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Acute coronary syndrome postpartum requiring five vessel CABG
Abstract Number: SAT-82
Abstract Type: Case Report/Case Series
Case: 37yo G4P2103 at 35w4d with PMHx of poorly controlled DM2, obesity BMI 36, cHTN, and tobacco abuse presented for IOL for intrauterine fetal demise. On admission she was hypertensive and diagnosed with superimposed pre-eclampsia without severe features, and labetalol was initiated. Her most recent HgbA1c was 5.5% (previously 10%) other labs were unremarkable. An epidural was placed HD1 (platelets 127) in anticipation for TOLAC. She had an uneventful VBAC and was discharged home on PPD1 without complications or cardiopulmonary symptoms.
On PPD2 she presented to an OSH with acute onset shortness of breath and back pain. A chest CT angiogram was performed to evaluate for thromboembolic disease. It showed pleural effusions and multifocal infiltrates. Troponin was 1.83ng/mL and she was transferred to our facility for further workup. Admission labs showed troponin of 3.96ng/mL, ECG with ST elevation in aVR, ST depression in inferolateral leads. Cardiology performed an emergent heart catheterization, which revealed triple vessel disease and diastolic dysfunction. She was started on aspirin, statin, nitroglycerin, and furosemide. Multidisciplinary discussion determined that the pulmonary edema and hypertensive disease were likely due to pre-eclampsia. She underwent 5 vessel CABG on PPD5. She tolerated surgery well and was discharged home on POD4 (PPD 9).
Discussion: Cardiovascular disease is the leading cause of maternal mortality and is a growing concern with advancing maternal age, obesity, DM and cHTN (3% of parturients)(1). Increased cardiac output and hormone-induced vascular changes of pregnancy are detrimental in the setting of pre-existing cHTN (1,2). Peripartum acute coronary syndrome (ACS) is rare, especially in patients with no prior cardiac disease. ACS occurs in 0.003-0.01% of pregnancies, with one-third of these cases occurring postpartum. Risks for peripartum ACS include thrombophilia, HTN, age>35, smoking, and eclampsia. 40% is due to CAD (2). Maternal mortality after ACS is estimated at 5–10% (can be as high as 37%)(4). Survival is improved with percutaneous or surgical revascularization (2). Before delivery, ACS may result in fetal mortality and prematurity, the risk is mainly related to the severity of maternal heart disease (3). IUFD is associated with consumptive coagulopathy and DIC, which may increase maternal morbidity. The contribution of IUFD to peripartum ACS is unknown, but there are common risk factors between the two (5).
The good outcome in our case shows the importance of rapid recognition of ACS in a peripartum patient. Anesthesiologists must be vigilant while managing the growing population of parturients with CVD risk factors, especially in the critical peripartum period.
1.Cardiovasc Res (2014) 101(4): 554-560
2.Intervent Cardiology Review, 2013;8(1):8-13
3.Eur Heart J. 2011;32(24)
4.Catheter Cardiovasc Interv, 2001;52:88–94
5.Journal of women’s health. 2009,18(4)