Non-ST Elevation Myocardial Infarction and Coronary Artery Stenting in Pregnancy in a Woman with Resistant Familial Hyperlipidaemia

Abstract

A 31-year-old woman with familial hyperlipidaemia and severe coronary artery disease presented at 6 weeks of pregnancy. She had been diagnosed with familial hyperlipidaemia at the age of 7 years, after her father suffered a myocardial infarction in his early forties. She was then lost to follow-up. At the age of 24 years, she had a non-ST elevation myocardial infarction (NSTEMI). A coronary angiogram at that time showed 6 areas of plaque affecting three branches of the coronary arteries. Her medications were simvastatin 20 mg daily, perindopril 4 mg daily, aspirin 150 mg daily and metoprolol 100 mg daily.After extensive counselling, she insisted on continuing with this pregnancy. Her total cholesterol level was 16.3 mmol/L. Simvastatin and perindopril were stopped due to early pregnancy foetal concerns. She was well until at 20-week gestation, she presented to the Accidents and Emergency Department with acute chest pain and shortness of breath. Her pulse rate was 120 bpm, and her BP was 109/65. Her ECG showed ST depression in leads II, III, aVF, V4-6 (Fig. 1). Cardiac enzymes were raised (CKMB 26.6, troponin T 2.1). A diagnosis of NSTEMI was made. Acute management of myocardial infarction was instituted, except for streptokinase which is contraindicated in pregnancy. She went into ventricular fibrillation and asystole (Fig. 2), but responded to defibrillation and resuscitation.