Anaesthetic considerations in a parturient with critical coronary artery disease and a drug-eluting stent presenting for caesarean section

Perioperative Complications in Patients with Drug-Eluting Stents: A Three-Year Audit at Geelong Hospital

Drug-eluting stents are a recommended treatment for lesions in the coronary arteries. Stent insertion requires the patient remain on antiplatelet medication for a minimum of six months after insertion. A serious consequence of ceasing antiplatelet medication is late stent thrombosis leading to myocardial infarction in the territory of the drug-eluting stent. Continuing antiplatelet medication can lead to excessive bleeding at the time of surgery. Understanding the risk of complications attributable to bleeding or myocardial ischaemia will help in defining the optimal management of these patients at the time of noncardiac surgery.

This study is a retrospective database analysis and case note review of all patients with drug-eluting stents presenting for noncardiac surgical procedures over a three-year period in one centre.

Twenty-four patients with drug-eluting stents inserted presented for 43 noncardiac surgical procedures. Severe bleeding problems were encountered in one case. Three of 15 patients (20%) who ceased clopidogrel prior to surgery without alternative anti-thrombotic prophylaxis suffered myocardial infarction due to stent thrombosis. Four patients who received alternative anti-thrombotic prophylaxis did not suffer complications. All 19 patients who ceased clopidogrel remained on aspirin prior to surgery.

Patients treated with drug-eluting stents for coronary artery stenosis represent a challenging group of patients for subsequent perioperative management. The risk of myocardial infarction when clopidogrel is stopped prior to surgery is 20%, if alternative anti-thrombotic prophylaxis is not used. This risk persists beyond one year after insertion of drug-eluting stents. Some treatments appear to be effective in reducing the risk of myocardial infarction.

Caesarean delivery during dual antiplatelet therapy after acute myocardial infarction and stenting

Background

Cardiac disease is the leading cause of maternal mortality during pregnancy in high-resource countries.

Case

A 31-year-old woman had an ST-elevated myocardial infarction (STEMI) at 16 gestational weeks. The patient received three coronary drug-eluting stents followed by dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. An elective caesarean delivery was performed under general anesthesia at 37+1 gestational weeks. Due to subnormal response to clopidogrel, administration was paused only 24 h perioperatively without bridging with tirofiban because of the slightly increased risk of stent thrombosis in clopidogrel nonresponders. There was no postoperative bleeding.

Conclusions

There is a lack of evidence-based guidelines regarding the management of acute myocardial infarction (AMI) during pregnancy; thus, delivery should be performed in a tertiary center with a multidisciplinary approach.

Dilemma in Timing of Delivery in a Patient with an Acute Myocardial Infarction

Introduction. Acute myocardial infarction (AMI) in a pregnant woman is rare. When occurring, AMI is a major cause of maternal and neonatal death. By presenting the following case we describe the dilemma concerning the timing of delivery.Case. A 36-year-old, multiparous women, at 35 6/7 weeks of gestation, suffered from an AMI due to an acute blockage of the left anterior descending artery (LAD). This was treated by angiographic thrombosuction and biodegradable stent placement. Within 5 hours after this procedure, a cesarean section (CS) was performed because of a nonreassuring fetal condition. A healthy son with an Apgar score of 9/10 was born. The patient’s postoperative course was complicated by a big wound hematoma, a hemoglobin drop, and heart failure.Discussion. In case of AMI during pregnancy, the cardiological management has absolute priority. The obstetrical management is not outlined. In a nonreassuring fetal condition, delivery is indicated after stabilization of the mother. However, delivery after recent AMI and angiography will bring new risks of cardiologic stress and bleeding complications. The limited literature available tends to an expectant obstetrical management, but this case emphasizes the difficulty of waiting in suspected fetal distress.

Pregnancy in women after coronary revascularization

Pregnancy after coronary revascularization presents unique challenges to the management of antiplatelet therapy, anesthesia and mode of delivery. We present two cases where women of reproductive age required coronary revascularization with drug eluting stents after a myocardial infarction, and discuss key aspects of pregnancy and labor management.

Ischemic heart disease in pregnancy

While ischemic heart disease in reproductive-age women is rare, cardiac disease is a leading cause of maternal mortality. In turn, coronary artery disease is one of the most common causes of maternal cardiac death. The incidence of coronary artery disease in pregnancy may be rising due to the increasing prevalence of comorbid risk factors. Diagnosis and clinical management of ischemic cardiac disease is largely similar in the pregnant and non-pregnant patient, and the majority of medications and diagnostic and interventional procedures are compatible with pregnancy with a few important exceptions. Care for ischemic cardiac disease in pregnancy may be suboptimal because: (1) diagnosis is delayed because many symptoms of ischemic cardiac disease are common in pregnancy, (2) a diagnostic workup is insufficiently thorough, and/or (3) consultants may be hesitant to perform diagnostic and interventional procedures in obstetric patients. Obstetric providers should be aware of the possibility of ischemic cardiac disease in pregnancy, particularly in patients with comorbid risk factors. If ischemic cardiac disease is suspected, a thorough workup should be performed.

Clopidogrel use throughout pregnancy in a patient with a drug-eluting coronary stent

BACKGROUND

Little information regarding the potential implications of drug-eluting stents and clopidogrel on pregnancy exists.

CASE

We report a case of a 27-year-old woman who received a drug-eluting coronary stent for an acute myocardial infarction and was started on clopidogrel as treatment. She was on clopidogrel when she conceived and delivered a child by cesarean. Her postpartum course was complicated by postoperative bleeding requiring transfusion.

CONCLUSION

This case highlights the perinatal and peripartum concerns of these interventions in women of childbearing age. It suggests that cesarean delivery is associated with an elevated risk of perioperative bleeding and may best be approached like other surgical procedures, with the optimal timing of surgery, when feasible, being 5 or more days after the discontinuation of clopidogrel.

The use of antiplatelet therapy in the outpatient setting: Canadian Cardiovascular Society Guidelines Executive Summary

Antiplatelet agents are a cornerstone of therapy for patients with atherosclerotic vascular disease. There is presently a lack of comprehensive guidelines focusing on the use of antiplatelet drugs in patients currently manifesting or at elevated risk of cardiovascular disease. The Canadian Antiplatelet Therapy Guidelines Committee reviewed existing disease-based guidelines and subsequently published literature and used expert opinion and review to develop guidelines on the use of antiplatelet therapy in the outpatient setting. This Executive Summary provides an abbreviated version of the principal recommendations. Antiplatelet therapy appears to be generally underused, perhaps in part because of a lack of clear, evidence-based guidance. Here, we provide specific guidelines for secondary prevention in patients discharged from hospital after acute coronary syndromes, percutaneous coronary intervention, or coronary artery bypass grafting; patients with a history of transient cerebral ischemic events or strokes; and patients with peripheral arterial disease. Issues related to primary prevention are also addressed, in addition to special clinical contexts such as diabetes, heart failure, chronic kidney disease, pregnancy or lactation, and perioperative management. Recommendations are provided regarding pharmacologic interactions that may occur during combination therapy with warfarin, clopidogrel, and proton-pump inhibitors, or aspirin and nonsteroidal anti-inflammatory drugs, as well as for the management of bleeding complications. The complete guidelines document is published as a supplementary issue of the Canadian Journal of Cardiology and is available at http://www.ccs.ca/.

The Management of Antiplatelet Therapy in Patients With Coronary Stents Undergoing Noncardiac Surgery

Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors’ recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.

Coronary artery disease and myocardial infarction in pregnancy: a review of epidemiology, diagnosis, and medical and surgical management

Ischemic heart disease is uncommon during pregnancy, occurring in approximately one in 10,000 live births. With the increasing age and fertility of mothers, the incidence of coronary artery disease in pregnancy is likely to increase. Atherosclerosis appears to be the most common cause of acute myocardial infarction, although coronary spasm, coronary dissection and thrombus have been reported, among others. The diagnosis of ischemic heart disease in the pregnant population can be challenging and not without risk to the fetus. Although there have been many reports of acute myocardial infarction and cardiopulmonary bypass surgery during pregnancy, most knowledge is based on anecdotal reports. Even less is known about the use of thrombolytics, percutaneous coronary intervention and the optimal medical management of ischemic heart disease during pregnancy. The epidemiology, diagnosis, medical and surgical treatment, and prognosis of ischemic heart disease in pregnancy are the subject of the present review.

Acute Myocardial Infarction in Pregnant Women

Acute myocardial infarction (AMI) in pregnant women is a rare but potentially lethal occurrence that should be carefully managed, especially in consideration of cardiac conditions being a rising cause of maternal deaths. Risk factors for AMI occurrence, in addition to typical cardiac-related risk factors, include medical conditions such as (pre) eclampsia, blood transfusions, thrombophilia and postpartum infections. Being older, multigravida or in the third trimester of pregnancy is also associated with an increased risk. The pathophysiological causes underlying AMI in pregnancy are diverse but generally associated with the coagulative and physiological changes related to the pregnancy. The selection of diagnostic modality and treatment options require careful consideration for pregnancy-related changes as well as risk of harm to the patient and fetus. This paper serves to review available literature regarding an extensive range of management issues that directly impact on maternal and fetal outcomes. Key words: Myocardial infarction, Pregnancy complications, Obstetric labour complications

The parturient with coronary heart disease

Cardiac disease is one of the leading indirect causes of maternal mortality in the UK, exceeding numbers of direct deaths from thromboembolism and hypertension combined. Over one year in our unit we managed six women with coronary heart disease. In this series five women had stable coronary heart disease. Three delivered electively by caesarean section under combined spinal-epidural anaesthesia, a further two women had spontaneous vaginal deliveries, one planned under epidural analgesia, the second unplanned after a rapid labour. The sixth woman had unstable angina requiring percutaneous coronary intervention in the 28th week of pregnancy and went on to deliver by caesarean section under general anaesthesia. Regional anaesthesia was avoided in this case because of antiplatelet and anticoagulant medication. There is a lack of level-one evidence to direct the management of these women. Clinical decisions were directed by guidelines for the perioperative management of patients with cardiac disease in non-cardiac surgery and the management of all cardiac disease in the obstetric population. A multi-disciplinary approach was taken, with a collaborative plan made for each pregnancy and delivery. A thorough clinical history and examination together with transthoracic echocardiography allows risk stratification of women with coronary heart disease at risk of peripartum cardiac events. Further investigation specific to each woman's management can then be undertaken.

[Coronary stents and anaesthesia]

The coronary stents are widely used to prevent coronary restenosis after percutaneous coronary intervention. Dual antiplatelet therapy (acetyl salicylic acid and a thienopyridine-clopidogrel or ticlopidine) are prescribed at least during six weeks after conventional stent and six months after drug eluting stent insertion to prevent stent thrombosis. When an invasive procedure is required, a risk of stent thrombosis arises after stopping antiplatelet therapy and a risk of bleeding when continuing this treatment. Therefore, cardiologists should choose carefully the type of coronary stent before insertion and concerned physicians (anaesthesiologists, surgeons, cardiologists) should decide a perioperative strategy in these high-risk patients.

A pregnant woman with acute myocardial infarction due to coronary artery dissection: Pre-hospital and in-hospital management

A young pregnant woman (32nd week of gestation) presented with acute chest pain due to right coronary artery dissection (CAD) in a pre-hospital setting. The pre-hospital diagnosis by the ambulance staff of an acute myocardial infarction in the antenatal period based on a 12-lead ECG combined with successful treatment by percutaneous coronary intervention with stenting is novel.

Successful management of patients with a drug-eluting coronary stent presenting for elective, non-cardiac surgery

This paper describes the management of three patients for elective surgery with drug-eluting stents in the coronary circulation. The risks posed at the time of surgery by such patients include acute coronary syndromes, as a result of stent thrombosis, after cessation of anti-platelet therapy and excessive bleeding from continued anti-platelet therapy. We describe a regime for the management of such patients that successfully avoided these risks in three patients with paclitaxel drug-eluting stents requiring elective non-cardiac surgery.

Modifying labor routines for the woman with cardiac disease

The childbearing woman with cardiac disease presents a unique challenge to healthcare providers. The physiologic adaptations that accompany pregnancy and labor predispose the woman with cardiac disease to cardiac decompensation. Ideally, these women are identified to perinatal nursing staff prior to admission to the hospital in labor or for obstetrical procedures in order to provide adequate time for review of the specific cardiac lesion and development of an interdisciplinary plan of care. This article provides a comprehensive review of typical intrapartum routines that require modification and discusses strategies for adapting labor management for the woman with cardiac disease.