From the Guidelines
ST elevation on electrocardiograms (ECGs) during pregnancy is a significant finding that warrants immediate cardiology consultation and potential reperfusion therapy, as it may indicate acute coronary syndromes such as ST-elevation myocardial infarction (STEMI) or spontaneous coronary artery dissection. During pregnancy, normal ECG changes include left axis deviation, sinus tachycardia, and non-specific ST-segment and T-wave changes due to the gravid uterus displacing the heart and increased cardiac output 1. However, true ST elevation should never be dismissed as a normal pregnancy finding. The diagnostic criteria for STEMI remain the same in pregnancy: ST elevation ≥1mm in two contiguous leads (≥2mm in V2-V3 for men, ≥1.5mm for women).
Key Considerations
- Immediate reperfusion therapy is crucial, with primary percutaneous coronary intervention (PCI) being the preferred treatment when available, as it allows for diagnosis of coronary artery dissection and has a lower risk of bleeding complications compared to thrombolytics 1.
- Thrombolytics may be considered if PCI is unavailable, though they carry increased bleeding risks in pregnancy, particularly subplacental bleeding 1.
- Aspirin and clopidogrel should be administered, but with caution and for the shortest duration possible, as the safety of thienopyridines during pregnancy is unknown 1.
- ACE inhibitors, angiotensin receptor blockers (ARBs), and renin inhibitors are contraindicated during pregnancy due to their potential harmful effects on the fetus 1.
Management Approach
- An invasive management approach should be considered for non-ST-elevation ACS with risk criteria, including coronary angiography with the possibility of coronary intervention (PCI) 1.
- In women with non-ST-elevation ACS with intermediate or high-risk criteria, an invasive approach to assess coronary anatomy is indicated, while in stable conditions with exertional symptoms, watchful waiting and medical therapy is the treatment of choice 1.
- If there is a deterioration in clinical status, an invasive strategy is indicated, and in the case of recurrent coronary dissections, pre-term delivery can be considered according to fetal viability 1.
From the Research
Significance of ST Elevation on ECGs During Pregnancy
The significance of ST elevation on electrocardiograms (ECGs) during pregnancy is a critical indicator of acute myocardial infarction (AMI) or ST-elevation myocardial infarction (STEMI) [(2,3,4,5)].
- ST elevation on an ECG is a sign of a heart attack, which can be devastating for both the mother and the fetus 2.
- The diagnosis and treatment of STEMI in pregnant women can be challenging due to the unique physiological changes that occur during pregnancy [(2,3,4)].
- The management of STEMI in pregnancy requires a multidisciplinary approach, involving cardiologists, maternal-fetal medicine specialists, and anesthesiologists [(2,5)].
Pathophysiology and Treatment
The pathophysiology of STEMI in pregnancy is similar to that in the general population, with a complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel 6.
- The treatment of STEMI in pregnancy involves early diagnosis and immediate reperfusion, which can be achieved through primary percutaneous coronary intervention (PCI) or fibrinolysis therapy 6.
- The use of antithrombotic therapy and preventive measures can also help reduce the risk of recurrent cardiovascular events after STEMI 6.
Clinical Considerations
The clinical management of STEMI in pregnancy requires careful consideration of the potential risks and benefits of different treatment options [(3,4,5)].