Asian Cardiovasc Thorac Ann 2005;13:175-177
© 2005 Asia Publishing EXchange Ltd
Acute Myocardial Infarction in The First Trimester of Pregnancy
Amar M Salam, MD
Department of Cardiology & Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
For reprint information contact: Amar M Salam, MD Tel: 974 439 2642 Fax: 974 439 2454 Email: amaramin{at}yahoo.com, Department of Cardiology & Cardiovascular Surgery, Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
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ABSTRACT
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Acute myocardial infarction rarely occurs in women during pregnancy. However, when it does occur, it usually carries a high risk of maternal and perinatal mortality. There is a lack of awareness that this condition can occur in pregnancy since coronary artery disease is uncommon in women of childbearing age. In this report, a 43-year-old lady with acute anterior myocardial infarction in her eighth week of pregnancy is presented. The challenges involved in diagnosing this condition in pregnancy are briefly discussed.
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INTRODUCTION
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Acute myocardial infarction (AMI) rarely occurs during pregnancy. Its overall incidence is estimated at 1 in 10,000.1 It was first reported in 1922, and since then more than 130 cases have been documented in the literature.2 There is a lack of awareness that this condition can occur in pregnancy, since coronary artery disease is uncommon in women of childbearing age. Nonetheless, with the increased incidence of cigarette smoking in women of childbearing age, the occurrence of AMI during pregnancy is expected to increase.
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CASE REPORT
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A 43-year-old lady in her eighth week of pregnancy presented with chest pain of 3 days duration. The pain was retrosternal, radiating to the left arm, compressing in nature, precipitated by exertion, lasting for about half an hour and relieved by rest. About 10 hours prior to admission, the pain became more severe, continuous, and was accompanied by sweating and nausea. She was an insulin-dependent diabetic with retinopathy, nephropathy, and peripheral neuropathy. She was on oral Enalapril and Tegretol. Her obstetric history included gravida 10: para 5 and 4 abortions. She denied being a smoker. On examination, she was prostrate and in good general condition. Clinical investigations revealed a regular pulse rate of 112 beats·min–1, blood pressure 130/90 mm Hg, temperature 36.4°C, and a respiratory rate of 22 breaths·min–1. Chest and heart examinations were normal. The rest of the physical examination was unremarkable. Electrocardiography (EKG) showed ST segment elevation in leads V2 to V5.
The patient was admitted to the coronary care unit with a diagnosis of acute anterior myocardial infarction. She was treated with intravenous heparin and nitrates. Enteric-coated aspirin and the beta-blocker propranolol were given orally. The patient eventually stabilized and had no further chest pain. Thrombolytic therapy was not given because of her late presentation (more than 8 hours). Serial cardiac enzymes showed creatine kinase (IU·L–1) 199, 187, 110 and creatine kinase MB-isoenzyme (ng·mL–1) 13.2, 10.8, 73. Her total cholesterol was 5.07 mmol·L–1, and triglyceride level was 265 g·L–1. Complete blood count (CBC), urea, electrolytes, prothrombin time and partial thromboplastin time were within normal range. Blood sugar was 13.4 mmol·L–1.
Hyperglycemia was controlled with subcutaneous regular insulin. Echocardiography revealed hypokinetic septum and apex with a left ventricular ejection fraction of 59%. The risks and benefits of therapeutic options, such as continuation of pregnancy with medical treatment of myocardial ischemia, coronary angiography during pregnancy, and therapeutic abortion, were discussed with the patient at length. She elected to terminate the pregnancy. The pregnancy was terminated under general anesthesia and presented no complications.
Coronary angiography demonstrated proximal 50% and midpart 90% lesions of the left anterior descending (LAD) coronary artery. The right coronary artery was occluded proximally. Balloon angioplasty was performed on the LAD stenosis, with good results. The patient was discharged in good general condition.
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DISCUSSION
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Identified risk factors for coronary artery disease in young women include diabetes mellitus, cigarette smoking, familial dyslipidemia, family history of coronary artery disease, and previous use of oral contraceptives.4 Our patient, who had insulin-dependent diabetes mellitus and was in the first trimester of pregnancy, presented with chest pain that proved to be due to an acute anterior myocardial infarction with underlying obstructive coronary artery disease.
The diagnosis of AMI in pregnancy is often difficult. The classic symptoms of myocardial ischemia such as chest pain, diaphoresis, and shortness of breath can at times be attributed to the normal physiological changes of pregnancy. In addition, the sensitivity of EKG in non-pregnant individuals who have AMI may be as low as 50%. EKG changes mimicking myocardial ischemia have been reported in as many as 37% of patients undergoing cesarean section4 without underlying coronary artery disease.
The serum enzyme markers, lactate dehydrogenase, aspartate aminotransferase, myoglobin, creatine kinase and its MB isoenzyme, are not reliable indicators of myocardial injury during pregnancy as they can be normally elevated, especially during labor and early puerperium.5 Only troponin I levels remain undetectable during and after delivery, and therefore it is the most useful biochemical marker for monitoring pregnant women for myocardial injury.6,7 Troponin I was not measured in our patient since it was not available at that time. Echocardiography can be done safely during pregnancy to confirm the presence of ischemia by showing wall motion abnormalities.
The underlying precipitating factors of AMI in pregnancy are thought to be multifactorial and attributable to the physiological events that occur during pregnancy. There is increased myocardial oxygen demand because of the marked increases in blood volume, stroke volume, and heart rate that are usually seen during pregnancy. Additionally, due to the profound alterations in the coagulation and fibrinolytic system that occur during pregnancy, there is an increased risk of thrombosis. At the same time, the physiological anemia and decreased diastolic blood pressure that occur may reduce myocardial oxygen supply.
Moreover, although atherosclerotic coronary heart disease should be viewed as the underlying cause of AMI in pregnancy, especially in patients with known risk factors, acute coronary dissection has been reported and documented during pregnancy.8 The increased hormonal levels have been associated with changes in the medial layer of the arteries mimicking cystic medial necrosis found in connective tissue diseases. Spontaneous dissection usually occurs somewhat later in pregnancy but can simultaneously affect one or all coronaries with similar presenting symptoms. The prognosis for AMI during pregnancy is guarded, with maternal mortality rates ranging from 20% to 37%.2 For this reason, abortion was offered to our patient as an option.
This is the first case of AMI in pregnancy reported in our institution and, we believe, in the Gulf region. We report this case to heighten physicians’ awareness that this clinical entity can occur and should be included in the differential diagnoses of pregnant women presenting with chest pain, especially if they have risk factors for developing coronary artery disease.
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REFERENCES
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- Brezinka V, Padmos I. Coronary heart disease risk factors in women. Eur Heart J 1994;15:1571–84.[Abstract/Free Full Text]
- Palmer CM, Norris MC, Giudici MC, Leighton BL, DeSimone CA. Incidence of electrocardiographic changes during cesarean delivery under regional anesthesia. Anesth Analg 1990;70:36–43.[Abstract/Free Full Text]
- Leiserowitz GS, Evans AT, Samuels SJ, Omand K, Kost GJ. Creatine kinase and its MB isoenzyme in the third trimester and the peripartum period. J Reprod Med 1992;37:910–6.[Medline]
- Adams JE 3rd, Bodor GS, Davila-Roman VG, Delmez JA, Apple FS, Ladenson JH, et al. Cardiac troponin I. A marker with high specificity for cardiac injury. Circulation 1993;88:101–6.[Abstract/Free Full Text]
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A. Roth and U. Elkayam
Acute myocardial infarction associated with pregnancy.
J. Am. Coll. Cardiol.,
July 15, 2008;
52(3):
171 - 180.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
