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INTRODUCTION

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Women of reproductive age are usually regarded as young and healthy individuals with a decreased risk of developing a serious illness. However, the physiologic changes that occur during pregnancy are demanding on the cardiovascular system. Total cardiac output increases by about 50% from a combination of increased blood volume and pulse along with a decrease in peripheral resistance. These changes can place a significant stress on a normal heart and can become dangerous to individuals with underlying cardiac disorders. An estimated 0.4% to 4.1% of all pregnancies are complicated by cardiovascular diseases, and the number of patients who develop cardiac problems during pregnancy is increasing.1 Acute myocardial infarction (MI) although a more rare, but possibly lethal event during pregnancy, delivery, or the peripartum period, can occur in previously asymptomatic women who are experiencing the cardiac stress associated with normal pregnancy. Maternal mortality following MI in pregnancy develops secondary to different etiologies such as atherosclerosis, coronary vasospasm, thrombosis, and coronary dissection. Although the number of such patients presenting to the individual physician is small, knowledge of the risks associated with MI during pregnancy and its management are of pivotal importance.

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This chapter will focus on acute MI in pregnancy with an emphasis on diagnosis and disease management. The occurrence of the disease during pregnancy, unlike in a nonpregnant patient, requires special consideration to the fact that all measures concern not only the mother but also the fetus. Therefore, the optimum treatment of both must be targeted.

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EPIDEMIOLOGY

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Incidence

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First described by Katz in 1922, the frequency of MI in pregnancy has been increasing in parallel with the growing number of pregnancies in women at older ages. With the continuing trend of childbearing at older ages and advances in reproductive technology enabling older women to conceive, it may be expected that the incidence of MI in pregnancy will continue to increase.2,3,4 A recent publication reviewing documented cases of pregnancy-associated MI between 1995 and 2005 showed patient ages ranged from 19 to 44 years, but that the majority of cases (72%) occurred in patients who were older than 30 years. In addition, the review noted that MI occurred mostly (78%) in the anterior cardiac wall.5 Ladner et al. in 2005 reviewed hospital discharge records for deliveries in California between 1991 and 2000 and reported an incidence of 1 MI in 35,700 deliveries or 2.8 in 100,000 deliveries.6 Subsequently, James et al. published a population-based study in the United States looking at the Nationwide Inpatient Sample for the years 2000 to 2002 that estimated the incidence of pregnancy-related MI to be 6.2 per 100,000 deliveries.7 The higher incidence reported by James et al. either reflects improvements in diagnostic capabilities or an increasing trend in the number of cases as the pregnancy cohort grows older. This would parallel similar findings reported by Ladner et ...

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