Associate Director, Cardiology, Max Hospital, Gurugram
Part 10 of 10 in Diagnosis and Management of Ischemic Heart Disease
Heart Attack Drugs in Pregnancy and Distinguishing Aortic Dissection from ACS
September 4, 2026
Two questions from the Jivo Masterclass audience pushed Dr. Rohit Goel beyond the standard protocol into situations that referring doctors are less likely to have a ready answer for: a pregnant patient having a heart attack, and a chest pain presentation that turns out not to be a heart attack at all.
Treating a heart attack during pregnancy
When a pregnant patient develops a heart attack, Dr. Goel's first principle is that the mother's safety comes first. Aspirin, clopidogrel, statins and beta blockers are all safe in pregnancy and should be used without hesitation; low molecular weight heparin is also safe. ACE inhibitors should not be given, and thrombolysis is contraindicated outright in pregnant patients. In place of thrombolysis, these patients should be referred for primary angioplasty, with the fetal risk explained to the family while treatment proceeds, since the mother's life takes priority.
Telling aortic dissection apart from a heart attack
Dissection can mimic acute coronary syndrome closely enough to be dangerous, because thrombolyzing a patient with an undiagnosed dissection can trigger sudden cardiac arrest and worsen the dissection itself. Once dissection is confirmed, the location decides the treatment: dissection involving the ascending aorta or the aortic arch requires surgical management, while dissection confined to the descending thoracic or abdominal aorta can be treated with percutaneous repair instead.
When ischemia isn't from a blocked artery at all
A separate audience question raised myocardial bridging, a congenital anomaly where a coronary artery dips briefly under the heart muscle instead of running along its surface, as a cause of chest pain. Dr. Goel's approach starts with medical management, beta blockers, calcium channel blockers or nitrates, and moves to bypass surgery, rather than angioplasty, if symptoms persist, since angioplasty does not work well for a bridged segment of artery.
This article is based on a Jivo Masterclass session conducted by Dr. Rohit Goel, Principal Consultant, Cardiology, Max Hospital, Gurgaon. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a cardiology consultation or a second opinion on ischemic heart disease? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass — Dr. Rohit Goel taught doctors across Africa on June 1, 2025.
FROM THE LIVE Q&A
Dr. Isaiah
Can you elaborate more on glycoprotein 2b3a inhibitors and low molecular weight heparin?
Dr. Rohit Goel
There are three glycoprotein 2b3a inhibitors: abciximab, tirofiban and eptifibatide. These were used far more commonly a decade ago, before stents and catheterization labs were as standardized and widely available as they are now. Today their use has decreased and they are reserved for high-risk patients, such as those with a high thrombotic burden or delayed presentation, because of the increased risk of bleeding in the brain, stomach and at the local puncture site.
Frequently Asked Questions
What is the prognosis of patients with ST-elevation MI if thrombolysis is not done, especially when there are contraindications?▼
The prognosis is poor when a patient with ST-elevation MI cannot be thrombolyzed because of a contraindication. Ideally these patients should be sent for primary angioplasty; if that is also unavailable, they should be managed medically in an ICU with aspirin, clopidogrel or ticagrelor, statins, beta blockers, ACE inhibitors, nitrates and heparin or low molecular weight heparin, using whatever resources are available. Outcomes can be described as roughly 50/50: some patients respond well to this treatment, while others deteriorate and need referral to a higher-level facility.
What is the approach for aortic dissection presenting like acute coronary syndrome?▼
Management of aortic dissection depends on which part of the aorta is involved. If the dissection involves the ascending aorta or the arch, it needs surgical management. If it involves the descending thoracic aorta or the descending abdominal aorta, percutaneous repair of the aneurysm is possible instead.
What is the lag time between the onset of symptoms and ST elevation on ECG?▼
Once symptoms begin, the earliest ST elevation can appear on ECG within 15 to 30 minutes. This ST elevation persists if there is complete occlusion of the artery, and can still be present up to 48 hours later. If blood flow is restored spontaneously, whether from medicines or other reasons, the ST elevation resolves; otherwise it persists until the artery is reopened.
What is the mortality rate for patients with ST-elevation MI?▼
Mortality in ST-elevation MI can be quite high if the patient is not treated properly, up to 30 to 50%, which is why adequate and timely treatment matters so much. Cardiac echo, alongside ECG and cardiac enzymes, is very important and can pick up early signs of heart damage; it is now one of the first-line investigations at tertiary care hospitals in suspected cases.
Is cardiac ultrasound of no importance in ischemic heart disease, and could you give a summary of its management?▼
Cardiac echo is important and is now done routinely, alongside cardiac enzymes and ECG, in suspected cases of heart attack at every tertiary care hospital where it is available. In summary, once ischemic heart disease is confirmed, every patient is loaded with aspirin (325 mg) along with clopidogrel (300 mg), prasugrel (60 mg) or ticagrelor (180 mg), a statin (atorvastatin or rosuvastatin, 40 to 80 mg), a beta blocker if blood pressure and heart rate allow, and glyceryl trinitrate for pain relief alongside oxygen. From there, ST-elevation MI patients receive heparin ahead of primary angioplasty, or are thrombolyzed if angioplasty is unavailable; non-ST-elevation MI and unstable angina patients are managed medically with low molecular weight heparin or fondaparinux instead of thrombolysis, and are escalated to coronary angiography and angioplasty or bypass surgery if they are high-risk or not improving.
Can a pregnant patient be thrombolyzed for a heart attack?▼
No. Thrombolysis is contraindicated in pregnancy. Primary angioplasty is used instead, with aspirin, clopidogrel, statins, beta blockers and low molecular weight heparin considered safe to use.
Does angioplasty work for chest pain caused by myocardial bridging?▼
Not well. Dr. Goel starts with medical management (beta blockers, calcium channel blockers or nitrates) and moves to bypass surgery, rather than angioplasty, if symptoms don't improve.
In This Series: Diagnosis and Management of Ischemic Heart Disease
- 1.Diagnosis and Management of Ischemic Heart Disease
- 2.Recognizing a Heart Attack: Classical and Atypical Symptoms of Acute Coronary Syndrome
- 3.ECG and Cardiac Biomarkers: The Two Investigations That Diagnose a Heart Attack
- 4.STEMI, Non-STEMI and Unstable Angina: How to Tell Them Apart
- 5.Emergency Drug Protocol for ST-Elevation Myocardial Infarction
- 6.Primary Angioplasty or Thrombolysis: Choosing the Right Reperfusion Strategy
- 7.Thrombolytic Drugs and When Thrombolysis Should Not Be Used
- 8.Managing Non-STEMI and Unstable Angina
- 9.Cardiac Rehabilitation, Follow-Up and Preventing the Next Heart Attack
- 10.Heart Attack Drugs in Pregnancy and Distinguishing Aortic Dissection from ACS