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............................................................................................................................................................................. 7. Coronary artery disease

The incidence of CAD in women of childbearing age is unclear and varies between countries.232 Although acute MI (AMI)/acute coronary syndromes (ACS) complicating pregnancy is relatively uncommon (1.7–6.2/100 000 deliveries),233–235 CAD accounts for >20% of all maternal cardiac deaths.3 The current background information and detailed discussion of the data for the following section of these Guidelines can be found in ESC CardioMed.

7.1 Aetiology

Pregnancy is associated with a three- to four-fold increase in AMI risk compared with age-matched non-pregnant women.232,234,236,237 Risk factors include smoking,238 maternal age, hypertension, diabetes, obesity, and dyslipidaemia.233,234,237,239,240 Additional risk factors include (pre-)eclampsia, thrombophilia, transfusion, post-partum infection, cocaine use, multiparity, and post-partum haemorrhage.233,234 As the birth rate in women >40 years increases, ACS complicating pregnancy will become more common, as for every year increase in maternal age there is a 20% increase in MI risk.235 The aetiology of CAD in pregnancy differs from the general population; the majority of CAD has nonatherosclerotic mechanisms, including pregnancy-related spontaneous coronary artery dissection (P-SCAD) (43%), angiographically normal coronary arteries (18%), and coronary thrombosis (17%).239,241 P-SCAD-related AMI occurs most commonly in late pregnancy/early post-partum, and predominantly involves the left-sided coronaries, frequently with multivessel involvement.237,239 Potential pregnancyrelated precipitating factors include fluctuating oestrogen/progesterone levels resulting in structural changes in coronary vasculature, in background of fibromuscular dysplasia or connective tissue disease, and increased coronary shear stresses associated with labour.242–244 The mechanisms of AMI with angiographically normal coronary arteries remains unclear and include transient coronary spasm (increased vascular reactivity and/or use of ergot derivatives),237,245 rather reflecting the limitations of this diagnostic technique.246,247 Coronary thrombosis in the absence of atherosclerosis is most likely due to the hypercoagulability of pregnancy248 and can result from paradoxical embolization. Increasing survival in Kawasaki disease (in the USA it is predicted that by 2030, one in every 1600 adults will have suffered from Kawasaki disease) presents an additional challenge.249 Relevant Kawasaki disease manifestations include aneurysms, coronary blood flow alteration, coronary stenoses, myocardial ischaemia/fibrosis, congestive cardiac failure, and valvular abnormalities.249 Coronary thrombosis in the absence of atherosclerosis is most likely due to the hypercoagulability of pregnancy248 and can result from paradoxical embolization.

7.2 Presentation and diagnosis

Development of pregnancy-related ACS/AMI is most common during the third trimester [STEMI 25% and non-STEMI (NSTEMI) 32%] or post-partum (STEMI 45% and NSTEMI 55%). Clinical presentation is the same as in the non-pregnant population.250,251 ECG interpretation can be challenging, with inverted T waves in the absence of coronary ischaemia, and anaesthesia induction for caesarean section associated with ST-segment depression.237 A serum troponin rise should suggest myocardial ischaemia, even in pre-eclampsia.252,253 Where the ECG is non-diagnostic, echocardiography may be helpful.254 The main differential diagnoses include PE, aortic dissection, and pre-eclampsia. Potential complications include HF/cardiogenic shock (38%), arrhythmias (12%), recurrent angina/AMI (20%), maternal mortality (7%), and foetal death (7%).239

7.3 Management

AMI management in pregnancy is similar to that in the general population, including revascularization techniques. In P-SCAD, enhanced vascular vulnerability should be considered when applying revascularization strategies.241,255 Management should be multidisciplinary, including emergency, obstetric, and cardiovascular teams, and any revascularization should be undertaken by the most experienced operator due to the attendant risks associated with coronary intervention in this patient population. In cardiogenic shock, there should be facilities for emergency mechanical circulatory support. Close monitoring of the mother and foetus is required, with a delivery strategy in place in case there is sudden maternal or foetal deterioration. In the event of maternal cardiac arrest, resuscitation (and delivery) should be performed according to existing guidelines.256

7.4 Pharmacotherapy

There is little information regarding the foetal safety of guidelinerecommended drug therapy in AMI.257 Low-dose aspirin appears to be safe, but there is little information regarding P2Y12 inhibitors. Clopidogrel should be used only when strictly necessary and for the shortest duration.239 In the absence of data regarding glycoprotein IIb/IIIa inhibitors-bivalirudin, prasugrel, and ticagrelor, their use is not recommended. Beta-blockade may be beneficial in reducing shear stress in P-SCAD. Recombinant tissue plasminogen activator does not cross the placenta but may induce bleeding complications (subplacental bleeding). The benefits of short-term heparinization during PCI probably outweigh the risk of bleeding complications.

7.5 Intervention

The effects of ionizing radiation should not prevent primary PCI in pregnant patients with standard indications for revascularization in AMI. However, the radiation dose must be minimized. In stable, lowrisk NSTEMI, a non-invasive approach should be considered.258 Although CT coronary angiography provides an alternative diagnostic method,259 it requires radiation, potentially high-dose beta-blockade, and may fail to demonstrate limited P-SCAD.

7.5.1 Stent choice and antiplatelet therapy The majority of reports regarding STEMI in pregnancy relate to baremetal stents. However, new-generation drug-eluting stents (DES) are recommended according to the 2017 AMI STEMI Guidelines.251 Because no complications have been reported in stented pregnant patients treated with clopidogrel and aspirin, and because pregnancy is a high bleeding-risk situation, use of a more potent P2Y12 inhibitor should be considered with caution. The duration of dual antiplatelet therapy with a second/third-generation DES can be shortened, particularly in the absence of great thrombotic burden. Bioabsorbable stent usage has been reported in spontaneous coronary artery dissection; however, there is currently no evidence to recommend them in pregnancy. Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026