Acute Coronary Syndrome In Pregnancy TOG 2023 / ESC 2018

Question 1

What is the quoted worldwide incidence and mortality rates of ACS

Answer 1

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)

Question 2

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

Answer 2

Ischaemic heart disease

Question 3

What constitutes acute coronary syndrome?

Answer 3

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

Question 4

What are the risk factors for ACS?

Answer 4

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

Question 5

When is ACS more common in pregnancy?

Answer 5

Significantly more common in third trimester than at earlier gestations.

73% occur in pregnancy
27% postpartum

Question 6

What % of ACS are due to STEMI

Answer 6

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

Question 7

What are the clinical features of NSTEMI

Answer 7

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

Question 8

What are the features of unstable angina

Answer 8

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

Question 9

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

Answer 9

Artherosclerosis in 39-40%

Thrombosis and thromboembolism in 10-20%

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

Question 10

What are the typical symptoms of ACS?

Answer 10

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

Question 11

What causes are commonly associated with STEMI or NSTEMI ?

Answer 11

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

Stable/unstable angina:artheromatous disease only !

Question 12

What is the role of raised cardiac troponin in ACS ?

Answer 12

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

Question 13

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

Answer 13

Cardiac catheterisation and angiography +- angioplasty

Question 14

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

Answer 14

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

Question 15

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

Answer 15

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

Question 16

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

Answer 16

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

Question 17

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

Answer 17

6% fetal loss
6% preterm delivery
PCI is favoured

Question 18

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

Answer 18

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

Alternative : Clopidogrel 600mg loading and then 65 mg daily

Question 19

When to stop antiplatelets prior to delivery ?

Answer 19

Continue aspirin
Stop clopidogrel 5-7 days before regional anaesthesia

Question 20

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

Answer 20

Bisoprolol- cardioselective

Question 21

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

Answer 21

9%

Question 22

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

Answer 22

12 months even without continuing is ischemia or residual cardiac dysfunction

Question 23

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

Answer 23

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

Question 24

What are the normal ECG changes in pregnancy?

Answer 24

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

Question 25

What are the ECG changes in acute ACS

Answer 25

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

Question 26

What are the physiological changes on echocardiograms in pregnancy

Answer 26

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

Question 27

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

Answer 27

Radial approach is preferred to femoral approach

Question 28

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

Answer 28

It does not. Fetal exposure occurs through scatter

Question 29

Iodinated contrast media cross the placenta and therefore contraindicated in pregnancy

Answer 29

False They cross the placenta but are not teratogenic

Question 30

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

Answer 30

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

Question 31

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

Answer 31

Third trimester and up to 3 months postpartum

Question 32

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

Answer 32

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

Question 33

What are the pathological ECG changes in acute MI

Answer 33

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

Question 34

What’s the primary treatment for STEMI and NSTEMI

Answer 34

Coronary angiography and primary percutaneous coronary intervention is treatment of choice for STEMI Antiplatelet therapy is the treatment of choice for NSTEMI

Question 35

The single greatest cause of maternal death from stroke

Answer 35

Intracerebral haemorrhage