A woman with hopes to conceive was diagnosed with severe vasospastic angina (VSA); however, she was able to carry a healthy baby to full term without angina attacks after starting treatment of a calcium channel blocker, according to a clinical case published Dec. 6 in a special Cardio-Obstetrics focus issue of JACC: Case Reports.

Hirohiko Aikawa, MD, et al., presented a case of a patient with no medical history who was in the process of trying to conceive. VSA is often overlooked in patients presenting with chest pain but can result in acute myocardial infarction in pregnant women. VSA can be triggered during pregnancy when hormonal and nervous system changes occur. Due to its risks on pregnancy, it is important for clinicians to make a definitive diagnosis of VSA, determine its severity and provide proper treatment.

People with VSA are usually treated with calcium channel blockers, however, there is some concern of their safety when prescribed to pregnant people.

"Pregnant patients with vasospastic angina may require special management," said Kota Murai, MD, PhD, an author of the study. "Clinicians must be able to accurately assess the advantages and disadvantages of certain VSA treatments and determine which is most beneficial to the health of both the mother and child. This case offers clear evidence of the advantages of the careful management of calcium channel blockers for people who are pregnant or trying to get pregnant."

The use of calcium channel blockers is under speculation for pregnant patients due to reports of teratogenicity in animal studies. They are unlicensed for use in pregnancy in many countries. However, study authors conclude that calcium channel blockers – such as diltiazem – should be considered under certain conditions. Conditions include prior consultation with the patient, family, obstetricians and cardiologists, invasive catheterization and testing.

To make the patient's diagnosis and determine perinatal cardiovascular risk, doctors performed invasive coronary catheterization and vasospasm provocation testing, which resulted in sub-occlusion in the left main trunk with chest pain, ST segment depression in the V4-6 leads and hypotension. She was then administered an infusion of isosorbide mononitrate and nicorandil, which alleviated her symptoms. After testing, the patient was confirmed to have severe vasospastic angina and was administered a calcium channel blocker.

The patient was prescribed diltiazem 200 mg daily and successfully conceived shortly after treatment. The effectiveness of diltiazem was confirmed when she experienced chest pain after treatment was temporarily discontinued due to hyperemesis gravidarum.

Her pregnancy progressed without VSA symptoms after the second trimester and there were no signs of abnormal development of the fetus. After delivery, the patient continued treatment with no recurrence of symptoms and the child did not have any disabilities.

Other manuscripts published in the cardio-obstetrics focus issue of JACC: Case Reports include:

• Successful Pregnancy after Cardiac Arrest in a Women with Severe Coronary Vasospasm
• Severe Aortic Stenosis in a Pregnant Patient Displaced by the Ukrainian-Russian War
• Management of Pregnancies Complicated by Type B Aortic Dissections

In a guest editor's page, Ki Park, MD, FACC, and Natalie A. Bello, MD, FACC, co-chairs of ACC's Reproductive Health & Cardio-Obstetrics Member Section, explain how ACC's Board of Trustees approved the Section in 2023 recognition of the importance of the field and a desire to foster its advancement. "The Reproductive Health and Cardio-Obstetrics Section now serves as a home for: 1) educational initiatives and resource development targeted to all levels of learners from introductory to advanced; 2) involvement in advocacy; and 3) cross-societal collaborations," they note.

There is still time to secure your spot for Cardio-Obstetrics Essentials: Team-Based Management of Cardiovascular Disease and Pregnancy, taking place virtually on Friday, Dec. 15. This interprofessional course will provide education on the evolving field of cardio-obstetrics including current recommendations for the evaluation, clinical management, treatment, and risk stratification of people with, or at risk for, cardiovascular disease during pregnancy. Register today!

Clinical Topics: Stable Ischemic Heart Disease, Chronic Angina

Keywords: Calcium Channel Blockers, Coronary Vasospasm, Hyperemesis Gravidarum