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Myocardial infarction in pregnant women — Case reports
International Journal of Cardiology 121 (2007) 207 – 209 www.elsevier.com/locate/ijcard
Letter to the Editor
Myocardial infarction in pregnant women — Case reports M. Janion ⁎, J. Sielski, A. Janion-Sadowska Swietokrzyskie Centrum Kardiologii, Grunwaldzka 45, 25-736 Kielce, Poland Received 20 June 2006; received in revised form 9 August 2006; accepted 10 August 2006 Available online 30 November 2006
Abstract Five cases of women with MI in pregnancy are presented. Their past and present heart condition, therapy and cardiovascular disease risk factors were analyzed. The mean follow-up period was 14.6 years. The observed women had an atherosclerotic etiology of MI with multiple risk factors of ischaemic heart disease. Pulmonary oedema complicating MI in presented cases had no influence on long-term prognosis. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Follow-up; Myocardial infarction; Pregnancy
Myocardial infarction (MI) may occur any time during pregnancy, delivery or puerperium. Ischaemic heart disease (IHD) was reported only in 13% of pregnant women with MI. It may occur in women with IHD risk factors or those considered healthy [1,2]. The prevalence of MI during pregnancy is reported as rare (1/10,000–1/30,000 pregnancies) [2,3]. However, increase in MI morbidity among pregnant women is explained by the tendency for late maternity and the appearance of the new assisted reproduction techniques allowing older women with many IHD risk factors to become pregnant [3,4]. The low prevalence, differences in etiopathogenesis, diagnostic difficulties and complex therapy of this sudden disease make it a real clinical challenge. The most frequent MI complications in pregnancy are ventricular arrhythmias, cardiogenic shock, and left heart failure. The appearance of MI during pregnancy is related to higher mother and fetus mortality [1,2]. The available publications lack data on long-term prognosis in such cases. In order to examine this issue, five cases of MI during pregnancy in the period between 1981 and 2005 were analyzed. The follow-up period after the MI was 5 to 25 years (mean 14.6 years). Basic clinical characteristics are presented in Table 1. ⁎ Corresponding author. Tel./fax: +48 41 3671456. E-mail address: [email protected] (M. Janion). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.085
All women presented typical clinical manifestation of MI. In three cases it was a direct reason for seeking medical care and in one case the chest pain was accompanied by a loss of consciousness. Two patients presented at the hospital after the complications have occurred. In all women the MI occurred during the second or the third trimester. All women were multiparae. The average age was 31.6 years, and was comparable with the data from available literature (32– 33.8 years old) [1–3]. The inferior MI was the most frequent one. The cause of MI in older women (cases I to III) with IHD risk factors (smoking, dyslipidaemia, and hypertension in two of them) was atherosclerosis, confirmed angiographically in case III. As in the other two cases coronary angiography was not performed, a spontaneous dissection of coronary artery or a spasm followed by acute thrombosis [2] should be considered as another probable cause. Coronary artery spasm is often mentioned as a pathology leading to MI during pregnancy, but so far only one angiographically documented case has been reported [4]. Spontaneous artery dissection is rare in general population, but its incidence is higher among women either pregnant or not [6]. Physiological changes occurring during pregnancy may contribute both to spasm (increased renin secretion) [4,6] and dissection (hormone-mediated changes in connective tissue) [5,6]. Because of the ability of self-healing of these two pathologies, coronary angiography performed after the acute coronary syndrome may reveal no abnormalities
208
M. Janion et al. / International Journal of Cardiology 121 (2007) 207–209
Table 1 Baseline characteristics and follow-up Feature
Age (years) Period of pregnancy No. of pregnancies IHD risk Smoking factors Hypertension
Case I
II
III
IV
V
32 32nd week 3 + + +
41 puerperium 6 + + 0
35 18th week 6 + 0 0
21 32nd week 2 0 0 0
29 17th week 2 quit 5 years before no yes
Family history Total cholesterol LDL HDL Triglicerides Organic heart disease Etiology of MI Localization of the MI Complications
226
166
239
176
215
140 49 185 0 Atherosclerotic Inferior Ventricular arrhythmia
– 14 432 0 Atherosclerotic Inferior Pulmonary oedema (2×)
Conservative Caesarean delivery
Follow-up (years) Angina NYHA class Exercise test Ejection fraction Wall motion disturbances Resting ECG Current treatment
25 0 II Normal Normal 0 0 ASA, ACEi, diuretic, statin
5 +(CCS II) II + Normal 0 Past MI ASA, ACEi, diuretic, CCA, statin
13 0 II Normal 35% + Past MI ASA, ACEi, betablocker, statin
111 23 209 + Embolic Anterior Pulmonary oedema CABG, MVR Caesarean delivery 15 0 I Normal Normal + Past MI Betablocker, oral anticoagulant
107 82 129 + Embolic Inferior 0
Therapy Delivery
104 26 180 0 Atherosclerotic Anterior Pulmonary oedema Conservative Vaginal
Lipids
PCI Vaginal
Conservative Caesarean delivery 15 0 II Normal Normal 0 0 ASA, ACEi, betablocker
ASA – acetylosalicylic acid, ACEi – angiotensin converting enzyme inhibitor, CCA – calcium channel antagonist, CABG – coronary artery by-pass graft, MVR – mitral valve replacement, PCI – percutaneous coronary angioplasty.
[2,5,6]. In younger women (cases IV and V) with the past history of organic heart disease the MI was a consequence of a coronary artery embolism complicating infectious endocarditis in one case and mitral commissurotomy in the other one. The presence of smoking, hypertension, dyslipdaemia and age of 32 or more (which is known to increase the risk of MI 3 to 4 times as compared to those aged 21–25) [3], may be helpful in identifying the group of older women as being at high risk of MI. In case of the remaining two younger women, the embolic etiology of MI was related to coexisting organic heart disease. Presented data is in accordance with other available scientific publications that emphasize nonatherosclerotic causes of MI as more frequent in younger pregnant women [1–3]. The most frequent complication of MI was acute heart failure manifested as pulmonary oedema (PO) (cases II to IV) and ventricular arrhythmia in one patient. Haemodynamic changes related to pregnancy like increased cardiac output, increased blood volume and tachycardia also played an important role in the pathogenesis of PO [6]. In one patient PO occurred on the third day of puerperium, while in the other it occurred at the beginning of the third trimester
and once more on the 12th day of the puerperium. In the third woman a mechanical complication of MI (acute mitral regurgitation) resulted in pulmonary oedema. PO is commonly known to complicate large myocardial infarctions and to worsen in-hospital and long-term prognosis [7]. All those women present in NYHA class I or II in the long-term follow-up. The PO had no significant influence on the longterm prognosis. Despite the fact that caesarean section is reported to have more negative influence on prognosis than vaginal delivery [2,4,6], it was performed in 3 patients as a consequence of hemodynamic instability in one patient, acute fetal asphyxia in the other and occurrence of MI 6 weeks before scheduled date of delivery in the last one. Two patients had vaginal delivery. One of them delivered on the 4th day of an undiagnosed MI, another one had a premature delivery in the 22nd week of pregnancy (a newborn did not survived). None of those five women had further delivery. Their overall condition in the long-term follow-up remains stable. Three women modified their IHD risk factors and they are on hypotensive and plaque stabilising pharmacotherapy. The oldest patient (46 years old) remains in the CCS class II, with clinically negative and ECG positive exercise test (ET).
M. Janion et al. / International Journal of Cardiology 121 (2007) 207–209
Remaining four women do not complain of angina and their submaximal ET is within normal limits. Resting ECG shows features of past MI in three patients. All women remain in the NYHA class I or II. The transthoracic ultrasound examination shows wall motion disturbances in two patients, but only one has a significantly decreased left ventricular ejection fraction. It remains within normal limits in four other patients. References [1] Badui E, Enciso R. Acute myocardial infarction during pregnancy and puerperium: a review. Angiology 1996;47:739–56. [2] Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. Ann Intern Med 1996;125:751–62.
209
[3] Ladner HE, Danielsen B, Gilbert WM. Acute myocardial infarction in pregnancy and the puerperium: a population-based study. Obstet Gynecol 2005;105:480–4. [4] Iadanza A, Del Pasqua A, Barbati R, et al. Acute ST elevation myocardial infarction in pregnancy due to coronary vasospasm: a case report and review of literature. Int J Cardiol 2007;115:81–5. [5] Maeder M, Ammann P, Angehrn W, Rickli H. Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Cardiol 2005;101(3):363–9. [6] Abbas AE, Lester SJ, Connolly H. Pregnancy and the cardiovascular system. Int J Cardiol 2005;98(2):179–89. [7] Janion M. Myocardial infarction in women. Gender related differences in clinical course and 6 year long term follow-up. Kardiol Pol 1999;51:305–18.
Letter to the Editor
Myocardial infarction in pregnant women — Case reports M. Janion ⁎, J. Sielski, A. Janion-Sadowska Swietokrzyskie Centrum Kardiologii, Grunwaldzka 45, 25-736 Kielce, Poland Received 20 June 2006; received in revised form 9 August 2006; accepted 10 August 2006 Available online 30 November 2006
Abstract Five cases of women with MI in pregnancy are presented. Their past and present heart condition, therapy and cardiovascular disease risk factors were analyzed. The mean follow-up period was 14.6 years. The observed women had an atherosclerotic etiology of MI with multiple risk factors of ischaemic heart disease. Pulmonary oedema complicating MI in presented cases had no influence on long-term prognosis. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Follow-up; Myocardial infarction; Pregnancy
Myocardial infarction (MI) may occur any time during pregnancy, delivery or puerperium. Ischaemic heart disease (IHD) was reported only in 13% of pregnant women with MI. It may occur in women with IHD risk factors or those considered healthy [1,2]. The prevalence of MI during pregnancy is reported as rare (1/10,000–1/30,000 pregnancies) [2,3]. However, increase in MI morbidity among pregnant women is explained by the tendency for late maternity and the appearance of the new assisted reproduction techniques allowing older women with many IHD risk factors to become pregnant [3,4]. The low prevalence, differences in etiopathogenesis, diagnostic difficulties and complex therapy of this sudden disease make it a real clinical challenge. The most frequent MI complications in pregnancy are ventricular arrhythmias, cardiogenic shock, and left heart failure. The appearance of MI during pregnancy is related to higher mother and fetus mortality [1,2]. The available publications lack data on long-term prognosis in such cases. In order to examine this issue, five cases of MI during pregnancy in the period between 1981 and 2005 were analyzed. The follow-up period after the MI was 5 to 25 years (mean 14.6 years). Basic clinical characteristics are presented in Table 1. ⁎ Corresponding author. Tel./fax: +48 41 3671456. E-mail address: [email protected] (M. Janion). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.085
All women presented typical clinical manifestation of MI. In three cases it was a direct reason for seeking medical care and in one case the chest pain was accompanied by a loss of consciousness. Two patients presented at the hospital after the complications have occurred. In all women the MI occurred during the second or the third trimester. All women were multiparae. The average age was 31.6 years, and was comparable with the data from available literature (32– 33.8 years old) [1–3]. The inferior MI was the most frequent one. The cause of MI in older women (cases I to III) with IHD risk factors (smoking, dyslipidaemia, and hypertension in two of them) was atherosclerosis, confirmed angiographically in case III. As in the other two cases coronary angiography was not performed, a spontaneous dissection of coronary artery or a spasm followed by acute thrombosis [2] should be considered as another probable cause. Coronary artery spasm is often mentioned as a pathology leading to MI during pregnancy, but so far only one angiographically documented case has been reported [4]. Spontaneous artery dissection is rare in general population, but its incidence is higher among women either pregnant or not [6]. Physiological changes occurring during pregnancy may contribute both to spasm (increased renin secretion) [4,6] and dissection (hormone-mediated changes in connective tissue) [5,6]. Because of the ability of self-healing of these two pathologies, coronary angiography performed after the acute coronary syndrome may reveal no abnormalities
208
M. Janion et al. / International Journal of Cardiology 121 (2007) 207–209
Table 1 Baseline characteristics and follow-up Feature
Age (years) Period of pregnancy No. of pregnancies IHD risk Smoking factors Hypertension
Case I
II
III
IV
V
32 32nd week 3 + + +
41 puerperium 6 + + 0
35 18th week 6 + 0 0
21 32nd week 2 0 0 0
29 17th week 2 quit 5 years before no yes
Family history Total cholesterol LDL HDL Triglicerides Organic heart disease Etiology of MI Localization of the MI Complications
226
166
239
176
215
140 49 185 0 Atherosclerotic Inferior Ventricular arrhythmia
– 14 432 0 Atherosclerotic Inferior Pulmonary oedema (2×)
Conservative Caesarean delivery
Follow-up (years) Angina NYHA class Exercise test Ejection fraction Wall motion disturbances Resting ECG Current treatment
25 0 II Normal Normal 0 0 ASA, ACEi, diuretic, statin
5 +(CCS II) II + Normal 0 Past MI ASA, ACEi, diuretic, CCA, statin
13 0 II Normal 35% + Past MI ASA, ACEi, betablocker, statin
111 23 209 + Embolic Anterior Pulmonary oedema CABG, MVR Caesarean delivery 15 0 I Normal Normal + Past MI Betablocker, oral anticoagulant
107 82 129 + Embolic Inferior 0
Therapy Delivery
104 26 180 0 Atherosclerotic Anterior Pulmonary oedema Conservative Vaginal
Lipids
PCI Vaginal
Conservative Caesarean delivery 15 0 II Normal Normal 0 0 ASA, ACEi, betablocker
ASA – acetylosalicylic acid, ACEi – angiotensin converting enzyme inhibitor, CCA – calcium channel antagonist, CABG – coronary artery by-pass graft, MVR – mitral valve replacement, PCI – percutaneous coronary angioplasty.
[2,5,6]. In younger women (cases IV and V) with the past history of organic heart disease the MI was a consequence of a coronary artery embolism complicating infectious endocarditis in one case and mitral commissurotomy in the other one. The presence of smoking, hypertension, dyslipdaemia and age of 32 or more (which is known to increase the risk of MI 3 to 4 times as compared to those aged 21–25) [3], may be helpful in identifying the group of older women as being at high risk of MI. In case of the remaining two younger women, the embolic etiology of MI was related to coexisting organic heart disease. Presented data is in accordance with other available scientific publications that emphasize nonatherosclerotic causes of MI as more frequent in younger pregnant women [1–3]. The most frequent complication of MI was acute heart failure manifested as pulmonary oedema (PO) (cases II to IV) and ventricular arrhythmia in one patient. Haemodynamic changes related to pregnancy like increased cardiac output, increased blood volume and tachycardia also played an important role in the pathogenesis of PO [6]. In one patient PO occurred on the third day of puerperium, while in the other it occurred at the beginning of the third trimester
and once more on the 12th day of the puerperium. In the third woman a mechanical complication of MI (acute mitral regurgitation) resulted in pulmonary oedema. PO is commonly known to complicate large myocardial infarctions and to worsen in-hospital and long-term prognosis [7]. All those women present in NYHA class I or II in the long-term follow-up. The PO had no significant influence on the longterm prognosis. Despite the fact that caesarean section is reported to have more negative influence on prognosis than vaginal delivery [2,4,6], it was performed in 3 patients as a consequence of hemodynamic instability in one patient, acute fetal asphyxia in the other and occurrence of MI 6 weeks before scheduled date of delivery in the last one. Two patients had vaginal delivery. One of them delivered on the 4th day of an undiagnosed MI, another one had a premature delivery in the 22nd week of pregnancy (a newborn did not survived). None of those five women had further delivery. Their overall condition in the long-term follow-up remains stable. Three women modified their IHD risk factors and they are on hypotensive and plaque stabilising pharmacotherapy. The oldest patient (46 years old) remains in the CCS class II, with clinically negative and ECG positive exercise test (ET).
M. Janion et al. / International Journal of Cardiology 121 (2007) 207–209
Remaining four women do not complain of angina and their submaximal ET is within normal limits. Resting ECG shows features of past MI in three patients. All women remain in the NYHA class I or II. The transthoracic ultrasound examination shows wall motion disturbances in two patients, but only one has a significantly decreased left ventricular ejection fraction. It remains within normal limits in four other patients. References [1] Badui E, Enciso R. Acute myocardial infarction during pregnancy and puerperium: a review. Angiology 1996;47:739–56. [2] Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. Ann Intern Med 1996;125:751–62.
209
[3] Ladner HE, Danielsen B, Gilbert WM. Acute myocardial infarction in pregnancy and the puerperium: a population-based study. Obstet Gynecol 2005;105:480–4. [4] Iadanza A, Del Pasqua A, Barbati R, et al. Acute ST elevation myocardial infarction in pregnancy due to coronary vasospasm: a case report and review of literature. Int J Cardiol 2007;115:81–5. [5] Maeder M, Ammann P, Angehrn W, Rickli H. Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Cardiol 2005;101(3):363–9. [6] Abbas AE, Lester SJ, Connolly H. Pregnancy and the cardiovascular system. Int J Cardiol 2005;98(2):179–89. [7] Janion M. Myocardial infarction in women. Gender related differences in clinical course and 6 year long term follow-up. Kardiol Pol 1999;51:305–18.