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Antonijevic N, Gosnjic N, Marjanovic M, Antonijevic J, Culafic M, Starcevic J, Plavsic M, Mostic Stanisic D, Uscumlic A, Lekovic Z, Matic D. Antiplatelet Drugs Use in Pregnancy-Review of the Current Practice and Future Implications. J Pers Med 2024; 14:560. [PMID: 38929781 PMCID: PMC11205062 DOI: 10.3390/jpm14060560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/19/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
When clinicians opt for antithrombotic therapy to manage or prevent thrombotic complications during pregnancy, it is imperative to consider the unique physiological state of the pregnant woman's body, which can influence the pharmacokinetics of the drug, its ability to traverse the placental barrier, and its potential teratogenic effects on the fetus. While the efficacy and safety of aspirin during pregnancy have been relatively well-established through numerous clinical studies, understanding the effects of newer, more potent antiplatelet agents has primarily stemmed from individual clinical case reports necessitating immediate administration of potent antiplatelet therapy during pregnancy. This review consolidates the collective experiences of clinicians confronting novel thrombotic complications during pregnancy, often requiring the use of dual antiplatelet therapy. The utilization of potent antiplatelet therapy carries inherent risks of bleeding, posing threats to both the pregnant woman and the fetus, as well as the potential for teratogenic effects on the fetus. In the absence of official guidelines regarding the use of potent antiplatelet drugs in pregnancy, a plethora of cases have demonstrated the feasibility of preventing recurrent thrombotic complications, mitigating bleeding risks, and successfully managing pregnancies, frequently culminating in cesarean deliveries, through meticulous selection and dosing of antiplatelet medications.
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Affiliation(s)
- Nebojsa Antonijevic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia
| | - Nikola Gosnjic
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, 11 000 Belgrade, Serbia
| | - Marija Marjanovic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
| | - Jovana Antonijevic
- Center for Anesthesiology and Resuscitation, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
| | - Milica Culafic
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, 11 000 Belgrade, Serbia
| | - Jovana Starcevic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
| | - Milana Plavsic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
| | - Danka Mostic Stanisic
- Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
| | - Ana Uscumlic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia
| | - Zaklina Lekovic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
| | - Dragan Matic
- Clinic for Cardiology, University Clinical Center of Serbia, 11 000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia
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Kim JA, Kim SY, Virk HUH, Alam M, Sharma S, Johnson MR, Krittanawong C. Acute Myocardial Infarction in Pregnancy. Cardiol Rev 2024:00045415-990000000-00222. [PMID: 38411170 DOI: 10.1097/crd.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
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.
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Affiliation(s)
- Jitae A Kim
- From the Department of Cardiology, University of Buffalo, New York, NY
| | - Sophie Y Kim
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, El Paso, TX
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mahboob Alam
- Division of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Mark R Johnson
- Academic Department of Obstetrics and Gynaecology, Institute of Reproductive and Developmental Biology, Chelsea and Westminster Hospital, Imperial College London, London, UK; and
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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4
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 601] [Impact Index Per Article: 601.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Markson F, Shamaki RG, Antia A, Osabutey A, Ogunniyi MO. Trends in the incidence and in-patient outcomes of acute myocardial infarction in pregnancy: Insights from the national inpatient sample. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 34:100318. [PMID: 38510954 PMCID: PMC10946051 DOI: 10.1016/j.ahjo.2023.100318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 03/22/2024]
Abstract
Study objective Pregnancy-related morbidity and mortality rates in the United States are rising despite advances in knowledge, technology, and healthcare delivery. Cardiovascular disease is the leading cause of adverse pregnancy outcomes, with acute myocardial infarction (AMI) being a potential contributor to the worse outcomes in pregnancy. Design/setting We analyzed data from the national inpatient sample database to examine trends in the incidence and in-hospital outcomes of myocardial infarction in pregnancy from 2016 to 2020. Participants Using ICD-10-CM codes, we identified all admissions from a pregnancy-related encounter with a diagnosis of type 1 AMI. Main outcome Using the marginal effect of years, we assessed the trends in the incidence of AMI and utilized a multivariate logistic regression model to compare our secondary outcomes. Results Of the 19,524,846 patients with an obstetric-related admission, 3605 (0.02 %) had a diagnosis of type 1 AMI. Overall, we observed an approximately 2-fold increase in the trend of AMI from 1.4 to 2.5 per 10,000 obstetric admissions, with the highest incidence trend of 2.5 to 5.2 per 10,000 obstetric admissions seen in Black patients. Among patients diagnosed with AMI, we found significantly higher rates of in-hospital mortality (Adjusted Odds Ratio (AOR): 22.9, 12.2-42.8), cardiogenic shock (AOR:54.3, 33.9-86.6), preeclampsia (AOR: 2.2, 1.65-2.94) and spontaneous abortion (AOR:6.3, 3.71-10.6). Conclusion Over the 5-year period, we found increasing trends in the incidence of AMI in pregnancy, especially among Black patients. Incident AMI was also associated with worse pregnancy outcomes.
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Affiliation(s)
- Favour Markson
- Department of Medicine, Lincoln Medical Center, Bronx, NY, USA
| | | | - Akanimo Antia
- Department of Medicine, Lincoln Medical Center, Bronx, NY, USA
| | - Anita Osabutey
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia;USA
| | - Modele O. Ogunniyi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia;USA
- Grady Health System, Atlanta, Georgia, USA
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Gédéon T, Akl E, D'Souza R, Altit G, Rowe H, Flannery A, Siriki P, Bhatia K, Thorne S, Malhamé I. Acute Myocardial Infarction in Pregnancy. Curr Probl Cardiol 2022; 47:101327. [PMID: 35901856 DOI: 10.1016/j.cpcardiol.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.
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Affiliation(s)
- Tara Gédéon
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Elie Akl
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gabriel Altit
- Department of Paediatrics, McGill University Health Centre, Montreal, Canada
| | - Hilary Rowe
- Department of Pharmacy, Nanaimo Regional General Hospital, Island Health, Nanaimo, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alexandria Flannery
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Kailash Bhatia
- Department of Anaesthesia, Manchester University Hospitals and St Mary's Hospital, University of Manchester, Manchester, United Kingdom
| | - Sara Thorne
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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Cai E, Czuzoj-Shulman N, Malhamé I, Abenhaim HA. Maternal and neonatal outcomes in women with disorders of lipid metabolism. J Perinat Med 2021; 49:1129-1134. [PMID: 34213841 DOI: 10.1515/jpm-2021-0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The effects of lipid metabolism disorders (LMD) on pregnancy outcomes is not well known. The purpose of this study is to evaluate the impact of LMD on maternal and fetal outcomes. METHODS Using the Healthcare Cost and Utilization Project - National Inpatient Sample from the United States, we carried out a retrospective cohort study of all births between 1999 and 2015 to determine the risks of complications in pregnant women known to have LMDs. All pregnant patients diagnosed with LMDs between 1999 and 2015 were identified using the International Classification of Disease-9 coding, which included all patients with pure hypercholesterolemia, pure hyperglyceridemia, mixed hyperlipidemia, hyperchylomicronemia, and other lipid metabolism disorders. Adjusted effects of LMDs on maternal and newborn outcomes were estimated using unconditional logistic regression analysis. RESULTS A total of 13,792,544 births were included, 9,666 of which had an underlying diagnosis of LMDs for an overall prevalence of 7.0 per 10,000 births. Women with LMDs were more likely to have pregnancies complicated by diabetes, hypertension, and premature births, and to experience myocardial infarctions, venous thromboembolisms, postpartum hemorrhage, and maternal death. Their infants were at increased risk of congenital anomalies, fetal growth restriction, and fetal demise. CONCLUSIONS Women with LMDs are at significantly higher risk of adverse maternal and newborn outcomes. Prenatal counselling should take into consideration these risks and antenatal care in specialized centres should be considered.
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Affiliation(s)
- Emmy Cai
- Department of Obstetrics & Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | | | - Isabelle Malhamé
- Department of Medicine, Division of General Internal Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Haim A Abenhaim
- Department of Obstetrics & Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada.,Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada
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Michaelis T, Gunaga S, McKechnie T, Shafiq Q. Acute Myocardial Infarction in a Patient with Twin Pregnancy: A Case Report. Clin Pract Cases Emerg Med 2021; 5:507-510. [PMID: 34813459 PMCID: PMC8610456 DOI: 10.5811/cpcem.2021.6.52939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/22/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Acute myocardial infarction (AMI) rarely occurs during pregnancy and presents unique challenges in diagnosis and management. Traditionally, pregnancy has not readily been considered a risk factor for AMI in the emergency department despite the potential for adverse impacts on maternal and fetal health. As cardiovascular risk factors and advanced maternal age become more prevalent in society over time, the incidence will continue to increase. Prior cases with singular gestation have been reported; however, only one previous case during a twin pregnancy was identified in the medical literature. CASE REPORT We describe a rare case of acute ST-segment elevation myocardial infarction in a 37-year-old woman at 24 weeks gestation with a dichorionic diamniotic twin pregnancy. CONCLUSION It is important for the emergency physician to recognize acute coronary syndrome as a part of the differential diagnosis of chest pain in pregnant patients and be familiar with the diagnostic and management options available for this special population.
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Affiliation(s)
- Tony Michaelis
- Henry Ford Wyandotte Hospital, Department of Emergency Medicine, Wyandotte, Michigan
| | - Satheesh Gunaga
- Henry Ford Wyandotte Hospital, Department of Emergency Medicine, Wyandotte, Michigan
| | - Tyson McKechnie
- Henry Ford Wyandotte Hospital, Department of Emergency Medicine, Wyandotte, Michigan
| | - Qaiser Shafiq
- Henry Ford Wyandotte Hospital, Department of Medicine/Division of Cardiology, Wyandotte, Michigan
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Samuel R, Alfadhel M, McAlister C, Nestelberger T, Saw J. Coronary Events in the Pregnant Patient: Who Is at Risk and How Best to Manage? Can J Cardiol 2021; 37:2026-2034. [PMID: 34530109 DOI: 10.1016/j.cjca.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022] Open
Abstract
Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimise maternal and fetal outcomes. The early involvement of the "cardio-obstetrics" team in prepregnancy counselling, the antenatal period, delivery, and postpartum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing owing to a number of factors, including advancing maternal age and increases in traditional cardiac risk factors contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have previous coronary disease, and the pathologic mechanisms involved are predominantly nonatherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnoses, and management strategies for patients at risk of or presenting with coronary events in pregnancy.
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Affiliation(s)
- Rohit Samuel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
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Guo YZ, Zhao ZW, Li SM, Chen LL. Clinical efficacy and safety of tirofiban combined with conventional dual antiplatelet therapy in ACS patients undergoing PCI. Sci Rep 2021; 11:17144. [PMID: 34433885 PMCID: PMC8387390 DOI: 10.1038/s41598-021-96606-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 08/12/2021] [Indexed: 11/09/2022] Open
Abstract
Challenges remain for clinicians over balancing the efficacy of active antithrombotic therapy and simultaneous bleeding reduction in patients. The clinical data of 347 patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) were retrospectively analyzed. On the basis of the given tirofiban, the patients were assigned into three different dose groups: high dose group (group H), medium dose group (group M), and low dose group (group L). The tirofiban efficacy was evaluated in terms of major adverse cardiovascular event (MACE) parameters and lab endpoints, including platelet count and function. The tirofiban safety was assessed by the occurrence of bleeding events. The patients were followed up for 1 month after the PCI. No significant difference in MACE events was evident among these groups (p > 0.05). Groups H and M reported an obvious reduction in platelet count (p < 0.05 for both) and an increased platelet inhibition rate (p < 0.05 for both). Group H showed a higher rate of total bleeding events than the other groups (Group H vs. Group M: 34.4% vs. 16.5%; Group H vs. Group L: 34.4% vs. 10.3%; p < 0.05 for both). A proper administration of a low dose of tirofiban may be a superior alternative in treating ACS patients, which can produce a similar favorable clinical outcome and a decrease in bleeding complication.
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Affiliation(s)
- Yong-Zhe Guo
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China
| | - Zi-Wen Zhao
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China
| | - Shu-Mei Li
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China
| | - Liang-Long Chen
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China.
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11
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Mehta N, Shah K, Bhatt Y. Caesarean section in a case of acute coronary syndrome - A case report. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.4103/joacc.joacc_94_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Manolis TA, Manolis AA, Apostolopoulos EJ, Papatheou D, Melita H, Manolis AS. Cardiac arrhythmias in pregnant women: need for mother and offspring protection. Curr Med Res Opin 2020; 36:1225-1243. [PMID: 32347120 DOI: 10.1080/03007995.2020.1762555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.
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13
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Khaing PH, Buchanan GL, Kunadian V. Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy. ACTA ACUST UNITED AC 2020; 15:e04. [PMID: 32536975 PMCID: PMC7277904 DOI: 10.15420/icr.2020.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/02/2020] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.
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Affiliation(s)
- Phyo Htet Khaing
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Newcastle upon Tyne, UK
| | | | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Newcastle upon Tyne, UK.,Cardiothoracic Centre, Freeman Hospital Newcastle Upon Tyne, UK
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14
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Ramlakhan KP, Johnson MR, Roos-Hesselink JW. Pregnancy and cardiovascular disease. Nat Rev Cardiol 2020; 17:718-731. [PMID: 32518358 DOI: 10.1038/s41569-020-0390-z] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/13/2022]
Abstract
Cardiovascular disease complicates 1-4% of pregnancies - with a higher prevalence when including hypertensive disorders - and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.
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Affiliation(s)
- Karishma P Ramlakhan
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mark R Johnson
- Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, London, UK
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15
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Wang H, Feng M. Influences of different dose of tirofiban for acute ST elevation myocardial infarction patients underwent percutaneous coronary intervention. Medicine (Baltimore) 2020; 99:e20402. [PMID: 32501985 PMCID: PMC7306376 DOI: 10.1097/md.0000000000020402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Tirofiban is widely used in patients with acute ST elevation myocardial infarction (STEMI) underwent percutaneous coronary intervention (PCI). This drug can efficiently improve myocardial perfusion and cardiac function, but its dose still remains controversial. We here investigated the effects of different dose of tirofiban on myocardial reperfusion and heart function in patients with STEMI. A total of 312 STEMI patients who underwent PCI in our hospital from March 2017 to March 2018 were enrolled and randomly divided into control group (75 cases, 0 μg/kg), low-dose group (79 cases, 5 μg/kg), medium-dose group (81 cases, 10 μg/kg) and high-dose group (77 cases, 20 μg/kg). The infarction-targeted artery flow grade evaluated by thrombolysis in myocardial infarction (TIMI), corrected TIMI frame count (CTFC) and sum-ST-segment resolution were recorded. At Day 7 and Day 30 after PCI, the left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter, left ventricular end systolic diameter, major adverse cardiovascular events and the hemorrhage and thrombocytopenia were also evaluated. After PCI, the rate of TIMI grade 3, CTFC and incidence of sum-ST-segment resolution > 50% of high-dose group were significantly higher than those of control group, low-dose group and medium-dose group (P < .05), and the CTFC of medium -dose group were significantly higher than that of control group, low-dose group (P < .05). Moreover, the LVEF, left ventricular end diastolic diameter and left ventricular end systolic diameter of high-dose group were significantly improved than those of other groups, and the LVEF of medium-dose group was significantly superior to that of low-dose group (P < .05). However, the incidence of major adverse cardiac events in high-dose group was significantly decreased, while the hemorrhage and incidence of thrombocytopenia of high-dose group were significantly higher than those of other 3 groups (P < .05). The tirofiban can effectively alleviate the myocardial ischemia-reperfusion injury and promote the recovery of cardiac function in STEMI patients underwent PCI. Although the high-dose can enhance the clinical effects, it also increased the hemorrhagic risk. Therefore, the rational dosage application of tirofiban become much indispensable in view of patient's conditions and hemorrhagic risk, and a medium dose of 10 μg/kg may be appropriate for patients without high hemorrhagic risk.
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Affiliation(s)
- Haixia Wang
- Department Pharmacy, the Second Clinical Hospital of Shanxi Medical University, Taiyuan, Shanxi
| | - Meiqin Feng
- AstraZeneca (Wuxi) trading co. LTD, Wuxi, Jiangsu, China
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16
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Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:3-31. [PMID: 32768092 PMCID: PMC7528571 DOI: 10.1016/b978-0-444-64240-0.00001-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Jean Rodriguez Lopez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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17
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Edupuganti MM, Ganga V. Acute myocardial infarction in pregnancy: Current diagnosis and management approaches. Indian Heart J 2019; 71:367-374. [PMID: 32035518 PMCID: PMC7013191 DOI: 10.1016/j.ihj.2019.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/19/2019] [Accepted: 12/09/2019] [Indexed: 12/29/2022] Open
Abstract
Acute myocardial infarction during pregnancy is a very uncommon condition; atherosclerotic coronary artery disease is by far the most common cause of an acute coronary syndrome in the general population. The causes of an acute coronary syndrome in the pregnant patient are wide and varied. This has important implications with respect to the diagnosis of the etiology and the subsequent management of the cause of the acute coronary syndrome. There are a number of diagnostic tools for the diagnosis of coronary artery disease but it is important to understand their role in pregnant patients. Spontaneous coronary artery dissection is one of the most common causes of acute coronary syndrome in pregnant patients. Understanding its pathophysiology and knowing the natural history of this condition is paramount in the management of this condition. The article also lists the various therapeutic modalities available to the clinician faced with an acute coronary syndrome in the pregnant patient. Finally, we discuss the delivery of the baby and post partum care of these complex patients.
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Affiliation(s)
- Mohan M Edupuganti
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas for Medical Sciences, USA.
| | - Vyjayanthi Ganga
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas for Medical Sciences, USA
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18
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Abstract
PURPOSE OF REVIEW The review is intended to serve as a practical clinical aid for the clinician called to maternal cardiac arrest. RECENT FINDINGS Anesthesia complications comprise an important cause of maternal cardiac arrest in developed countries Also predominant are hemorrhage and infections. Recent in-depth reports highlight fractionated care for pregnant women with cardiac and also probably neurological comorbidities. Pathology reports reveal a prevalence of thromboembolic phenomena that is higher than previously assumed but still rare. These are accompanied by particularly high mortality rates. The presenting rhythms of cardiac arrest which differ from most cardiac arrest populations, suggest the need for further in-depth investigation of both the causes and management of these cases. Despite these, outcomes are far better than those of most arrests. Key differences in treatment include are consideration of early airway management and possible medication complications. Pulseless electrical activity and VF should always alert to the possibility of hemorrhage. Echocardiography can diagnose thromboembolism. Also different are the need for Left uterine displacement and early delivery within after 4-5 min of initiation of resuscitation effort in cases with suspected compromise of the venous return or a poor likelihood of a good maternal outcome. SUMMARY Maternal cardiac arrest should be managed similarly to other adult cardiac arrests. At the same time its unique reversible causes require a different form of thought regarding diagnosis and treatment during the code.
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19
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Ismail S, Wong C, Rajan P, Vidovich M. ST-elevation acute myocardial infarction in pregnancy: 2016 update. Clin Cardiol 2017; 40:399-406. [PMID: 28191905 PMCID: PMC6490392 DOI: 10.1002/clc.22655] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/09/2016] [Indexed: 12/26/2022] Open
Abstract
Acute myocardial infarction (AMI) during pregnancy or the early postpartum period is rare, but can be devastating for both the mother and the fetus. There have been major advances in the diagnosis and treatment of acute coronary syndromes in the general population, but there is little consensus on the approach to diagnosis and treatment of pregnant women. This article reviews the literature relating to the pathophysiology of AMI in pregnant patients and the challenges in diagnosis and treatment of ST-elevation myocardial infarction (STEMI) in this unique population. From a cardiologist, maternal-fetal medicine specialist, and anesthesiologist's perspective, we provide recommendations for the diagnosis and management of STEMI occurring during pregnancy.
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Affiliation(s)
- Sahar Ismail
- Division of CardiologyEmory UniversityAtlantaGeorgia
| | - Cynthia Wong
- Department of AnesthesiaUniversity of Iowa Carver College of MedicineIowa CityIowa
| | - Priya Rajan
- Department of Obstetrics and Gynecology, Maternal–Fetal MedicineNorthwestern University Feinberg School of MedicineChicagoIllinois
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20
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Abstract
OPINION STATEMENT Cardiovascular disease (CVD) is the leading cause of pregnancy-associated mortality, with an increasingly complex pregnant population. While our understanding of CVD in pregnancy continues to evolve, there remains a need to develop widely accessible tools to follow pregnant women both with and without preexisting disease with respect to cardiovascular risk, particularly for those presenting with symptoms suggestive of cardiovascular pathology. Thus, research is emerging with respect to the potential role of novel and established cardiac biomarkers in diagnosing and following CVD in pregnancy. Here, we review the normal hemodynamics of pregnancy and the behavior of various biomarkers in both normal and complicated pregnancies.
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Affiliation(s)
- Emily S Lau
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Amy Sarma
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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