411. The investigation of cardiac-sounding chest pain in pregnant women

Abstract

Introduction Cardiac disease remains the leading cause of maternal mortality. 21% of cardiac deaths during pregnancy are attributed to ischaemic heart disease. Despite the presence of NICE guidance on the management of cardiac-sounding chest pain, the UK Obstetric Surveillance System demonstrated large variability in the investigation of such symptoms in pregnant women. This may reflect concerns clinicians have regarding safety of investigations in pregnancy. Objectives Determine clarity with regards the appropriate investigation of cardiac-sounding chest pain in pregnancy. Methods Review the case of a patient with a myocardial infarction (MI) postpartum and undertake a literature review. Results A 38-year-old female with type 1 diabetes mellitus reported exertion chest pain prior to and during pregnancy. She underwent routine blood tests, troponin, BNP, ECG and an echocardiogram all of which were normal. She was re-assured and advised to seek urgent medical attention if she developed red flag features. During the postpartum period she suffered an acute MI with an occlusion in her left anterior descending artery. Following percutaneous coronary stent insertion she recovered well. Discussion NICE guidelines recommend CT coronary angiogram (CTCA) in patients describing stable angina. If CTCA is unavailable or non-diagnostic a number of functional tests can be considered. If patients remain symptomatic of angina despite optimal medical management, revascularisation should be considered. The literature reveals that the radiation from CTCA to the mother ranges from 4 to 15 mSv with no fetal data available, compared to standard CTPA which is 5–10 mSv to mother and 0.01–0.1 mGy to fetus. Stress agents are considered category B, gadolinium and tectnetium-99 are avoided if possible. In light of increasing prevalence and mortality from cardiac disease in pregnancy, work to develop guidance to provide clarity regarding the appropriate diagnostic tests may be warranted. The importance of multidisciplinary team involvement in obstetric patient management remains paramount.