Pregnancy-related myocardial infarction
Pregnancy-related myocardial infarction
H. Lameijer 0 1 2 3
M. C. Lont 0 1 2 3
H. Buter 0 1 2 3
A. J. van Boven 0 1 2 3
P. W. Boonstra 0 1 2 3
P. G. Pieper 0 1 2 3
0 Department of Emergency Medicine, University of Groningen, UMCG Groningen , Groningen , The Netherlands
1 Department of Cardiology, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
2 Department of Cardiology and Cardiothoracic Surgery, Medical Centre Leeuwarden , Leeuwarden , The Netherlands
3 Department of Intensive Care, Medical centre Leeuwarden , Leeuwarden , The Netherlands
Introduction The risk of acute myocardial infarction in young women is low, but increases during pregnancy due to the physiological changes in pregnancy, including hypercoagulability. Ischaemic heart disease during pregnancy is not only associated with increased maternal morbidity and mortality, but also with high neonatal complications. Advancing maternal age and other risk factors for cardiovascular diseases may further increase the risk of ischaemic heart disease in young women. Methods We searched the coronary angiography database of a Dutch teaching hospital to identify women with acute myocardial infarction who presented during pregnancy or postpartum between 2011 and 2013. Results We found two cases. Both women were in their early thirties and both suffered from myocardial infarction in the postpartum period. Acute myocardial infarction was due to coronary stenotic occlusion in one patient and due to coronary artery dissection in the other patient. Coronary artery dissection is a relatively frequent cause of myocardial infarction during pregnancy. Both women were treated by percutaneous coronary intervention and survived.
Pregnancy; Myocardial infarction; Ischaemic heart disease; Gender
© The Author(s) 2017. This article is an open access publication.
Ischaemic heart disease (IHD) and acute myocardial
infarction in fertile women are rare . However, pregnancy
greatly increases the risk for IHD in these women [2, 3].
This can be explained by the physiological changes in
pregnancy, including a hyperdynamic circulation and
hypercoagulability. Advancing maternal age and other risk factors
for cardiovascular diseases may further increase the risk
of IHD in young women [4, 5]. IHD during pregnancy is
not only associated with increased maternal morbidity and
mortality, but also with high neonatal complications [2, 6,
7]. Information about IHD during pregnancy or the
postpartum period is scarcely available and mainly consists of case
reports, two studies, and few reviews [2, 6–9]. While the
treatment of IHD advances, contemporary cases of
pregnancy-related IHD are scarce . We therefore present two
recent cases of acute myocardial infarction presenting
during pregnancy or in the postpartum period.
We searched the coronary angiography database of the
Department of Cardiology of the Medical Centre
Leeuwarden, a teaching hospital in Leeuwarden, the Netherlands.
We selected fertile women (defined as <45 years) who
unFig. 1 An ECG showing ST segment elevation in leads II, III, aVF and V2–V5 and minimal ST segment depression in aVL, suggesting
derwent coronary angiography between March 2011 and
March 2013. Women who underwent coronary
angiography during pregnancy or up to three months postpartum
were included. We searched their medical files for proven
IHD, coronary artery disease or acute myocardial infarction,
based on coronary angiography results during pregnancy
and up to three months postpartum.
Fourteen young, fertile women underwent coronary
angiography; two women met our inclusion criteria.
A 31-year-old woman, gravida 8 para 4 (G8P4), presented
at our cardiology department with chest pain three weeks
after delivery of a healthy neonate. She had a history
of alcohol and recreational drug abuse (cocaine and
amphetamine). Other risk factors for cardiovascular diseases
were smoking, hypertension and hypercholesterolaemia.
She presented with chest pain, and additional complaints
were nausea, vomiting, excessive perspiration and
epigastric pain. Physical examination showed a pale woman
with clammy skin. She was hypotensive (blood pressure
87/53 mm Hg) with a heart rate of 60 beats per minute.
Cardiac auscultation showed no abnormalities.
Electrocardiogram (ECG) showed acute ST elevation myocardial
infarction (STEMI) (Fig. 1). Echocardiography showed
a moderately reduced left ventricular function with
akinesia of the septal, anterior and distal inferior wall, without
signs of pericardial effusion. A coronary angiography was
performed (Fig. 2). She was treated with bare metal
stenting. Creatine kinase (CK) levels were elevated to 3760 U/l,
CK-MB levels to 217 U/l. A toxicology screening was
performed at presentation and she tested negative for cocaine
or other recreational drugs. She was discharged after five
days; her condition was stable. During follow-up, she was
admitted to a cardiac rehabilitation programme and was
encouraged to alter her high-risk lifestyle.
Echocardiography during follow-up showed an estimated left ventricular
ejection fraction of 40–45%.
A 30-year-old woman, G3P3, with a history of migraine
headaches for which she incidentally used tramadol and
acetaminophen, presented at our emergency department three
months postpartum. She complained about chest pain and
excessive perspiration. Pain diminished after
administration of nitroglycerine sublingually. Physical examination
revealed that she was in shock; she had a systolic blood
pressure of 90 mm Hg and a regular tachycardia of 120
Fig. 2 A coronary angiography
of patient 1, showing occlusion
of the left anterior descending
artery distally from the first
diagonal artery before and after
Fig. 3 A coronary angiography of patient 2, showing an occlusion
of the left main coronary artery and a dissection of the left anterior
descending artery and circumflex coronary artery
beats per minute. She also had a pale, cold skin.
Auscultation revealed no cardiac murmurs. ECG suggested a STEMI
of the anterior wall. Coronary angiography was performed
and revealed an occlusion of the left main coronary artery
and a dissection of the left anterior descending artery and
circumflex coronary artery (Fig. 3). During coronary
angiography, external defibrillation was applied twice to treat
ventricular fibrillation. Echocardiography after the coronary
angiography showed akinesia of the anterior wall and mitral
valve regurgitation grade II. Because of her compromised
haemodynamic state despite the initiation of inotropics, an
intra-aortic balloon pump was inserted. Emergency
coronary artery bypass grafting was performed with a left
internal mammary artery graft to the left anterior descending
artery and a saphenous venous graft to the anterolateral
and obtuse marginal branches. A subsequent postoperative
cardiogenic shock was treated with the intra-aortic balloon
pump for one day and inotropics for two days. Her
condition steadily improved and she was discharged from the
intensive care unit after five days. At hospital discharge, ten
days after admission, echocardiography showed a
moderately reduced left ventricular function without valvular
regurgitation. At follow-up, three weeks after discharge, she
was in stable condition without any signs or symptoms of
ischaemia or heart failure.
We identified two cases of pregnancy-related IHD in
a teaching hospital over a two-year period. As
previously described in this journal, pregnancy-related IHD is
rare, with an incidence of 2.8 to 6.2 per 100,000
deliveries described in recent reviews [2, 3, 6]. In this large
teaching hospital, only 14 women of fertile age underwent
a coronary angiography during the period searched, and
two of them (14%) had pregnancy-related IHD. One of
our patients had several risk factors for IHD, consistent
with the literature where a high prevalence of risk factors
is reported in pregnancy-associated IHD, specifically when
atherosclerotic disease is present . Our second patient,
who had a coronary artery dissection, however, had no risk
factors for coronary artery disease, which is again
consistent with current literature . Coronary artery dissection,
which is rare outside pregnancy, is one of the main
aetiologies of acute myocardial infarction during pregnancy or
the postpartum period .
Both women presented with chest pain in the postpartum
period. This is consistent with the literature, where the
majority of cases of acute myocardial infarction during
pregnancy present with chest pain in the third trimester or the
postpartum period and predominantly involve the anterior
myocardial wall [2, 3, 6].
Both women were treated successfully for IHD and
survived. Myocardial infarction during or shortly after
pregnancy is a very high-risk condition with maternal mortality
rates ranging from 5.1 to 11% [2, 3, 6]. When a pregnant
woman presents with chest pain, the diagnoses that should
be considered are pulmonary embolism, aortic dissection
and myocardial infarction. ECG and troponin levels should
be assessed to diagnose infarction, while echocardiography
and computerised tomography are needed to diagnose
aortic dissection and pulmonary embolism. Percutaneous
coronary intervention is the preferred treatment in women with
STEMI or non-STEMI who have risk factors, according to
current guidelines . Bare metal stents are preferred over
drug-eluting stents in pregnant women, because prolonged
dual antiplatelet therapy is preferably avoided [8, 9]. In
stable patients with coronary artery dissection a more
conservative approach has been advocated, since spontaneous
healing often occurs and percutaneous coronary
intervention is fraught with technical difficulties and a high
failure rate . Medical treatment may include beta blockers
and acetylsalicylic acid. Clopidogrel, though safe in animal
studies, should be used with caution since experience in
humans is limited. ACE-inhibitors and angiotensin
receptor blockers are contra-indicated during pregnancy.
Vaginal delivery is usually appropriate . Standard IHD risk
factor management such as reducing smoking habits,
obesity, hypertension and hypercholesterolaemia and treating
lipoprotein disorders should be implemented. Additionally,
antiphospholipid syndrome as a contributor to myocardial
infarction in young women with a history of pregnancy
morbidity such as spontaneous abortions, as observed in
our first case, should be evaluated .
Physicians should be aware of this increased risk of
manifestations of IHD when encountering young pregnant or
postpartum women with chest pain.
Conflict of interest H. Lameijer, M. C. Lont, H. Buter, A. J. van
Boven, P. W. Boonstra and P. G. Pieper declare that they have no
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