnosis categorized by the modified World Health Organization classification and those without a cardiac diagnosis.

METHODS

This retrospective study used the 2015 to 2018 Nationwide Readmissions Database. Delivery hospitalizations, comorbidities, and outcomes were identified using diagnosis and procedure codes. The exposure was isolated IHD. The primary outcome was severe maternal morbidity (SMM) or death during the delivery hospitalization, analyzed using adjusted relative risk (aRR) regression and weighted to account for the Nationwide Readmissions Database's complex survey methods.

RESULTS

Of 11,556,136 delivery hospitalizations, 65,331 had another cardiac diagnosis, and 3,009 had IHD alone. Patients with IHD were older and had higher rates of diabetes and hypertension. In unadjusted analyses, adverse outcomes were more common among patients with IHD alone than among patients with no cardiac disease and modified World Health Organization class I-II disease. After adjustment, patients with IHD alone were associated with a higher risk of SMM or death (aRR: 1.51; 95% CI: 1.19-1.92) than those without a cardiac disease. In comparison, the aRR was 1.90 (95% CI: 1.76-2.06) for WHO class I-II diseases and 5.87 (95% CI: 5.49-6.27) for WHO II/III-IV diseases. Nontransfusion SMM or death (aRR: 1.60; 95% CI: 1.11-2.30) and cardiac SMM or death (aRR: 2.98; 95% CI: 1.75-5.08) were also higher for those with IHD.

CONCLUSIONS

Isolated IHD in pregnancy is associated with worse outcomes than no cardiac disease during delivery hospitalization and approximates the risk associated with WHO I-II diagnoses.

Pathophysiology, Diagnosis and Treatment of Spontaneous Coronary Artery Dissection in Peripartum Women

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of nonobstructive ischemic heart disease in previously healthy young women and therefore is not usually considered in differential diagnoses. The overall incidence of SCAD in angiographic series is between 0.28 and 1.1%, with a clear predominance in young, healthy women (70%) of whom approximately 30% are in the postpartum period. In the United Kingdom, between 2008 and 2012, SCAD was the cause of 27% of acute myocardial infarctions during pregnancy, with a prevalence of 1.81 per 100,000 pregnancies. Regarding the mechanism of arterial obstruction, this may be due to the appearance of an intramural hematoma or to a tear in the intima of the arteries, both spontaneously. Although multiple diagnostic methods are available, it is suggested to include an appropriate anamnesis, an electrocardiogram in the first 10 min after admission to the service or the onset of symptoms, and subsequently, a CT angiography of the coronary arteries or urgent coronary angiography if the hemodynamic status of the patient allows it. Treatment should be individualized for each case; however, the appropriate approach is generally based on two fundamental pillars: conservative medical treatment with antiplatelet agents, beta-blockers, and nitrates, and invasive treatment with percutaneous coronary intervention for stent implantation or balloon angioplasty, if necessary.

Perioperative management of acute myocardial infarction in the 31st week of pregnancy: A case report and literature review

Pregnancy-related acute myocardial infarction (PAMI) is rare but life-threatening. The incidence of PAMI is growing over time for multiple reasons, and the management of parturients with acute myocardial infarction is challenging in terms of diagnosis and treatment. To date, there are still no clear guidelines on the best practice for PAMI. We present a case of a 41-year-old woman with PAMI at 31 weeks of pregnancy. Through multidisciplinary collaboration, successful outcomes were achieved for both the mother and fetus.

Interventional Cardiac Procedures and Pregnancy

As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.

Incidence and outcomes of acute high-risk chest pain diseases during pregnancy and puerperium

Aim

To investigate the incidence and outcomes of acute high-risk chest pain diseases, including acute myocardial infarction (AMI), aortic dissection (AD), and pulmonary embolism (PE) during pregnancy and puerperium.

Methods

The National Inpatient Sample was queried to identify pregnancy-related hospitalizations from January 1, 2008 to December 31, 2017. Temporal trends in the incidence and mortality of AMI, AD and PE were extracted.

Results

Among 41,174,101 hospitalizations, acute high-risk chest pain diseases were diagnosed in 40,285 (0.098%). The incidence increased from 79.92/100,000 in 2008 to 114.79/100,000 in 2017 (P_trend < 0.0001). The most frequent was PE (86.5%), followed by AMI (9.6%) and AD (3.3%). The incidence of PE in pregnancy decreased after 2014 and was lower than AMI and AD, while its incidence in puerperium was higher than AMI and AD consistently (P_trend < 0.0001). Subgroup analysis showed the incidence of these diseases was higher in black women, lowest-income households, and elderly parturients (P_trend < 0.0001). The mortality decreased from 2.24% in 2008 to 2.21% in 2017 (P_trend = 0.0240), exhibiting 200-fold higher than patients without these diseases. The following factors were significantly associated with these diseases: aged ≥ 45 years (OR, 4.25; 95%CI, 3.80–4.75), valvular disease (OR, 10.20; 95%CI, 9.73–10.70), and metastatic cancer (OR, 9.75; 95%CI, 7.78–12.22). The trend of elderly parturients increased from 14.94% in 2008 to 17.81% in 2017 (P_trend < 0.0001), while no such up-trend was found in valvular disease and metastatic cancer.

Conclusion

The incidence of acute high-risk chest pain diseases, especially PE in puerperium, increased consistently. Although mortality has shown a downward trend, it is still at a high level. We should strengthen monitoring and management of acute high-risk pain diseases in pregnancy and puerperium, especially for black women, lowest-income households, and elderly parturients in the future.

The Utilization and Interpretation of Cardiac Biomarkers During Pregnancy: JACC: Advances Expert Panel

Cardiac biomarkers are widely used in the nonpregnant population when acute cardiovascular (CV) pathology is suspected; however, the behavior of these biomarkers in the context of pregnancy is less well understood. Pregnant individuals often have symptoms that mimic those of cardiac dysfunction, and complications of pregnancy may include CV disease. This paper will summarize our current knowledge on the use of cardiac biomarkers in pregnancy and provide suggestions on how to use these tools in clinical practice based on the available evidence. Natriuretic peptides and troponin should not be measured routinely in uncomplicated pregnancy, where values should remain low as in the nonpregnant population. In the context of pre-existing or suspected CV disease, these biomarkers retain their negative predictive value. Elevations of both natriuretic peptides and troponin may occur without clear clinical significance in the immediate postpartum period. Elevations of these markers should always prompt further investigation into possible CV pathology.

Acute Myocardial Infarction in Pregnancy

Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.

Acute Coronary Syndrome in Pregnancy and the Post-Partum Period

Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.

Changing Incidence and Mechanism of Pregnancy-Associated Myocardial Infarction in the State of California

Background The objective of this study was to evaluate the temporal trends in pregnancy-associated myocardial infarction (PAMI) in the State of California and explore potential risk factors and mechanisms. Methods and Results The California State Inpatient Database was analyzed from 2003 to 2011 for patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for acute myocardial infarction and pregnancy or postpartum admissions; risk factors were analyzed and compared with pregnant patients without myocardial infarction. A total of 341 patients were identified with PAMI from a total of 5 266 380 pregnancies (incidence of 6.5 per 100 000 pregnancies). Inpatient maternal mortality rate was 7%, and infant mortality rate was 3.5% among patients with PAMI. There was a nonsignificant trend toward an increase in PAMI incidence from 2003 to 2011, possibly attributable to higher incidence of spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome. PAMI, when compared with pregnant patients without myocardial infarction, was significant for older age (aged >30 years in 72% versus 37%, P<0.0005), higher preponderance of Black race (12% versus 6%, P<0.00005), lower socioeconomic status (median household income in lowest quartile 26% versus 20%, P=0.04), higher prevalence of hypertension (26% versus 7%, P<0.0005), diabetes (7% versus 1%, P<0.0005), anemia (31% versus 7%, P<0.0001), amphetamine use (1% versus 0%, P<0.00005), cocaine use (2% versus 0.2%, P<0.0001), and smoking (6% versus 1%, P=0.0001). Conclusions There has been a trend toward an increase in PAMI incidence in California over the past decade, with an increasing trend in spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome as mechanisms. These findings warrant further investigation.

Pregnancy-Associated Myocardial Infarction: A Review of Current Practices and Guidelines

PURPOSE OF REVIEW

Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy.

RECENT FINDINGS

Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.

Spontaneous coronary artery dissection in the third trimester-Implications for investigation and delivery

This case of spontaneous coronary artery dissection in pregnancy highlights the diagnostic, treatment and delivery dilemmas in the antepartum period. This is a rare condition that usually manifests in the postpartum period. This case provides multidisciplinary considerations that were encountered for optimal maternal and fetal outcome.

Management of Ischemic Heart Disease in Pregnancy

PURPOSE OF REVIEW

Cardiovascular disease is an escalating cause of maternal morbidity and mortality. Women are at risk for acute myocardial infarction (MI), and more are living with risk factors for ischemic heart disease (IHD). The purpose of this review is to describe the evaluation and management of women at risk for and diagnosed with IHD in pregnancy.

RECENT FINDINGS

Pregnancy can provoke MI which has been estimated as occurring in 1.5-10/100, 000 deliveries or 1/12,400 hospitalizations, with a high inpatient mortality rate of approximately 5-7%. An invasive strategy may or may not be preferred, but fetal radiation exposure is less of a concern in comparison to maternal mortality. Common medications used to treat IHD may be continued successfully during pregnancy and lactation, including aspirin, which has an emerging role in pregnancy to prevent preeclampsia, preterm labor, and maternal mortality. Hemodynamics can be modulated during pregnancy, labor, and postpartum to mitigate risk for acute decompensation in women with IHD. Cardiologists can successfully manage IHD in pregnancy with obstetric partners and should engage women in a lifetime of cardiovascular care.

Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient

The number of women of childbearing age with cardiovascular disease (CVD) is growing due to increased survival of children with congenital heart disease (CHD). More women are also becoming pregnant at an older age, which is associated with increased co-morbidities including hypertension, diabetes and acquired CVD. Over the last decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counseling, antenatal and postpartum cardiac surveillance, labor and delivery planning. Pre-pregnancy counseling by a COP should be offered to women with suspected CVD who are of child bearing age. In those women who present while pregnant, counseling should be performed by a COP as early as possible in pregnancy. The purpose of counseling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor and delivery. This Clinical Practice Update highlights the COP approach to pre-pregnancy counseling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment by a COP. We also describe the approach to some of the cardiac emergencies that the care provider may encounter in a pregnant woman.

Acute myocardial infarction in twin pregnancy after assisted reproduction: A case report

BACKGROUND

Acute myocardial infarction (AMI) during pregnancy is rare, especially in twin pregnancy, and it can endanger the lives of the mother and children. Except for conventional cardiovascular risk factors, pregnancy and assisted reproduction can increase the risk of AMI during pregnancy. AMI develops secondary to different etiologies, such as coronary spasm and spontaneous coronary artery dissection.

CASE SUMMARY

A 33-year-old woman, with twin pregnancy in the 31^st week of gestation, presented to the hospital with intermittent chest tightness for 12 wk, aggravation for 1 wk, and chest pain for 4 h. Combined with the electrocardiogram and hypersensitive troponin results, she was diagnosed with acute ST-elevation myocardial infarction. Although the patient had no related medical history, she presented several risk factors, such as age greater than 30 years, assisted reproduction, and hyperlipidemia. After diagnosis, the patient received antiplatelet and anticoagulant treatment. Cesarean section and coronary angiography performed 7 d later showed stenosis and thrombus shadow of the right coronary artery. After receiving medication, the patient was in good condition.

CONCLUSION

This case suggests that, with the widespread use of assisted reproductive technology, more attention should be paid to perinatal healthcare, especially when chest pain occurs, to facilitate early diagnosis and intervention of AMI, and the etiology of AMI in pregnancy needs to be differentiated, especially between coronary spasm and spontaneous coronary artery dissection.

Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 3/5

Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman's risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Preeclampsia Emerging as a Risk Factor of Cardiovascular Disease in Women

The objective of this literature review was to explore the long-term cardiovascular effects of preeclampsia in women. The primary goal was to determine which organs were most commonly affected in this population. Although it was previously believed that preeclampsia is cured after the delivery of the fetus and the placenta current evidence supports an association between preeclampsia and cardiovascular disease later in life, many years after the manifestation of this hypertensive pregnancy related disorder. Therefore preeclampsia may be emerging as a novel cardiovascular risk factor for women, which requires long-term follow up.

Postpartum multi-vessel spontaneous coronary artery dissection in the setting of cocaine and amphetamine use: a case report

Background 

Spontaneous coronary artery dissection (SCAD) is a recognized cause of acute coronary syndrome (ACS). Pregnancy, the postpartum period, and illicit drug use have all been reported as potential triggers.

Case summary 

We describe the case of a 41-year-old patient who presented to the emergency department with chest pain in the setting of recent cocaine and amphetamine use. The patient was 4 months postpartum following an uncomplicated pregnancy. Past medical history was non-contributory, with no known risk factors for ischaemic heart disease. Electrocardiogram was normal but high-sensitivity troponin T was significantly elevated. Coronary angiography revealed multi-vessel SCAD. This was managed conservatively as the patient remained clinically stable and pain free without high-risk anatomy (left main stem or proximal two-vessel coronary artery dissection).

Discussion 

Spontaneous coronary artery dissection must be considered in a postpartum patient presenting with ACS, particularly in the context of environmental stressors such as illicit drug use. Coronary angiography is key to determine diagnosis and guide management. Conservative therapy is favoured, except for patients with ongoing ischaemia, haemodynamic instability, and left main stem involvement. In this case, we suspect SCAD occurred due to the haemodynamic effects of cocaine and amphetamines in the context of structural arterial changes of the postpartum state.

Coronary Disease in Pregnancy: Myocardial Infarction and Spontaneous Coronary Artery Dissection

Pregnancy-related maternal mortality and morbidity rates continue to increase in the United States despite global improvements in maternal outcomes. The unique hemodynamic and physiological changes of pregnancy results in a 3- to 4-fold increased risk of acute myocardial infarction (AMI) which causes a substantial proportion of all maternal cardiac deaths. In addition to atherosclerosis, pregnancy-associated AMI is commonly caused by nonatherosclerotic etiologies such as spontaneous coronary artery dissection, embolus to the coronary artery, and coronary vasospasm. Herein, the epidemiology, etiologies, presentation, diagnosis, and management of AMI in pregnancy is discussed along with future directions for multidisciplinary care.

Repeat Pregnancy after Prior Aortic Valve-in-Valve Replacement: A Cautionary Tale

Transcatheter aortic valve replacement (TAVR) within a severely stenotic native aortic valve or previously placed surgical biologic aortic valve replacement (SAVR) is a rare occurrence in pregnant patients. The short- and long-term procedural outcomes for future pregnancies in these women or any woman of child bearing age who have received prior TAVR or TAVR in SAVR, are unknown. We describe the first result of a repeat pregnancy outcome in a woman with a history of prior TAVR in SAVR. Both maternal and fetal outcomes were favorable, but maternal cardiac complications observed in the third trimester emphasize our concerns regarding risk for cardiac complications in subsequent pregnancies in patients with a prior TAVR in SAVR. Despite the maternal complications that occurred during repeat pregnancy in this patient, a successful pregnancy outcome reaffirms our recommendation to utilize a multidisciplinary team for pregnancy management in patients with prior TAVR or TAVR in SAVR and to help in the management of any cardiac complications that may occur during or shortly after pregnancy.

ADIPS 2020 guideline for pre-existing diabetes and pregnancy

This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.

Risk Factors and Timing of Acute Myocardial Infarction Associated With Pregnancy: Insights From the National Inpatient Sample

Background

Pregnancy increases the risk of acute myocardial infarction (AMI). The purpose of this study was to examine timing and risk factors for AMI in pregnancy and poor outcome.

Methods and Results

National Inpatient Sample (2003–2015) was screened in pregnancy, labor and delivery, and postpartum. There were 11 297 849 records extracted with 913 instances of AMI (0.008%). One hundred eleven (12.2%) women experienced AMI during labor and delivery, 338 (37.0%) during pregnancy and most during the postpartum period (464; 50.8%). The prevalence of AMI in pregnancy has increased (P=0.0005). Most major adverse cardiovascular and cerebrovascular events occurred in the postpartum period (63.5%). Inpatient mortality was 4.5%. Predictors of AMI include known coronary artery disease (odds ratio [OR], 517.4; 95% CI, 420.8–636.2), heart failure (OR, 8.2; 95% CI, 1.9–35.2), prior valve replacement (OR, 6.4; 95% CI, 2.4–17.1), and atrial fibrillation (OR, 2.7; CI, 1.5–4.7; P<0.001). Risk factors of traditional atherosclerosis including hyperlipidemia, obesity, tobacco history, substance abuse, and thrombophilia were identified (P<0.001). Gestational hypertensive disorders (eclampsia OR, 6.0; 95% CI, 3.3–10.8; preeclampsia OR, 3.2; 95% CI, 2.5–4.2) were significant risk factors in predicting AMI. Risk factors associated with major adverse cardiovascular and cerebrovascular events included prior percutaneous coronary intervention (OR, 6.6; 95% CI, 1.4–31.2) and pre‐eclampsia (OR, 2.3; 95% CI, 1.3–3.9).

Conclusions

AMI is associated with modifiable, nonmodifiable, and obstetric risk factors. These risk factors can lead to devastating adverse outcomes and highlight the need for risk factor modification and public health resource initiatives toward the goal of decreasing AMI in the pregnant population.