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Acute Myocardial Infarction in Pregnancy: Current Diagnosis and Management Approaches

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Acute Myocardial Infarction in Pregnancy: Current Diagnosis and Management Approaches Indian Heart Journal 71 (2019) 367e374 Contents lists available at ScienceDirect Indian Heart Journal journal homepage: www.elsevier.com/locate/ihj Review Article Acute myocardial infarction in pregnancy: Current diagnosis and management approaches * Mohan M. Edupuganti , Vyjayanthi Ganga Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas for Medical Sciences, USA article info abstract Article history: Acute myocardial infarction during pregnancy is a very uncommon condition; atherosclerotic coronary Received 3 July 2019 artery disease is by far the most common cause of an acute coronary syndrome in the general population. Accepted 9 December 2019 The causes of an acute coronary syndrome in the pregnant patient are wide and varied. This has Available online 17 December 2019 important implications with respect to the diagnosis of the etiology and the subsequent management of the cause of the acute coronary syndrome. There are a number of diagnostic tools for the diagnosis of Keywords: coronary artery disease but it is important to understand their role in pregnant patients. Spontaneous Pregnancy coronary artery dissection is one of the most common causes of acute coronary syndrome in pregnant Acute myocardial infarction Spontaneous coronary artery dissection patients. Understanding its pathophysiology and knowing the natural history of this condition is para- mount in the management of this condition. The article also lists the various therapeutic modalities available to the clinician faced with an acute coronary syndrome in the pregnant patient. Finally, we discuss the delivery of the baby and post partum care of these complex patients. © 2019 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Epidemiology clinical standpoint it is important to recognize this difference because oftentimes it is impossible to distinguish among the Acute myocardial infarction (MI) during pregnancy is a rare various causes of acute coronary syndrome in pregnant women event and the estimated incidence is one acute myocardial infarc- based on the presentation alone. However, a reasonable guess can tion for every 16,000 deliveries.1 Up to one in four of these in- be made by paying attention to the underlying risk factors. An farctions is caused by coronary arterial dissection.2 The causes of MI analysis from the national inpatient sample (NIS) found 859 cases during pregnancy are presented in Table 1.3 Spontaneous coronary of MI (rate of 6.2 (95% confidence interval [CI] 3.0e9.4) per 100,000 dissection (SCAD) is the most common cause, found in 43%; deliveries).1 In 73% of cases, MI occurred antepartum and in 27% the atherosclerotic disease is the second most common cause and is MI occurred postpartum.1 Risk factors identified were age (33 vs. 27 found in 27%, a thrombus without angiographic evidence for years) and the risk was higher among black women compared to atherosclerotic disease is found in 17%, no cause is found by angi- Hispanics and white women (11.4 vs. 4.2 vs 7.6 per 100,000 de- ography in 11%.3 Although SCAD is rare in the general population liveries, respectively).1 Independent predictors of MI included hy- with an annual incidence is 0.26 per 100,000 persons or about 800 pertension (odds ratio [OR] 21.7), thrombophilia (OR 25.6), diabetes news cases per year in the United States (incidence in females and mellitus (OR 3.6), smoking (OR 8.4), transfusion (OR 5.1), and males À0.33 and 0.18 per 100,000 persons respectively),4 it is not postpartum infection (OR 3.2).1 uncommon in pregnant females presenting with an acute coronary The risk factors for SCAD in pregnancy differ from the risk fac- syndrome.3 Thus SCAD and atherosclerotic coronary artery disease tors for all-cause MI in pregnancy and include a history of smoking are the most common causes of MI in pregnancy.2,3 (23%), family history (16%), hypertension (9%), and lipid disorder (7%); only 9% had more than one risk factor, whereas 61% reported 5 2. Risk factors and etiology no known risk factors. This is similar to the findings of other studies of SCAD in non-pregnant patients which found that the It is interesting to note that the risk factors for atherosclerotic most common risk factors associated with SCAD are smoking (31%), coronary artery disease are different from those of SCAD. From a hypertension (18%), and a family history of coronary artery disease (25%).4 By contrast, the prevalence of other conventional risk fac- * Corresponding author. 8, Alban Lane, Little Rock, AR, 72223, USA. tors such as diabetes (2.2%) and chronic kidney disease (1.7%) is E-mail address: [email protected] (M.M. Edupuganti). https://doi.org/10.1016/j.ihj.2019.12.003 0019-4832/© 2019 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). 368 M.M. Edupuganti, V. Ganga / Indian Heart Journal 71 (2019) 367e374 Table 1 anterior wall is seen across a number of studies dealing with MI in 9 Causes of acute myocardial infarction during pregnancy. pregnant women irrespective of what the most common cause of 1,3 Cause Trimester Percentage of cases (%) MI is in each study (Atherosclerotic or SCAD). This is an important fi SCAD Third/post-partum 43 nding and explains the relatively higher frequency of catastrophic Atherosclerosis Any 27 presentation and complications of MI in pregnancy in general. The Thrombosis Second and post-partum 17 left ventricular ejection fraction was 40% in 54% of the cases, 30% Spasm Third/postpartum 2 in 24% of cases, and 20% in 9% of cases.3 Heart failure or cardio- Note: It is important to understand that any of the above causes of pregnancy genic shock occurred in 38% of the patients, ventricular arrhyth- associated myocardial infarction can present during any time in pregnancy or the mias in 12%, and recurrent angina or AMI in 20%.3 post partum period. In the largest case review compiled by Elkayam et al, SCAD- associated MI in pregnancy involved the left main artery in 26%, left anterior descending (LAD) in 34%, left circumflex (LCX) in 3%, right significantly lower when compared to atherosclerotic coronary e coronary artery (RCA) in 14%, and multivessel involvement in 39%.3 artery disease.3 6 This is similar to the vascular distribution seen in non-pregnant SCAD, in general, predominantly affects young white females individuals where the most common vessels involved were (83%) and one study showed no significant difference in the base- LAD (61%), LCX (25%), RCA (25%), and LM (4%).13 Multivessel coro- line characteristics between postpartum and non-postpartum pa- 7 nary involvement is seen in a significant number of patients tients with SCAD. SCAD affects multiparous women as opposed to e (15e20%).13 15 Studies in non-pregnant individuals show that the primipara and the average gravidity is 2.7, most cases present in the middle segments are the most common site of involvement (54% peripartum period with a range of 3e90 days post-partum.5 When mid, 27% distal, 19% proximal) and the number of vessels with TIMI the condition occurs antepartum it most commonly presents at 5 0e1 and 2e3 flow are almost equal at presentation (50e60% and 32 ± 4 weeks with a range of 23e36 weeks. e 60e80%, respectively).13 15 The pathophysiological basis for the reason why the left coronary system, in particular the LAD artery is 3. Pathophysiology the most commonly affected artery is not clear. It is hypothesized that this is because of hemodynamic and anatomic differences A number of conditions listed below can cause an acute coro- between the right and left coronary arterial system (the higher nary syndrome in the pregnant patient. number of branches in the left system subject it to a higher fi SCAD: SCAD is de ned as a non-iatrogenic and non-traumatic torsional force and the flow in the left system is mainly diastolic as 8 separation of the coronary arterial walls, creating a false lumen. opposed to a more uniform systolic and diastolic flow in the right The pathognomonic feature of SCAD is the separation of the system (RCA).16 SCAD presents in similar ways in pregnant and 9 layers within the arterial wall by an intramural hematoma (IMH). non-pregnant females. According to one study involving pregnant The hematoma can arise by an intimal rupture initiating medial females, 81% presented with STEMI, 25% were hemodynamically dissection or more commonly by a spontaneous intramedial hem- unstable at the time of presentation. A total of 14% received 9 orrhage due to a disruption of the vasa vasorum. The hematoma advanced cardiac life support interventions and 26% required 10 can then secondarily lead to an intimal tear. Excess levels of emergent intra-aortic balloon pump support.5 This is similar to the fi progesterone lead to a loss of normal corrugation of elastic bers presentation in non-pregnant females where 80e90% present with and a decrease in acid mucopolysaccharide ground substance and an acute coronary syndrome, about 40% present with STEMI, and 10 appear to play a major role in pathogenesis of the condition. Es- 40% present with NSTEMI. A total of 10e13% of episodes are trogen increases the release of matrix metalloproteinase which can complicated by cardiac arrest and cardiogenic shock occurs in e lead to cystic medial necrosis and lack of structural support for the 2e4%.13 15 10 vasa vasorum and rupture leading to IMH. It is helpful to classify the causes of acute coronary syndrome Spasm: A number of factors can contribute to the development based on the trimester of presentation.
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