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MRCOG PART 2 > Acute Coronary Syndrome In Pregnancy TOG 2023 / ESC 2018 > Flashcards

Acute Coronary Syndrome In Pregnancy TOG 2023 / ESC 2018 Flashcards

1
Q

What is the quoted worldwide incidence and mortality rates of ACS

A

6.2 per 100,000 deliveries
Mortality rate of 5.1 and 11.0%
MBRRACE 2017-19 cardiac disease 17% cause of maternal death( leading indirect cause)

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2
Q

What’s the leading cause of death from cardiac causes in pregnant women in UK?

A

Ischaemic heart disease

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3
Q

What constitutes acute coronary syndrome?

A
  1. ST elevation myocardial infarction( STEMI)
  2. Non ST elevation myocardial infarction (NSTEMI)
  3. Unstable angina.
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4
Q

What are the risk factors for ACS?

A

Risk for pregnancy associated spontaneous coronary artery dissection(PASCAD)
Marfan syndrome
Hypertension
Family history of spontaneous coronary artery dissection

Risk for atheromatous disease
Maternal age (>35)
Obesity
DM
Smoking
Dyslipidaemia
Personal/family history of IHD

Risk for thrombosis
Anaemia
Thrombophillia
Blood transfusion and use of ergotamine
Infection
Multiparity(>3)
Sickle cell disease

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5
Q

When is ACS more common in pregnancy?

A

Significantly more common in third trimester than at earlier gestations.

73% occur in pregnancy
27% postpartum

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6
Q

What % of ACS are due to STEMI

A

75%
Characterises by chest pain, SOB, ventricular arrhythmia
Hemodynamic instability
Raised bio markers
ECG: ST segment elevation or
New LBBB

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7
Q

What are the clinical features of NSTEMI

A

Mostly haemodynamically Stable condition
ECG: Normal or ST segment depression and T wave inversion
Cardiac bio markers are raised

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8
Q

What are the features of unstable angina

A

Chest pain or SOB at rest
ECG: normal or ST segment depression
T wave inversion
NORMAL bio markers

STABLE ANGINA
SOB and chest pain relived by rest
Normal ECG, normal bio markers

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9
Q

Currently What is the most common cause of ACS in pregnancy?

A

Artherosclerosis in 39-40%

Thrombosis and thromboembolism in 10-20%

Coronary artery spasm in 2% - terbutaline, ergotamine , bromocriptine, cocaine use

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10
Q

What are the typical symptoms of ACS?

A

Typical : Chest or epigastric pain radiating to the neck or arm
Atypical:
Nonspecific pain, nausea , vomiting, back pain
Dyspnea , hyperhydrosis, agitation

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11
Q

What causes are commonly associated with STEMI or NSTEMI ?

A

Pregnancy associated spontaneous coronary artery dissection( no prior cardiovascular risk factor)
Thrombosis
Coronary artery spasm

Stable/unstable angina:artheromatous disease only !

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12
Q

What is the role of raised cardiac troponin in ACS ?

A

It’s is highly sensitive but nonspecific marker used in excluding ACS as a primary diagnosis.

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13
Q

What is the gold standard for assessment of a patient with ACS?

A

Cardiac catheterisation and angiography +- angioplasty

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14
Q

When should percutaneous coronary intervention (PCI) be used for ACS in obstetric population?

A

For thrombotic and artherosclerotic lesions
Conservative management for pregnancy associated spontaneous coronary artery dissection (PASCAD) and coronary artery spasm (CAS)

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15
Q

When is the ideal time for percutaneous coronary intervention for ACS in pregnancy ?

A

Later in pregnancy( after 4th month)
Or after delivery

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16
Q

What Is the preferred stent in PCI for ACS in pregnant women

A

Drug Eluting stents( DES) in addition to Dual anti platelet therapy with aspirin/clopidogrel for 12 months.

17
Q

What’s the risk of fetal loss and preterm delivery with the use of thrombolysis in pregnancy

A

6% fetal loss
6% preterm delivery
PCI is favoured

18
Q

If delivery is not imminent in ACS in pregnancy , what acute medication can be used?

A

Aspirin 300mg loading dose then 75 mg daily
Plus therapeutic SC heparin

Alternative : Clopidogrel 600mg loading and then 65 mg daily

19
Q

When to stop antiplatelets prior to delivery ?

A

Continue aspirin
Stop clopidogrel 5-7 days before regional anaesthesia

20
Q

Which is the preferred beta blocker for use in ischaemic heart disease in pregnancy

A

Bisoprolol- cardioselective

21
Q

What’s the risk of recurrence of ACS in women with pre-existing IHD, ACS in previous pregnancy ?

A

9%

22
Q

How long after an acute coronary event can a woman get pregnant?

A

12 months even without continuing is ischemia or residual cardiac dysfunction

23
Q

What are the options of contraception (UKMEC) in women with a history of IHD?

A

COC- UKMEC 4
Systemic Progesterone only -UKMEC1
LNG-IUS, Cu-IUD, UA are all safe

24
Q

What are the normal ECG changes in pregnancy?

A

Sinus tachycardia
Left axis deviation
Reduction in PR interval
Q waves and T wave inversion in the inferior leads : lead II,III, aVF
T wave abnormalities in V1-V3

25
Q

What are the ECG changes in acute ACS

A

ST elevation with reciprocal ST depression in opposite leads
ST depression alone
T wave inversion
New bundle branch block

Facing/ reciprocal leads
PAILS mnemonic: Posterior Anterior Inferior Lateral Septal
ST elevation in the preceding letter is followed by ST depression in the corresponding next letter

26
Q

What are the physiological changes on echocardiograms in pregnancy

A

Increased left ventricular mass
Increased end diastolic left ventricular volume
Increased left atrial dimensions
Increased flow velocities across valves
LVEF remains same

27
Q

What is the preferred approach to angiographic assessment in pregnant woman with ACS

A

Radial approach is preferred to femoral approach

28
Q

By what % does fetal shielding with lead apron reduce radiation exposure from angiography?

A

It does not.
Fetal exposure occurs through scatter

29
Q

Iodinated contrast media cross the placenta and therefore contraindicated in pregnancy

A

False
They cross the placenta but are not teratogenic

30
Q

When is the highest risk for maternal death for MI in pregnancy?

A

If it occurs late in pregnancy of if delivery occur within 2 weeks of an MI event

31
Q

When is the risk of coronary artery dissection greatest in pregnancy (pregnancy associated spontaneous coronary artery dissection - PASCAD)

A

Third trimester and up to 3 months postpartum

32
Q

Which of vessel is most commonly affected in MI and what is the mortality rate?

A

Left anterior descending coronary artery (LAD-CA) in 80%
Mortality of 30-40%

33
Q

What are the pathological ECG changes in acute MI

A

ST elevation - most sensitive and specific ECG marker
ST depression
SYMMETRICAL T wave inversion
Newly developed Q waves

34
Q

What’s the primary treatment for STEMI and NSTEMI

A

Coronary angiography and primary percutaneous coronary intervention is treatment of choice for STEMI

Antiplatelet therapy is the treatment of choice for NSTEMI

35
Q

The single greatest cause of maternal death from stroke

A

Intracerebral haemorrhage

MRCOG PART 2 (8 decks)

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