Japan: Initiation of Diltiazem Therapy and Successful Birth

A recent case study published in JACC: Case Reports has shown that the initiation of diltiazem therapy led to pregnancy and the successful birth of a child in a woman diagnosed with severe vasospastic angina (VSA).

Vasospastic angina can sometimes result in acute myocardial infarction (MI) in pregnant women, potentially endangering the lives of both mother and child. Hirohiko Aikawa, from the National Cerebral and Cardiovascular Center in Suita, Osaka, Japan, and colleagues described a case of a young woman with suspected vasospastic angina who wished to become pregnant.

Vasospasm provocation testing revealed severe vasospasm, and subsequent appropriate management led to successful delivery.

Case Details

The case concerns a 29-year-old woman who presented with chest pain only at rest. The Holter electrocardiogram revealed ST-segment depression at the time of chest pain onset. A trial use of nitroglycerin sublingual tablets was effective. She was suggested to have vasospastic angina and wished to become pregnant. She had no medical history.

The possible differential diagnoses included:

• Coronary embolism
• Atherosclerotic coronary artery disease
• Spontaneous coronary artery dissection

The case was discussed by cardiologists and obstetricians who decided to perform invasive coronary catheterization and vasospasm provocation testing to determine a definitive diagnosis and perinatal cardiovascular risk, and to administer a calcium-channel blocker (CCB) if the test was positive.

Coronary angiography performed via her distal radial artery revealed no stenosis. Vasospasm provocation testing with acetylcholine administration into the left coronary artery resulted in sub occlusion in the left main trunk (LMT) with chest pain, ST-segment depression in the V4 to V6 leads, and hypotension. An intracoronary infusion of nicorandil and isosorbide mononitrate improved the LMT occlusion, eliminated electrocardiogram changes, and increased blood pressure (BP). She was confirmed to have severe VSA.

200 mg daily Diltiazem was initiated. She successfully conceived after a few weeks. Diltiazem's effectiveness was recognized after the appearance of chest pain shortly after the temporary discontinuation of diltiazem because of hyperemesis gravidarum. Her pregnancy progressed without chest pain after the second trimester, and the fetus developed well.

A labour induction was planned at the 40th gestation week because spontaneous labour did not occur until full term. Epidural analgesia was used at delivery to prevent vasospasm induction caused by hyperventilation or pain stress.

She gave birth to a healthy girl without any anomaly. For postpartum atonic haemorrhage, oxytocin was used instead of methylergonovine. She had no chest pain or electrocardiogram abnormality in the peripartum period.

The patient continued to take diltiazem after delivery and has had no recurrence of angina attacks. The child was growing up without any disabilities. The amount of diltiazem ingested by the infant via breast milk is small and is unlikely to negatively affect breastfed infants.

"It is important to make a definitive VSA diagnosis for women who wish to be pregnant, determine its severity and provide suitable treatment," the researchers wrote.

"Under conditions of adequate prior consultation with the patient, obstetricians, family, and cardiologists, invasive catheterization including provocation test should be performed, and CCB administration should be considered for VSA," they concluded.

Reference

Aikawa H, Murai K, Aoki-Kamiya C, Yoshimatsu J, Noguchi T. Diagnosis and Management of Vasospastic Angina in a Young Woman Wishing to Become Pregnant. JACC Case Rep. 2023 Dec 6;27:102051. doi: 10.1016/j.jaccas.2023.102051. PMID: 38094717; PMCID: PMC10715958.