Acute Coronary Syndrome in Pregnancy

Cardiovascular disease is the primary driver of maternal mortality in the United States. Acute coronary syndrome (ACS) in pregnancy is increasing in prevalence and a source of substantial morbidity and mortality. The primary cause of pregnancy associated myocardial infarction (PAMI) is non-atherosclerotic pregnancy-associated spontaneous coronary artery dissection (p-SCAD); however, due to the unique hormonal and pro-thrombotic state of pregnancy, coronary atherothrombosis, coronary vasospasm, and coronary emboli are also common causes of ACS in pregnancy. Women with pregnancy complicated by ACS should be managed by a multidisciplinary cardio-obstetrics team with expertise in the safe and timely diagnosis and management of ACS in pregnancy. Despite the limited data regarding the safety profile of cardiac medications used in the treatment of ACS, pregnant women should be treated with guideline-directed medical therapies, with few exceptions. Pregnant women with ST elevation MI (STEMI) and high-risk non-STEMI (NSTEMI) including refractory symptoms, heart failure, arrhythmias, or cardiogenic shock should all be considered for early invasive coronary angiography with possible revascularization. Given the risk of dissection propagation with coronary interventions and the natural history of spontaneous healing of most SCAD lesions, conservative management is favored in most patients with p-SCAD. Women with a history of ischemic heart disease and SCAD are at risk for recurrent ACS and recommendations regarding subsequent pregnancies should be individualized (Central Illustration).