Pregnancy-associated Myocardial Infarction Research Articles

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.

Spontaneous coronary artery dissection outcomes among pregnant vs. non-pregnant women.

Spontaneous coronary artery dissection (SCAD) has become increasingly recognized. It accounts for <1-4% of acute coronary syndrome presentations. Overall, however, it makes up over 40% of pregnancy-associated myocardial infarction. Furthermore, pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is described to have a greater degree of clinical manifestations, including left ventricular dysfunction, shock, and left main or multivessel involvement. The findings are disconcerting, though many studies evaluating P-SCAD are based on case series data or are single centre studies. The aim of this study was to evaluate a larger national dataset to evaluate the outcomes of SCAD and specifically P-SCAD in an attempt to better characterize the severity and clinical nature of this condition. To conduct this study, we analysed the National Readmission Database from January 2016 to December 2020. Propensity matching was done using the Greedy 1:1 method. Multivariate logistics and time-to-event Cox regression analysis models were built by including all confounders significantly associated with the outcome on univariable analysis with a cut-off P-value of 0.2. In multivariate regression analysis, P-SCAD patients had a non-propensity matched odds ratio (OR) of 0.21 (0.3-1.54, P = 0.123) of dying and a propensity matched OR of 0.11 (0.02-0.61, P = 0.012) of dying. Thirty-day readmission rate for P-SCAD was 15.8% (n = 93) and for non-pregnant spontaneous coronary artery dissection (NP-SCAD) was 11.2% (n = 2286); non-propensity matched OR for readmission for PSCAD patients was 1.68 (1.24-2.29, P = 0.001) and propensity matched OR was 3.39 (1.93-5.97, P < 0.001). Among hospitalized patient, P-SCAD was associated with similar clinical outcomes and reduced incidence of death when compared with NP-SCAD, though had higher rates of 30-day readmission. Larger-scale observational data will be needed to ascertain the true incidence of cardiovascular complications as it relates to P-SCAD.

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.

Abstract 12660: Outcomes of Pregnancy-Associated Myocardial Infarction: A Systematic Review and Meta-Analysis

Background: Cardiovascular disease is the leading cause of maternal mortality worldwide. The aim of this systematic review and meta-analysis was to investigate complications associated with Pregnancy-associated myocardial infarction (PAMI), which has been linked to various obstetric and fetal complications. Methods: We included a total of 11 studies which reported complications in women who had myocardial infarction (MI) during pregnancy. Our outcomes included maternal mortality, postpartum hemorrhage, postpartum infection, preterm labor, eclampsia and pre-eclampsia. Analysis was performed to calculate the pooled proportions. Data was pooled as mean differences or risk ratio and 95% confidence interval (CI) was used. Results: Mortality was reported in 7.6% of women who had MI with effect estimate 0.189, 95% CI [0.113, 0.266] (Fig 1a). Incidence of postpartum hemorrhage was reported in 13% of women with effect estimate 0.143, 95% CI [0.060, 0.226] (Fig 1b) and postpartum infection was reported in 15.1% with effect estimate 0.269, 95% CI [0.030, 0.507]. Incidence of eclampsia and pre-eclampsia was reported in 10.98% with effect estimate 0.213, 95% CI [0.125, 0.301] (Fig 2a). Incidence of pre-term labor was reported in 12.87% with effect estimate 0.313, 95% CI [0.116, 0.510] (Fig 2b). Conclusion: Our study demonstrated that PAMI was associated with higher rates of major obstetric complications including maternal mortality, postpartum hemorrhage, pre-term labor, pre-eclampsia, eclampsia and postpartum infection.

Assessment of extra-coronary peripheral arteriopathy in spontaneous coronary dissection: state of the art in non-invasive imaging techniques and future perspectives.

Spontaneous coronary artery dissection (SCAD) has been recognized as an important cause of acute coronary syndrome in women ≤ 50 years old, and up to 43% of pregnancy-associated myocardial infarction. SCAD has a strong association with extra-coronary arteriopathies, including either more common entities such as dissections, intracranial or other aneurysms, and extra-coronary and coronary arterial tortuosity or less common inherited vascular disorders such as Ehlers-Danlos syndrome, Marfan syndrome, and Loeys-Dietz syndrome, leading to the conclusion that systemic arterial disorders may underlie SCAD. Fibromuscular dysplasia is the most common extra-coronary vascular abnormality identified among these patients, also sharing a common genetic variant with SCAD. The American Heart Association, in a scientific statement regarding the management of SCAD, recommends that patients with SCAD should undergo additional evaluation with imaging techniques including either computed tomography angiography (CTA) or magnetic resonance angiography (MRA). MRA has been shown to have sufficient diagnostic accuracy in identifying extra-coronary arterial abnormalities, almost equal to CTA and conventional angiography. The aim of this review is to appraise the most recent important evidence of extra-coronary arteriopathy in the setting of SCAD and to discuss the strengths and weaknesses of various non-invasive imaging methods for screening of extra-coronary arteriopathies in patients with SCAD.

The role of coronary computed tomography angiography in pregnancy-associated myocardial infarction

Pregnancy-associated coronary artery dissection is one of the critical causes of myocardial infarction in young females. The challenges in the diagnosis and follow-up of pregnancy-associated myocardial infarction prompted us to highlight the potential role of coronary computed angiography in managing this life-threatening medical condition. We describe a case of a 29-year-old female with sudden onset chest discomfort one-week postpartum. She presented to the hospital with an ST-elevation myocardial infarction and was urgently taken to the cath lab for PCI and stent placement. Thirteen months later, with intermittent chest discomfort, an coronary computed tomography was done, demonstrating evidence of SCAD and aneurysm formation in the left main coronary artery and left circumflex coronary artery. Repeat cardiac catheterization confirmed the same diagnosis. Given her refractory chest discomfort and the chance of aneurysm rupture decision was made to proceed with a three-vessel CABG. At 3-month and 1-year followup visits, the patient is doing well and remains pain-free. In this case presentation, we aim to highlight the potential role of Coronary Computed tomography angiography in the diagnosis and follow-up of pregnancy-associated spontaneous coronary artery dissection, given the high accuracy and non invasiveness of this diagnostic modality in the context of the high prevalence of spontaneous coronary artery dissection in symptomatic or asymptomatic pregnancy-associated myocardial infarction.

Pregnancy-Associated Spontaneous Coronary Artery Dissection: A Case Report and the Lessons from Practice

Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is one of the fatal conditions that most commonly causes pregnancy-associated myocardial infarction. We herein report a case of P-SCAD in a 26-year-old multigravida woman, who complained of angina postpartum with raised cardiac biomarkers and transient ST-segment elevation on electrocardiograms. We emphasize the importance of a high degree of suspicion in the diagnosis of P-SCAD, together with the common presentation, the management approach, and its psychological impacts on the patients.

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.

Spontaneous Coronary Artery Dissection: New Insights into This Not-So-Rare Condition.

Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute myocardial infarction (MI) among young and middle-aged women and is an important cause of pregnancy-associated MI. Over 90% of SCAD patients are women. Compared to patients with MI caused by atherosclerosis, SCAD patients have fewer cardiovascular risk factors but more often have systemic arteriopathy, most commonly fibromuscular dysplasia. Angiographically, SCAD is characterized by the presence of an intramural hematoma with or without an intimal tear. Accurate recognition of characteristic findings on coronary angiography is critical, as there are important differences in the acute and long-term management of MI caused by SCAD versus atherosclerosis. Acutely, most SCAD patients should be managed conservatively, since percutaneous revascularization is associated with more complications and SCAD-affected vessels usually heal without intervention. Randomized clinical trials and other prospective evaluations are needed, especially to clarify optimal treatment and prevention strategies.

Mechanical Prosthetic Valve Thrombus in a Term Pregnant Woman Presenting as Acute Heart Failure: Case Report and Review of Literature

Abstract Cardiovascular disease in pregnancy contributes to a significant proportion of death worldwide. Though pregnancy-associated myocardial infarction and aortic dissection are the common causes of adverse cardiac events in developed countries, rheumatic heart diseases continue to be the important reason for cardiovascular morbidity and mortality in developing countries. The risk of adverse cardiac outcome is dependent on the type and severity of valvular abnormality, functional status, left ventricular function, and pulmonary arterial pressure. Managing a pregnant woman with a mechanical heart valve prosthesis is challenging because of the difficulty in achieving optimal anticoagulation in the presence of hypercoagulability. Mitral valve thrombus is a life-threatening event and women can present with acute heart failure or thromboembolic events. We report successful management of a 26-year-old primigravida with rheumatic heart disease diagnosed to have huge thrombus on mechanical prosthetic mitral valve presented with acute heart failure at 36 weeks. She received multidisciplinary care and underwent concurrent cesarean section followed by thrombectomy under cardiopulmonary bypass. She had a good recovery following surgery and the complexity surrounds the management merit the presentation with a review of management strategies for a women with mechanical prosthetic heart valve in pregnancy.

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

BackgroundThe 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 ResultsThe 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).ConclusionsThere 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.

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. 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.

Abstract 16692: Spontaneous Coronary Artery Dissection Associated With Pregnancy

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare but life threatening cause of acute coronary syndrome and a common etiology of pregnancy-associated myocardial infarction (PAMI). Hypothesis: We aimed to examine the clinical presentation, treatment, and outcomes of the largest pregnancy associated-SCAD (P-SCAD) patient cohort to date. Methods: A total of 128 women enrolled in the Mayo Clinic SCAD Registry between 2010-2020 who were pregnant or up to 1 year postpartum at time of P-SCAD were identified. We subdivided P-SCAD in an “early” group with &lt;12 weeks of delivery and a “late” group presenting between &gt;12 weeks -12 months following delivery. Results: Among the 128 women with P-SCAD, 7(5%) occurred during pregnancy (2/7 first trimester, 5/7 third trimester). Of the 121 women with postpartum P-SCAD, 88/121(72%) occurred &lt;12 weeks of delivery and 33/121(27%) at 12 weeks to 1 year postpartum. The mean age of P-SCAD was 35.3 +/- 4 years (26-48). The most common symptom on presentation was chest pain 118/128(92%); 62/128(48%) presented with ST elevation MI and 58/128(45%) presented with non-ST elevation MI. Multivessel involvement occurred in 40/128(31%), left anterior descending artery (LAD) in 88/128(69%), and left main (LM) in 28/128(22%) of all P-SCAD. Percutaneous coronary intervention (PCI) was performed in 52/128(41%) with a success rate of 81%. Coronary artery bypass grafting was performed in 24/128(19%) of which 6/24 patients had an unsuccessful PCI, 14/24 had proximal or multivessel SCAD, and 4/24 had persistent or extension of initial SCAD. Of those treated conservatively 52/128(40%), 11/52(21%) had LM and LAD. Among all the P-SCAD patients, 84/128 (66%) were screened for an underlying arteriopathy, of whom 44 (52 %) were diagnosed with fibromuscular dysplasia. At a median follow up of 3 years (IQR 1 to 6), 12/128 (9%) of all P-SCAD survivors had a recurrent SCAD event and 7/12 (58%) were within 1 year postpartum. There were no deaths. Conclusions: P-SCAD most commonly presents with ST-elevation MI and multivessel involvement within the initial 12 weeks postpartum. Clinicians need to be familiar with this etiology of PAMI to avoid delay in diagnosis and appropriate management.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management.

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

INCIDENCE, MORTALITY, AND CLINICAL CHARACTERISTICS OF PREGNANCY ASSOCIATED MYOCARDIAL INFARCTION IN THE STATE OF CALIFORNIA

The objective of this study was to evaluate the temporal trends in Incidence, mortality and clinical characteristics of pregnancy associated myocardial infarction (PAMI) in the state of California. The California state inpatient database was analyzed from 2003 to 2011 with ICD 9 codes for acute

Urgent Cesarean Delivery Following a Spontaneous Coronary Artery Dissection.

Patient: Female, 44Final Diagnosis: Coronary artery dissectionSymptoms: Chest painMedication: —Clinical Procedure: Coronary angiography • CT scan • transthoracic echocardiography • urgent cesarean deliverySpecialty: CardiologyObjective:Rare diseaseBackground:Spontaneous coronary artery dissection is the most common etiology of pregnancy-associated myocardial infarction. It is characterized by high rates of maternal morbidity and mortality and may cause fetal complications and death as well.Case Report:A 44-year-old female (G2P1) suffered from pregnancy-related spontaneous coronary artery dissection with dissection of distal left anterior descending coronary artery. The patient was hemodynamically stable and did not required revascularization, but signs of fetal distress were detected and thus an urgent cesarean delivery was performed. This emergency procedure was undertaken in the catheterization laboratory (Cath-Lab) right after coronary angiography, thanks to a multidisciplinary team. Health conditions of the newborn were good. The patient instead suffered from a recurrence of spontaneous coronary artery dissection 6 days later, complicated by left ventricular apical thrombus and epistenocardial pericarditis. The dissection self-healed in 1 month.Conclusions:Careful evaluation of pregnancy-related spontaneous coronary artery dissection is needed to assess and manage both maternal and fetal complications. Under specific circumstances, a cesarean delivery may be required and be even performed in the Cath-Lab after coronary catheterization.

Pregnancy-Associated Myocardial Infarction.

To educate clinicians about the epidemiology, etiologies, diagnosis, and management of pregnancy-associated myocardial infarction (PAMI). The risk of myocardial infarction is increased more than threefold around the time of pregnancy. In the recent series, PAMI is most commonly caused by spontaneous coronary artery dissection, followed by atherosclerosis. Percutaneous coronary intervention or coronary artery bypass grafting may be required, but conservative management with medical therapy is generally advised when possible, particularly in cases of coronary dissection. Labor and delivery in women with PAMI warrants advanced planning by a multidisciplinary team involving obstetrics, anesthesia, and cardiology. Women with myocardial infarction should be referred to cardiac rehabilitation. Pregnancy-associated myocardial infarction is a significant contributor to maternal morbidity and mortality. Management should be tailored based on the underlying etiology and on whether the patient is still pregnant or postpartum. Further research is needed to define optimal evaluation and management of this condition.

Spontaneous Coronary Artery Dissection Associated With Pregnancy

BackgroundSpontaneous coronary artery dissection (SCAD) is the most common cause of pregnancy-associated myocardial infarction and remains poorly characterized. ObjectivesThis study sought to assess presentation, clinical factors, and outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD) compared with spontaneous coronary artery dissection not associated with pregnancy (NP-SCAD). MethodsA Mayo Clinic registry was established in 2010 to include comprehensive retrospective and prospective SCAD data. Records were reviewed to identify women who were pregnant or ≤12 weeks postpartum at time of SCAD. Complete records were available for 323 women; 54 women met criteria for P-SCAD (4 during pregnancy) and they were compared with 269 women with NP-SCAD. ResultsMost events occurred within the first month postpartum (35 of 50). Compared with NP-SCAD, P-SCAD patients more frequently presented with ST-segment elevation myocardial infarction (57% vs. 36%; p = 0.009), left main or multivessel SCAD (24% vs. 5%; p < 0.0001; and 33% vs. 14%; p = 0.0027, respectively), and left ventricular function ≤35% (26% vs. 10%; p = 0.0071). Among women with imaging of other vascular territories, P-SCAD was less likely with a diagnosis of fibromuscular dysplasia and extracoronary vascular abnormalities (42% vs. 64%; p = 0.047; and 46% vs. 77%; p = 0.0032, respectively). Compared with U.S. birth data, women with P-SCAD were more often multiparous (p = 0.0167), had a history of infertility therapies (p = 0.0004), and had pre-eclampsia (p = 0.001). On long-term follow-up (median 2.3 years) recurrent SCAD occurred in 51 patients, with no difference in the Kaplan Meier 5-year recurrence rates (10% vs. 23%; p = 0.18). ConclusionsP-SCAD patients had more acute presentations and high-risk features than women with NP-SCAD did. The highest frequency of P-SCAD occurred during the first postpartum month and P-SCAD patients less often had extracoronary vascular abnormalities. Hormonal, hemodynamic variations, and yet-undefined mechanisms might be significant contributors to P-SCAD. (The “Virtual” Multicenter Spontaneous Coronary Artery Dissection [SCAD] Registry [SCAD]; NCT01429727; Genetic Investigations in Spontaneous Coronary Artery Dissection [SCAD]; NCT01427179)

POSTPARTUM AND PREGNANCY-ASSOCIATED SPONTANEOUS CORONARY ARTERY DISSECTION: PRESENTATION, CLINICAL FEATURES AND OUTCOMES

Background: Spontaneous coronary artery dissection (SCAD) is the most common cause of pregnancy-associated myocardial infarction and remains incompletely characterized to date. Methods: Records of all women enrolled in the Mayo Clinic “Virtual” Multi-Center SCAD Registry were reviewed to

Incidence of myocardial infarction in pregnancy: a systematic review and meta-analysis of population-based studies.

AimsCardiac disease is one of the leading causes of indirect maternal death, and myocardial infarction (MI) is one of its most common aetiologies. The objectives of this systematic review and meta-analysis were to characterize the incidence of pregnancy-associated MI (PAMI), as well as the maternal mortality and the case-fatality rates due to PAMI.Methods and resultsArticles were obtained by searching electronic databases, bibliographies and conference proceedings with no language or date restrictions. Two reviewers independently selected population-based cohort and case-control studies reporting on incidence, mortality and case-fatality rates for pregnancy-associated MI. Meta-analysis was performed to estimate pooled maternal incidence, mortality and case-fatality rates. Meta-regression was performed to explore heterogeneity. Based on 17 included studies, the pooled incidence of PAMI and maternal mortality from PAMI were 3.34 (2.09–4.58) and 0.20 (0.10–0.29) per 100 000 pregnancies, respectively. The case-fatality rate was 5.03% (3.78–6.27%). Country/region (meta-regression P = 0.006) and years of study (meta-regression P = 0.04) were potential explanations for the observed heterogeneity in the pooled incidence estimates of maternal MI and its associated mortality, with more recent studies and those conducted in the USA revealing the highest rates.ConclusionThis article provides a global estimate of the incidence, mortality rate, and case fatality rate of pregnancy-associated MI. We identified higher rates of PAMI in the USA (relative to Canada and European countries) and rising rates over time. Further research regarding this population is needed, especially given rising maternal age and the increasing prevalence of cardiovascular risk factors.