Assessing the incidence of peripartum subclinical myocardial ischemia using the troponin T assay: an observational pilot study

Ischemic heart disease in pregnancy: a practical approach to management

Ischemic heart disease is a crucial issue during pregnancy. The term is composed of both preexisting conditions and acute coronary syndrome in pregnancy, including pregnancy-associated myocardial infarction, which can have a significant effect on maternal and fetal outcomes. This review provides a complete guide to managing ischemic heart disease in pregnant women, emphasizing the importance of multidisciplinary care and individualized treatment strategies. Cardiovascular disease, particularly ischemic heart disease, is now the leading cause of maternal mortality worldwide. Pregnancy introduces unique physiological changes that increase the risk of acute myocardial infarction, with pregnancy-associated myocardial infarction cases often associated with factors, such as advanced maternal age, chronic hypertension, and preexisting cardiovascular conditions. This review distinguishes between preexisting ischemic heart disease and pregnancy-associated myocardial infarction. It will emphasize the various etiologies of pregnancy-associated myocardial infarction, including coronary atherosclerosis and plaque rupture presenting as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and other nonatherosclerotic causes, including spontaneous coronary artery dissection, vasospasm, and embolism. Our study discusses the practical management of ischemic heart disease in pregnancy, with a focus on preconception counseling, risk assessment, and tailored antenatal planning for women with preexisting ischemic heart disease. Moreover, this document focuses on the challenges of diagnosing cardiovascular disease, especially when presented with nonclassical risk factors and presentation. It provides insight into the appropriate diagnostic testing methods, such as electrocardiogram, cardiac biomarkers, and echocardiography. In addition, the review covers various treatment strategies, from medical management to more invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft. Special attention is given to medication safety during pregnancy, including anticoagulation, beta-blockers, and antiplatelet agents. The complexities of delivery planning in women with ischemic heart disease are discussed, advocating for a multidisciplinary team-based approach and careful consideration of the timing and mode of delivery. Furthermore, the roles of breastfeeding and postpartum care are explored, emphasizing the long-term benefits and the suitability of various medications during lactation. Lastly, this review provides crucial insights into the management of ischemic heart disease in pregnancy, stressing the need for heightened awareness, prompt diagnosis, and tailored management to optimize maternal and fetal health outcomes.

First Trimester Cardiac Biomarkers among Women with Peripartum Cardiomyopathy: Are There Early Clues to This Late-Pregnancy Phenomenon?

OBJECTIVE

Whether biomarkers may enable early identification of women who develop peripartum cardiomyopathy (PPCM) prior to disease onset remains a question of interest.

STUDY DESIGN

A retrospective nested case-control study was conducted to determine whether first trimester N-terminal pro-B type natriuretic peptide (NT-proBNP) or high sensitivity cardiac troponin I (hs-cTnI) differed among women who developed PPCM versus unaffected pregnancies. Cases were matched to unaffected women by age, race, parity, and gestational age of sample (control A) and then further by blood pressure and pregnancy weight gain (control B).

RESULTS

First trimester NT-proBNP concentrations were numerically higher among women who subsequently developed PPCM (116 pg/mL [83-177]) as compared with women in control A (56.1 pg/mL [38.7-118.7], p = 0.3) or control B (37.6 [23.3 - 53.8], p <0.05). A higher proportion of women who subsequently developed PPCM (50%) had detectable levels of hs-cTnI as compared with control A (0%, p = 0.03) or control B (18.8%, p = 0.52). Among both cases and controls, hs-cTnI values were low and often below the limit of detection.

CONCLUSION

There were differences in first trimester NT-proBNP and hs-cTnI concentrations between women who subsequently developed PPCM and those who did not, raising the possibility the early pregnancy subclinical myocardial dysfunction may be associated with this late-pregnancy disease.

KEY POINTS

· First trimester NT-proBNP is numerically higher among women who subsequently develop PPCM.. · First trimester hs-cTnI was nominally higher among women who developed PPCM versus those who did not.. · A significant proportion of normal pregnant women have undetectable hs-cTnI..

The Utilization and Interpretation of Cardiac Biomarkers During Pregnancy: JACC: Advances Expert Panel

Cardiac biomarkers are widely used in the nonpregnant population when acute cardiovascular (CV) pathology is suspected; however, the behavior of these biomarkers in the context of pregnancy is less well understood. Pregnant individuals often have symptoms that mimic those of cardiac dysfunction, and complications of pregnancy may include CV disease. This paper will summarize our current knowledge on the use of cardiac biomarkers in pregnancy and provide suggestions on how to use these tools in clinical practice based on the available evidence. Natriuretic peptides and troponin should not be measured routinely in uncomplicated pregnancy, where values should remain low as in the nonpregnant population. In the context of pre-existing or suspected CV disease, these biomarkers retain their negative predictive value. Elevations of both natriuretic peptides and troponin may occur without clear clinical significance in the immediate postpartum period. Elevations of these markers should always prompt further investigation into possible CV pathology.

Acute Coronary Syndrome in Pregnancy and the Post-Partum Period

Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.

Coronary Events in the Pregnant Patient: Who Is at Risk and How Best to Manage?

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.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Transthoracic echocardiographic assessment of the right ventricle before and after caesarean delivery: A preliminary investigation

Transthoracic echocardiographic evaluation of the right ventricle is more difficult than the left ventricle and has not been well characterised in the parturient during delivery. As a preliminary investigation, our goal was to use bedside transthoracic echocardiography to evaluate right ventricular myocardial function before and after caesarean delivery. Term parturients undergoing caesarean delivery under spinal anaesthesia were enrolled. Echocardiography was performed pre- and postoperatively. Assessment of myocardial function included longitudinal myocardial strain using 2D-speckle tracking for both ventricles, and fractional area change for the right ventricle. Troponin-T, creatine kinase-muscle/brain and brain natriuretic peptide were measured pre- and postoperatively. One hundred patients were enrolled; 98 completed the study. Adequate images from both timepoints (pre- and postoperatively) were obtained in 85 patients for left ventricle assessment, and 66 for the right ventricle. Right ventricular fractional area change (mean (standard deviation)) (24.9% (8.9%) to 24.9% (9.2%); P = 0.99) and strain (-19.7% (6.8%) to -18.1% (6.5%); P = 0.08) measurements suggested mild baseline dysfunction and did not change after delivery. Left ventricular strain values were normal and unchanged after delivery (-23.8% (7.4%) to -24.3% (6.7%); P = 0.51). One patient had elevated troponin-T and demonstrated worse biventricular function. Elevation of brain natriuretic peptide (n=7) was associated with mildly decreased left ventricular strain, but creatine kinase-muscle/brain (n=4) was not associated with consistent changes in cardiac function. Further investigations into peripartum right ventricular function are required to validate the findings in this preliminary study. Findings of baseline mild right ventricular dysfunction and functional changes associated with troponin-T and brain natriuretic peptide warrant rigorous investigation.

ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Pregnancy-Associated Myocardial Infarction

PURPOSE OF REVIEW

To educate clinicians about the epidemiology, etiologies, diagnosis, and management of pregnancy-associated myocardial infarction (PAMI).

RECENT FINDINGS

The risk of myocardial infarction is increased more than threefold around the time of pregnancy. In the recent series, PAMI is most commonly caused by spontaneous coronary artery dissection, followed by atherosclerosis. Percutaneous coronary intervention or coronary artery bypass grafting may be required, but conservative management with medical therapy is generally advised when possible, particularly in cases of coronary dissection. Labor and delivery in women with PAMI warrants advanced planning by a multidisciplinary team involving obstetrics, anesthesia, and cardiology. Women with myocardial infarction should be referred to cardiac rehabilitation. Pregnancy-associated myocardial infarction is a significant contributor to maternal morbidity and mortality. Management should be tailored based on the underlying etiology and on whether the patient is still pregnant or postpartum. Further research is needed to define optimal evaluation and management of this condition.

Review article: Investigations and the pregnant woman in the emergency department - part 1: Laboratory investigations

Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound and electrocardiography. In addition the emergency physician needs to be cognisant of disorders that are unique to or more common in pregnancy. Part 1 of this review addresses potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy, and the important causes of abnormal laboratory results in pregnancy. Part 2 will address the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, physiological changes in electrocardiography, and the safety of radiological procedures in the pregnant patient.

Management of Cardiovascular Disease During Pregnancy

Cardiovascular disease is a leading cause of maternal death. The normal cardiovascular hemodynamic adaptations to pregnancy are remarkable, but tolerated without difficulty in the majority of women. However, in women with cardiovascular dysfunction, these adaptations may precipitate cardiovascular decompensation. Risk stratification of pregnancy risk should preferably take place before conception. Management of these women requires multidisciplinary involvement of all key areas, including cardiology, nursing, maternal/fetal medicine and obstetric anesthesia. For higher-risk lesions, pregnancy should be managed in centers with expertise in this field.

The Role of Cardiac Biomarkers in Pregnancy

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.