Non-ST elevation myocardial infarction in pregnancy-a critical review of current evidence and guidelines

Treatment for acute coronary syndrome (ACS) in women during pregnancy is challenging. Current standard treatment for ACS includes coronary angioplasty with guideline-directed medical therapy including aspirin, P2Y12 inhibitors, beta-blockers, angiotensin converting enzyme inhibitors, which may portend adverse effects to the fetus. ACS increases ischemic and obstetric complications during pregnancy and the postpartum period. Management of these patients necessitates balancing the potential risks and benefits to both maternal and fetal health. We present a case of a 37-year-old female with a background of hypertension and hyperlipidemia who presented with Non-ST segment elevation myocardial infarction (NSTEMI). The urine pregnancy test that was performed turned positive with an estimated gestational age of four weeks. After counselling on the potential risks and benefits, a diagnostic angiogram was performed which revealed triple vessel disease with critical stenosis in all three vessels. Percutaneous coronary intervention (PCI) was performed successfully with precautions taken to minimize radiation exposure to the fetus. In such cases, there is a fundamental trade-off between maternal and fetal health in the treatment of NSTEMI. Medications used for the treatment of acute coronary syndrome will need to be balanced against the potential risks to the fetus. Invasive coronary angiogram results in exposure to potentially teratogenic ionizing radiation and hence all efforts must be made to minimize exposure. Thus, risks and benefits of treatment ought to be discussed with patients and measures need to be taken to minimize potential harm to both the mother and fetus.