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

Pregnancy-Associated Myocardial Infarction in Alberta: A Population-Based Study

Background

Cardiac disease is the leading cause of maternal mortality in developed countries, and myocardial infarction (MI) is an important cause of pregnancy-associated morbidity and mortality. These infrequent, but very serious, events are not optimally described in the medical literature.

Objectives

This study describes a 15-year consecutive, retrospective cohort of confirmed pregnancy-associated MIs (PAMIs) identified in Alberta, Canada (2003-2017).

Methods

Utilizing a provincial administrative database, a cohort of women with PAMI were identified using a validated algorithm. Additional cases were identified by reviewing provincial maternal mortality records. Medical record review was conducted on each case with further details obtained via linkage with a provincial coronary heart disease registry. Available angiographic images were also reviewed.

Results

Forty-three cases of PAMI were identified in Alberta between 2003 and 2017, providing a crude incidence of ∼5.64/100,000 births. Rates of PAMI increased over the study period. Of the identified MIs, 16.3% occurred antepartum (mean gestational age of 18 weeks), while 30.2% were peripartum and 53.4% occurred within 6 months postpartum (at a mean of 7.8 weeks after delivery). The most common mechanism of PAMI was spontaneous coronary artery dissection (44.2%) and this mechanism predominated postpartum. Coronary artery disease was a frequent antepartum cause of MI, whereas demand ischemia was the leading cause of peripartum MI. Maternal mortality was approximately 9%.

Conclusions

PAMI is an increasing cause of maternal morbidity and mortality in Alberta. Clinicians should have a high index of suspicion for PAMI and ensure optimal management of this dangerous complication of pregnancy.

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.

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.

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 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.