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

Abstract

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 optimize maternal and fetal outcomes. The early involvement of the cardio-obstetrics team in pre-pregnancy counselling, the antenatal period, delivery and post-partum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing due 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 prior coronary disease, and the pathological mechanisms involved are predominantly non-atherosclerotic. 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, diagnosis and management strategies for patients at risk of or presenting with coronary events in pregnancy.