Myocardial infarction complicating the initial phase of an ovarian stimulation protocol

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Ovarian Hyperstimulation Syndrome and Myocardial Infarction: A Systematic Review

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a rare but serious complication of ovarian stimulation occurring during assisted reproduction technologies (ART). It is characterized by increased vascular permeability and hypercoagulable states resulting in strokes and peripheral ischemia. Acute myocardial infarction and cardiac thrombosis, however, have been rarely reported complications of OHSS.

METHODS

A literature search was performed for reports on myocardial infarction and cardiac thrombosis associated with ovarian stimulation with a summary of their clinical characteristics.

RESULTS

A total of twelve published cases were reviewed with 5 out of 12 (41.67%) of the reported cases were 35 years of age or older. Myocardial infarction was reported in 10 out of the 12 cases (83.3%). Two of the cases were pregnant at presentation (16.67%). The mean duration between starting ovarian stimulation medications and clinical presentation was 23 days. Chest pain was the most common presenting symptom (66.67%), 2 cases presented with stroke (16.67%) and 2 cases presented with abdominal distention (16.67%). A total of 8 patients underwent coronary angiography with 2 of these cases were treated with percutaneous coronary intervention. No mortality reported in any of the twelve cases.

CONCLUSION

Women of a relatively younger age undergoing ovarian stimulation may be at risk for developing myocardial infarction and cardiac thrombosis. Once thrombosis is suspected, initiating appropriate therapy in a timely manner is crucial.

The heart: a novel gonadotrophin-releasing hormone target

Gonadotrophin-releasing hormone (GnRH) is a hypothalamic hormone transported by the hypophyseal portal bloodstream to the pituitary gland, where it binds to GnRH receptors. However, GnRH receptors are expressed in multiple extrapituitary tissues, although their physiological relevance is not fully understood. GnRH agonists are employed extensively in steroid deprivation therapy, especially to suppress testosterone in prostate cancer. Because GnRH agonist treatment is associated with increased coronary heart disease and myocardial infarction, we investigated the impact of GnRH on cardiomyocyte contractile function. Cardiomyocytes were isolated from mouse hearts and mechanical and intracellular Ca(2+) properties were evaluated, including peak shortening amplitude (PS), time-to-PS (TPS), time-to-90% relengthening (TR(90) ), maximal velocity of shortening/relengthening (± dLdt), electrically-stimulated rise in Fura-2 fluorescence intensity (ΔFFI) and Ca(2+) decay. GnRH (1 ng/ml) increased PS, ± dL/dt, resting FFI and ΔFFI, and prolonged TPS, TR(90) and Ca(2+) decay time, whereas 1 pg/ml GnRH affected all these cardiomyocyte variables, except TPS, resting FFI and ΔFFI. A concentration of 1 fg/ml GnRH and the GnRH cleavage product, GnRH-[1-5] (300 pg/ml), had no effect on any cardiomyocyte parameter. The 1 pg/ml GnRH-elicited responses were attenuated by the GnRH receptor antagonist cetrorelix (10 μm), the protein kinase A (PKA) inhibitor H89 (1 μm) but not the protein kinase C inhibitor chelerythrine chloride (1 μm). These data revealed that GnRH is capable of regulating cardiac contractile function via a GnRH receptor/PKA-dependent mechanism. If present in the human heart, dysfunction of such a system may play an important role in cardiac pathology observed in men treated with GnRH agonists for prostate cancer.

[Myocardial infarction and ovarian stimulation: case report]

Female infertility treated by ovarian stimulation can lead to arterial thrombosis particularly when ovarian hyperstimulation syndrome emerges. Myocardial infarction have been reported thrice, in one case even before artificial ovulation induction. A 25-year-old female with primary infertility underwent ovarian stimulation and eight days after ovulation induction and intra-uterine insemination suffered from a troponin positive non-ST-elevation myocardial infarction of the inferior wall. Coronary angiogram was normal and contrast-enhanced cardiovascular magnetic resonance imaging confirmed the subendocardial inferior infarct. This protocol included sole triptorelin administration followed by 23 recombinant follicle stimulating hormone injections and concluded by recombinant choriogonadotrophin. There was no ovarian hyperstimulation syndrome. Large biological screening did not retrieve any predisposition for arterial thrombosis. Clinical outcome was excellent. Despite weak causal link, we emphasize that chest pain during ovarian stimulation protocol should rise clinical concern for acute coronary syndrome.

Compressive pleural effusion after ovarian hyperstimulation syndrome—a case report and review

OBJECTIVE

To report a case of early onset ovarian hyperstimulation with massive pleural effusion and respiratory failure before IVF.

DESIGN

Case report.

SETTING

University teaching intensive care unit.

PATIENT(S)

A 26-year-old healthy woman with an unexplained infertility transferred to the intensive care unit on day 4 after hCG injection for early severe presentation of ovarian hyperstimulation syndrome with massive compressive pleural effusion before she underwent embryo transfer.

INTERVENTION(S)

Mechanical ventilation, thoracocentesis.

MAIN OUTCOME MEASURE(S)

Resolution of symptoms/stopping of embryos transfer.

RESULT(S)

Drainage of 5,300 mL of sterile exudative pleural fluid for a period of 48 hours, which permitted resolution of symptoms and allowed mechanical weaning. The IVF procedure was stopped.

CONCLUSION(S)

This case described is unusual in that the patient presented with early massive pleural effusion on day 4 after hCG injection and before embryo transfer. This is much earlier than in any case report elsewhere.

Cardiac toxicity: old and new issues in anti-cancer drugs

Although rare, cardiotoxicity is a significant complication of cancer treatment. The incidence and severity of cardiovascular side effects are dependent on the type of drugs used, dose and schedule employed, and age of patients, as well as the presence of coexisting cardiac diseases and previous mediastinal irradiation. Classically, anthracyclines are among one of the most active agents in oncology, but their use is often hampered by their cumulative dose-limiting cardiotoxicity. In the past decade, combination therapy with new drugs such as taxanes or anti- EGFR, and Her-2 therapy as a single agent have also resulted in unexpected cardiotoxicity. Cardiac damage can be secondary to an alteration of cardiac rhythm, changes in blood pressure and ischaemia, and can also alter the ability of the heart to contract and/or relax. The clinical spectrum of these toxicities can range from subclinical abnormalities to being catastrophic, life-threatening and sometimes fatal. Knowledge of this toxicity can aid clinicians to choose the optimal and least toxic regimen suitable for an individual patient. In this work we present an exhaustive review of the cardiovascular side effects associated to new anticancer drugs, from new formulations of anthracyclines to tyrosine kinase inhibitors and monoclonal antibodies.