Pregnancy and heart disease coronary artery disease: Difference between revisions
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==Overview== | |||
In general, women of childbearing age are at relatively low risk for coronary artery disease. While rare, the risk of acute myocardial infarction (AMI) is 3-4 times higher during pregnancy, and negative fetal and maternal outcomes are associated with this condition. | |||
==Acute Myocardial Infarction in Pregnancy== | |||
AMI can occur at all stages of pregnancy, and is more common in multi-gravid patients. In a review performed in 2008, myocardial infarction (MI) location was mostly (78%) in the anterior wall and involved the left anterior descending artery; the most common cause was coronary dissection.<ref name="pmid18617065">{{cite journal| author=Roth A, Elkayam U| title=Acute myocardial infarction associated with pregnancy. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 3 | pages= 171-80 | pmid=18617065 | doi=10.1016/j.jacc.2008.03.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617065 }} </ref> This review also found a maternal mortality rate of 11% and a fetal mortality rate of 9%. | |||
The etiology of coronary dissection in pregnant patents is thought to be related to an excess of progesterone, which causes changes in the vessel wall, including loss of normal corrugation elastin fibers, fragmentation of reticular fibers, and decreases in the amount of acid mucopolysaccharides.<ref name="pmid4225694">{{cite journal| author=Manalo-Estrella P, Barker AE| title=Histopathologic findings in human aortic media associated with pregnancy. | journal=Arch Pathol | year= 1967 | volume= 83 | issue= 4 | pages= 336-41 | pmid=4225694 | doi= | pmc= | url= }} </ref><ref name="pmid3792352">{{cite journal| author=Bonnet J, Aumailley M, Thomas D, Grosgogeat Y, Broustet JP, Bricaud H| title=Spontaneous coronary artery dissection: case report and evidence for a defect in collagen metabolism. | journal=Eur Heart J | year= 1986 | volume= 7 | issue= 10 | pages= 904-9 | pmid=3792352 | doi= | pmc= | url= }} </ref> The increase in blood volume and cardiac output that occurs with pregnancy magnifies shear forces of the blood column in large vessels, which in combination with the vessel wall changes leaves these patients predisposed to coronary dissection. | |||
The following should be considered in diagnosis and treatment of this condition: | |||
*Criteria for diagnosis of AMI in pregnant women are in general the same as in non pregnant patients (symptoms, exam, ECG, biomarkers, +/- imaging/angiography) | |||
*Note that creatine kinase and its MB fraction can increase nearly 2-fold within 30 minutes after delivery, and troponin levels<ref name="pmid9914590">{{cite journal| author=Shivvers SA, Wians FH, Keffer JH, Ramin SM| title=Maternal cardiac troponin I levels during normal labor and delivery. | journal=Am J Obstet Gynecol | year= 1999 | volume= 180 | issue= 1 Pt 1 | pages= 122 | pmid=9914590 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9914590 }} </ref> | |||
*If exercise stress testing is indicated, a submaximal protocol (<70% of maximal predicted heart rate) with fetal monitoring is preferred<ref name="pmid8489079">{{cite journal| author=Kleinman B| title=Electrocardiographic changes during cesarean section. | journal=Anesthesiology | year= 1993 | volume= 78 | issue= 5 | pages= 997-8 | pmid=8489079 | doi= | pmc= | url= }} </ref> | |||
*Radionuclide imaging using 99m technetium-labeled sestamibi or 201 thallium, as well as cardiac catheterization or interventional procedure, are expected to yield<11 rad of radiation to the conceptus, which is generally considered safe; termination of pregnancy is generally recommended at a level of 10 rads<ref name="pmid6716610">{{cite journal| author=Elkayam U, Gleicher N| title=Cardiac problems in pregnancy. I. Maternal aspects: the approach to the pregnant patient with heart disease. | journal=JAMA | year= 1984 | volume= 251 | issue= 21 | pages= 2838-9 | pmid=6716610 | doi= | pmc= | url= }} </ref> | |||
*The treatment of pregnant women with AMI and its complications should follow the usual standard of care; a cardiologist should work in tandem with an obstetrician in order to tailor therapy to both the mother and the fetus | |||
Listed below are common drugs used with coronary disease and their pregnancy categories: | |||
:#Morphine Sulfate (Risk Category C) | |||
:#Organic Nitrates (Risk Category B: Nitroglycerin; Risk Category C: Isosorbide Dinitrate) | |||
:#Beta-Adrenergic Blocking Agents (Risk Category B: Metroprolol; Risk Category C: Atenolol) | |||
:#Calcium Channel Blockers (CCBs): (Risk Category C: Nifedipine, Diltiazem, Verapamil) | |||
:#Angiotensin Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Antagonists (ARBs) (Risk Category C) *teratogenic* | |||
:#Eplerenone (Risk Category B) | |||
:#HMG-CoA Reductase Inhibitors (Statins) (Risk Category X) | |||
:#Unfractionated (UFH) AND Low Molecular Weight Heparin (LMWH) (Risk Category B: LMWH; Risk Category C: UFH) | |||
:#Aspirin (Risk Category C) | |||
:#Thienopyridine derivatives (Risk Category B) | |||
:#Glycoprotein IIb/IIIa inhibitors (Risk Category B: eptifibatide, tirofiban; Risk Category C: abciximab) | |||
Revision as of 14:53, 25 October 2011
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Anjan K. Chakrabarti, M.D. [2]
Overview
In general, women of childbearing age are at relatively low risk for coronary artery disease. While rare, the risk of acute myocardial infarction (AMI) is 3-4 times higher during pregnancy, and negative fetal and maternal outcomes are associated with this condition.
Acute Myocardial Infarction in Pregnancy
AMI can occur at all stages of pregnancy, and is more common in multi-gravid patients. In a review performed in 2008, myocardial infarction (MI) location was mostly (78%) in the anterior wall and involved the left anterior descending artery; the most common cause was coronary dissection.[1] This review also found a maternal mortality rate of 11% and a fetal mortality rate of 9%.
The etiology of coronary dissection in pregnant patents is thought to be related to an excess of progesterone, which causes changes in the vessel wall, including loss of normal corrugation elastin fibers, fragmentation of reticular fibers, and decreases in the amount of acid mucopolysaccharides.[2][3] The increase in blood volume and cardiac output that occurs with pregnancy magnifies shear forces of the blood column in large vessels, which in combination with the vessel wall changes leaves these patients predisposed to coronary dissection.
The following should be considered in diagnosis and treatment of this condition:
- Criteria for diagnosis of AMI in pregnant women are in general the same as in non pregnant patients (symptoms, exam, ECG, biomarkers, +/- imaging/angiography)
- Note that creatine kinase and its MB fraction can increase nearly 2-fold within 30 minutes after delivery, and troponin levels[4]
- If exercise stress testing is indicated, a submaximal protocol (<70% of maximal predicted heart rate) with fetal monitoring is preferred[5]
- Radionuclide imaging using 99m technetium-labeled sestamibi or 201 thallium, as well as cardiac catheterization or interventional procedure, are expected to yield<11 rad of radiation to the conceptus, which is generally considered safe; termination of pregnancy is generally recommended at a level of 10 rads[6]
- The treatment of pregnant women with AMI and its complications should follow the usual standard of care; a cardiologist should work in tandem with an obstetrician in order to tailor therapy to both the mother and the fetus
Listed below are common drugs used with coronary disease and their pregnancy categories:
- Morphine Sulfate (Risk Category C)
- Organic Nitrates (Risk Category B: Nitroglycerin; Risk Category C: Isosorbide Dinitrate)
- Beta-Adrenergic Blocking Agents (Risk Category B: Metroprolol; Risk Category C: Atenolol)
- Calcium Channel Blockers (CCBs): (Risk Category C: Nifedipine, Diltiazem, Verapamil)
- Angiotensin Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Antagonists (ARBs) (Risk Category C) *teratogenic*
- Eplerenone (Risk Category B)
- HMG-CoA Reductase Inhibitors (Statins) (Risk Category X)
- Unfractionated (UFH) AND Low Molecular Weight Heparin (LMWH) (Risk Category B: LMWH; Risk Category C: UFH)
- Aspirin (Risk Category C)
- Thienopyridine derivatives (Risk Category B)
- Glycoprotein IIb/IIIa inhibitors (Risk Category B: eptifibatide, tirofiban; Risk Category C: abciximab)
References
- ↑ Roth A, Elkayam U (2008). "Acute myocardial infarction associated with pregnancy". J Am Coll Cardiol. 52 (3): 171–80. doi:10.1016/j.jacc.2008.03.049. PMID 18617065.
- ↑ Manalo-Estrella P, Barker AE (1967). "Histopathologic findings in human aortic media associated with pregnancy". Arch Pathol. 83 (4): 336–41. PMID 4225694.
- ↑ Bonnet J, Aumailley M, Thomas D, Grosgogeat Y, Broustet JP, Bricaud H (1986). "Spontaneous coronary artery dissection: case report and evidence for a defect in collagen metabolism". Eur Heart J. 7 (10): 904–9. PMID 3792352.
- ↑ Shivvers SA, Wians FH, Keffer JH, Ramin SM (1999). "Maternal cardiac troponin I levels during normal labor and delivery". Am J Obstet Gynecol. 180 (1 Pt 1): 122. PMID 9914590.
- ↑ Kleinman B (1993). "Electrocardiographic changes during cesarean section". Anesthesiology. 78 (5): 997–8. PMID 8489079.
- ↑ Elkayam U, Gleicher N (1984). "Cardiac problems in pregnancy. I. Maternal aspects: the approach to the pregnant patient with heart disease". JAMA. 251 (21): 2838–9. PMID 6716610.