Arrhythmias and Pregnancy - Management of Preexisting and New-Onset Maternal Arrhythmias - BINASSS
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A r r h y t h m i a s an d
Pregnancy
Management of Preexisting and New-Onset
Maternal Arrhythmias
Dominique S. Williams, MDa,*, Krasimira Mikhova, MDb,
Sandeep Sodhi, MDc
KEYWORDS
Pregnancy Maternal arrhythmias Arrhythmias Atrial fibrillation Supraventricular tachycardia
Ventricular tachycardia Structural heart disease
KEY POINTS
Women with preexisting arrhythmias are at high risk for recurrent arrhythmias and/or exacerbation
arrhythmias with pregnancy.
Arrhythmias may present at any time during pregnancy. Higher risk periods include the latter part of
the second trimester, third trimester, and peripartum period.
New-onset atrial fibrillation and ventricular arrhythmias should prompt evaluation for structural
heart disease.
BACKGROUND minute, and peripheral vascular resistance declines.
These changes are amplified in multiple gestation
Arrhythmias are the most common cardiovascular pregnancy, with cardiac output increasing by 60%
complication of pregnancy. Hospitalizations due to 70%.2,3 Physiologic changes peak in the second
to arrhythmias in pregnancy have increased by trimester, and again in labor and delivery where car-
58% from 2000 to 2012, mainly due to a rise in diac output increases due to “auto transfusion” with
atrial fibrillation.1 This rise is likely due to the in- uterine contractions. Sympathomimetic tone is also
crease in pregnancy in women with structural increased due multiple factors including neurohor-
heart disease. Arrhythmias may present for the monal changes during pregnancy, and pain and
first time in pregnancy, and in women with a his- anxiety during labor and delivery.3,4
tory of arrhythmias, pregnancy may lead to an Cardiac myocytes have estrogen and proges-
exacerbation of a previously controlled terone receptors. The downstream effects of es-
arrhythmia. Identification and appropriate man- trogen and progesterone on cardiac myocytes is
agement of arrhythmias are of utmost importance not well understood, but studies have shown these
in order to optimize maternal and fetal health. hormones play a role in repolarization.4 Temporary
cardiac remodeling during pregnancy may
PATHOPHYSIOLOGY contribute to the development of arrhythmias.
Cardiac output increases by 30% to 50% in preg- Atrial enlargement and stretch may create a sub-
nancy, heart rate increases by 10 to 15 beats per strate for atrial arrythmias.5,6
cardiology.theclinics.com
a
Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of
Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; b Cardiovascular Division,
Electrophysiology, John T. Milliken Department of Internal Medicine, Washington University School of Medi-
cine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; c Department of Medicine, Cardio-
vascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine, 660
South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
* Corresponding author.
E-mail address: dwillia1@wustl.edu
Cardiol Clin 39 (2021) 67–75
https://doi.org/10.1016/j.ccl.2020.09.013
0733-8651/21/Published by Elsevier Inc.
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PREMATURE BEATS Atrioventricular nodal reentrant tachycardia
(AVNRT) and atrioventricular reentrant tachycardia
Premature atrial and ventricular beats are common (AVRT) are the most common subtypes of SVT.
in pregnancy, occurring in w59% of pregnancies AVNRT is characterized by dual AV node physi-
in one study.7 Premature beats are often benign ology allowing anterograde and retrograde con-
and patient reassurance can be provided. Howev- duction. In AVRT conduction may occur through
er, in some patients, premature beats can be asso- the AV node or the accessory pathway. In anti-
ciated with structural heart disease and further dromic AVRT, the tachycardia conducts antero-
workup and evaluation are prudent. grade down the accessory pathway and
Premature ventricular contractions (PVC) may retrograde conduction through the AV node,
be an initial presentation of a cardiomyopathy or creating a regular wide complex tachycardia. Anti-
lead to the development of a cardiomyopathy. dromic AVRT accounts of 5% to 10% of AVRT.12
PVC burden has been shown to correlate with In patients with SVT, electrocardiograms in si-
left ventricular function. Most cases of PVC- nus rhythm are assessed for preexcitation, which
induced cardiomyopathy occur in patients with a may be asymptomatic and intermittently present
PVC burden of greater than 10% in 24 hours.8 on electrocardiogram. Findings of preexcitation
Tong and colleagues9 performed a prospective include a short PR interval less than 120 ms,
case control study of 53 pregnancies in 43 women slurred upstroke of the QRS, and QRS prolonga-
with a PVC burden of greater than 1%, mean PVC tion greater than 110 ms. Concern arises in pa-
burden of 13.9%, and no structural heart disease. tients with preexcited atrial fibrillation that may
PVCs presented more commonly in the first degenerate into ventricular fibrillation. Preexcita-
trimester. In 25 of 53 pregnancies, beta-blocker tion should be considered in patients with SVT
therapy was initiated due to symptoms and/or a who present with syncope or sudden cardiac
high burden. Adverse cardiovascular events death.
occurred in 11% of pregnancies and included
heart failure, and sustained and nonsustained ven-
tricular tachycardia. Pregnancies with adverse ATRIAL FIBRILLATION
cardiovascular events all had a PVC burden of Atrial fibrillation (AF) is the most common
greater than 5%. Adverse fetal events occurred arrhythmia in pregnancy, accounting for 27 per
in 13% of pregnancies and included small for 100,000 pregnancy hospitalizations for arryth-
gestational age and preterm birth.9 mias.1,13 In a meta-analysis of 7 studies totaling
Patients with significant symptoms and pre- 301,638 pregnancies, AF incidence was signifi-
served systolic function should be reassured.8 Med- cantly higher in women with structural heart dis-
ical therapy for PVCs is indicated for symptoms or in ease compared with women without structural
the setting of a reduced left ventricular ejection frac- heart disease (0.3% vs 2.2%).14
tion. First-line therapy with non-dihydropyridine cal- Risk factors for AF in pregnancy are similar to
cium channel blockers or beta-blockers, excluding risk factors in the nonpregnant state. Obesity and
atenolol, is recommended.8 age older than 40 significantly increase risk of
Premature atrial contractions (PACs) have primar- AF.15 Additional risk factors for AF identified in
ily been studied in the nonpregnant population. the Registry of Pregnancy and Cardiac Disease
Frequent PACs (>100 beats in 24 hours) have (ROPAC) include congenital heart disease, preex-
been shown to increase the risk of new-onset atrial isting history of AF, beta-blocker use before preg-
fibrillation, supraventricular tachycardia, and car- nancy, and valvular heart disease.16
diovascular morbidity and mortality in healthy pa- AF in pregnancy is associated with adverse
tients and patients with multiple comorbidities. maternal and fetal outcomes. Adverse fetal out-
including structural heart disease.10,11 comes include intrauterine growth restriction, res-
piratory distress syndrome, intraventricular
SUPRAVENTRICULAR TACHYCARDIA hemorrhage, and higher rates of neonatal intensive
care unit admissions. In addition, agents used for
Supraventricular tachycardia (SVT) is the second rate control may lead to maternal hypotension
most common arrhythmia in pregnancy, occurring and decreased placental perfusion, increasing
in 22 per 100,000 pregnancy hospitalizations.1 the risk for preterm labor. Adverse maternal out-
SVT may present at any stage of pregnancy, but comes include heart failure and thromboembolic
commonly presents in the second trimester. SVT events.15–17
presents with sudden onset of palpitations, which Management of AF is similar to the nonpregnant
may be associated with dyspnea, chest discom- state. In the nonpregnant population, trials have
fort, or presyncope. not shown a difference in cardiovascular
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outcomes and overall mortality between rate and heart rate with pregnancy. During pregnancy, the
rhythm control strategies.18,19 There are no data heart rate increases by 10 to 20 beats per minute
available comparing maternal and fetal outcomes but the resting heart rate rarely exceeds greater
in a rate control versus rhythm control approach. than 95 beats per minute.28 IST is characterized
According to the 2018 European Society of Cardi- by an elevated resting heart rate greater than 100
ology Guidelines, a rhythm control strategy is beats per minute or an average heart rate of
preferred for management of AF in pregnancy.20 greater than 90 beats per minute over 24 hours
Rhythm control allows for lower doses of rate con- in the absence of secondary causes. Symptoms
trolling medications, such as beta-blockers, which of IST include palpitations, fatigue, chest discom-
can associated with hypotension, intrauterine fort, dizziness, and poor exercise tolerance due to
growth restriction, and infant hypoglycemia. exaggerated rise in heart rate. In published case
Rhythm control can be accomplished with cardio- reports, IST appears to be well tolerated without
version and/or antiarrhythmic therapy. Cardiover- adverse of maternal or fetal outcomes.29,30
sion is safe in pregnancy and should be
considered if AF does not terminate within 24 hours VENTRICULAR TACHYCARDIA
of onset.21,22 Cardioversion within 48 hours of AF
onset does not negate the need for therapeutic Ventricular arrhythmias (VA) pose a significant risk
anticoagulation.23 Cardioversion results in atrial to maternal and fetal morbidity and mortality. VAs
stunning and activation prothrombotic factors.24 most commonly occur in the setting of structural
Thromboembolic events are highest the first heart disease, ischemia, inherited arrhythmia syn-
month following cardioversion; thus, anticoagula- dromes, or QT prolongation due to drugs or elec-
tion should be continued for a minimum of 4 weeks trolyte abnormalities. In an ROPAC study of 2966
following cardioversion. Extended or long-term pregnancies (56% congenital heart disease, 32%
anticoagulation should be based on the patients’ valvular heart disease), VAs occurred in 1.4%. Pre-
risk factors for thromboembolic events.23,25,26 If dictors of VAs included New York Heart Associa-
the onset of AF cannot be determined with accu- tion Class greater than 1 before pregnancy and
racy, transesophageal echocardiogram should moderate/severe left ventricular dysfunction.
be performed before cardioversion. There was a trend toward higher mortality in
In nonpregnant women, the CHADS2 VASC women with VAs (2.4% vs 0.3%, P 5 .15).31 VAs
Score (congestive heart failure, hypertension, age are more likely to occur in women with a prior his-
75 years, diabetes mellitus, stroke or transient tory of VAs.
ischemic attack, vascular disease, age 65 to 74
Arrhythmogenic Right Ventricular
years, sex category) guides anticoagulation man-
Cardiomyopathy
agement in AF. Therapeutic anticoagulation in rec-
ommended in patients with a nonsex Arrhythmogenic right ventricular cardiomyopathy
CHADS2VASC score greater than 1.23 The (ARVC) is characterized by fibrofatty displacement
CHADS2VASc score is often used in AF in preg- and thinning of the myocardium leading to ventric-
nancy; however, it has not been validated in preg- ular enlargement and dysfunction. ARVC predom-
nant women. There are case reports of left atrial inantly affects the right ventricle but left ventricular
appendage thrombus in pregnancy with persistent dysfunction may also occur. The degree of ventric-
AF and structurally normal hearts.27 Aspirin, thera- ular dysfunction correlates with outcome. ARVC
peutic anticoagulation, and prophylactic enoxa- may be symptomatic or present with PVCs, ven-
parin have been reported in the literature. tricular tachycardia or sudden cardiac death. VAs
Antithrombotic therapy for AF in pregnancies often present before ventricular dysfunction. In pa-
varies. Use of aspirin, therapeutic anticoagulation, tients with ARVC, VAs are often triggered by
prophylactic enoxaparin and no therapy have all increased adrenergic activity, such as exercise.32
been reported.27 If aspirin is prescribed for AF in Adverse cardiovascular events are not uncommon
pregnancy, the dose should not exceed 162 mg. during pregnancy in women with ARVC. Wu and
Full-dose aspirin increases the risk of premature colleagues33 reviewed 224 pregnancies in 120
closure of the ductus arteriosus. women with ARVC. Ninety-one (76%) women
had pregnancies before the diagnosis of ARVC.
INAPPROPRIATE SINUS TACHYCARDIA Adverse events occurred in 12 pregnancies and
included VAs and heart failure. Women at highest
Inappropriate sinus tachycardia (IST) may present risk of adverse outcomes had earlier onset of
during pregnancy and can be difficult to distin- symptoms and left ventricular dysfunction (50%
guish from postural orthostatic tachycardia syn- vs 60%, P 5 .004). In the women who became
drome as well as the physiologic increase in pregnant after being diagnosed with ARVC, there
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was no significant change in ventricular remodel- Catecholaminergic Polymorphic Ventricular
ing or function 1 year postpartum.33 In a study by Tachycardia
Hodes and colleagues34 of 26 women with ARVC
CPVT is a rare inherited arrhythmia syndrome that
and 39 pregnancies, 5% developed heart failure
often presents as syncope, VAs, or sudden death
and 13% developed VAs.
in the setting of exercise or an emotional stressor
in the absence of structural heart disease or pro-
Hypertrophic Cardiomyopathy longed QT interval. Polymorphic VT, bidirectional
VT and ventricular fibrillation are characteristic of
Hypertrophic cardiomyopathy (HCM) is due to mu- CPVT. CPVT mimics LQT1 and is not uncommonly
tations in genes encoding sarcomere proteins, misdiagnosed as LQT1 despite a normal QTc in-
leading to increased left ventricular wall thickness terval. Medical therapy for CVPT includes nonse-
and mass in the absence of secondary causes. It is lective beta-blockers and flecainide. Nadolol is
inherited in an autosomal dominant manner and the preferred beta-blocker in CPVT.39
may occur with or without LVOT obstruction. Heart
failure, arrhythmias, stroke, and sudden cardiac BRADYARRHYTHMIAS
death account for most cardiovascular morbidity
and mortality in HCM. In the ROPAC registry, Bradyarrhythmias are uncommon in pregnancy. If
VAs occurred in 22% of women with HCM with present, they are often due to chronotropic incom-
implantable cardioverter-defibrillators. There was petence or high-degree atrioventricular block,
no significant increase in VAs in women with which is often present before pregnancy. Women
HCM and no implantable cardioverter defibril- with repaired congenital heart disease or prior car-
lator.31 In a pooled cohort of 9 studies with 207 diac surgery are at an increased risk for bradyar-
women with HCM and 408 pregnancies, maternal rhythmias. In a study of 25 pregnancies in 18
mortality was less than 1% and 30% of pregnan- women, those with untreated atrioventricular
cies were associated with worsening symptoms block were more likely to have progression in con-
or arrythmias. Adverse fetal outcomes included duction disease with pregnancy. Women with
spontaneous abortion, stillbirth, and premature new-onset atrioventricular block were more likely
birth. Maternal deaths were due to sudden cardiac to require intervention compared with women
death.35 Validated risk factors of sudden cardiac with stable atrioventricular block before
death in HCM should be considered when coun- pregnancy.40
seling women on adverse cardiovascular out-
comes with pregnancy. DIAGNOSIS AND MANAGEMENT
Clinical evaluation should be performed in a step-
wise approach starting with a detailed clinical his-
Inherited Arrhythmia Syndromes
tory, obstetric history, family history and physical
Inherited arrhythmia syndromes (IAS) include examination. Red flags include exertional syn-
congenital long QT syndrome (LQTS), catechol- cope, syncope triggered by emotional stress
aminergic polymorphic ventricular tachycardia and/or auditory stimuli, palpitations associated
(CPVT), Brugada syndrome, short QT syndrome, with anginal chest pain or syncope, and a family
idiopathic ventricular fibrillation, and early repolar- history of sudden cardiac death.
ization syndrome. Data on IAS and pregnancy out- An electrocardiogram should be obtained in all
comes is limited as few studies specify types of patients with specific attention to signs of preexci-
IAS. IAS is not an absolute contraindication to tation, pathologic q waves, ventricular hypertro-
pregnancy. LQTS is the most common channelop- phy, and conduction delays and intervals. Mobile
athy, occurring in 1 in 2000. QTc greater than cardiac telemetry or Holter monitoring should be
500 ms and severe genotype (LQT2 or LQT3) is considered based on the frequency of symptoms.
associated with high risk of torsades de Use of implantable loop recorders in pregnancy
pointes.36,37 In a study of 136 pregnancies in 76 have been reported. In a study of 40 pregnant
women with LQTS and mean QTc 515 ms, women, implantable loop recorders increased
10.3% of pregnancies were associated with VAs. detection of arrhythmias and led to changes in
The increased risk of VAs persisted 9 months post- management.41 Identification of arrhythmias or
partum. Beta-blocker therapy was protective of frequent premature ventricular should prompt
VAs during pregnancy and postpartum.38 Beta- assessment of structural heart disease. Identifica-
blockers are a Class I indication in LQTS and tion of structural heart disease affects risk of car-
should be continued in pregnancy and diovascular complications with pregnancy and
postpartum.39 medical therapy. Transthoracic echocardiogram
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is readily available and can be performed with (72%). Beta-blockers significantly reduced birth
contrast enhancement in pregnancy. Exercise weight less than 200 g; however, this is unlikely
stress testing or advanced imaging should be to be clinically consequential. Metoprolol was
considered based on the clinical scenario associated with the smallest reduction in birth
(Table 1). weight by 119 g. Atenolol was associated with
the largest reduction in birthweight by 466 g and
PHARMACOTHERAPY is not recommended for use in pregnancy.44
There are no randomized trials regarding use of Calcium Channel Blockers (Food and Drug
cardiovascular disease medication in pregnancy. Administration Class C)
Most drugs are Food and Drug Administration
(FDA) class C or D. Class C drugs have limited Calcium channel blockers (CCBs) have not been
data in human pregnancy but have been studied associated with increased risk of congenital mal-
in animal reproduction and shown to have adverse formation. Due to the mechanism of action,
fetal effects. Class D drugs have shown adverse CCBs may cause hypotension and tocolysis. Prior
fetal effects when given in pregnancy in humans. studies suggested an increased risk of neonatal
Given limited data on pharmacotherapy in preg- seizures with CCB use in the third trimester; how-
nancy, risk versus benefit must be considered. ever, this was not shown in recent large cohort
Triggers to arrhythmias should be considered study with 22,908 pregnancies.45 Diltiazem has
before implementation of long-term medical ther- been associated with teratogenicity in animals
apy. Triggers include severe electrolytes abnor- but this has not been studied in pregnancy. Verap-
malities, illicit drug use, supplements, and certain amil is considered safe in pregnancy and
obstetric medications such as terbutaline and breastfeeding.20
magnesium sulfate. Severe hypermagnesemia
may lead to cardiac and respiratory arrest. The Digoxin (Food and Drug Administration Class
PR interval and QRS duration increase with C)
plasma levels of 5 mg/dL to 10 mg/dL. Conduction Digoxin predominantly affects the resting heart
defect and cardiac arrest may occur with plasma rate and is often used as an adjunct for rate control
levels greater than 10 mg/dL. It is important to in patients treated with beta-blockers or CCBs.
remember that to improve fetal and maternal out- Digoxin may also be used in heart failure with
comes, maternal health must be prioritized. reduced ejection fraction. Serum levels of digoxin
are not reliable in pregnancy due to an increase
Beta-Blockers (Food and Drug Administration
in unbound digoxin and an increase in renal clear-
Class C)
ance.46 Clinical signs and symptoms should be
Beta-blockers increase the risk of intrauterine used in addition with serum levels to assess for
growth restriction (IUGR), preterm birth, and digoxin toxicity.
neonatal hypoglycemia, bradycardia and hypoten-
sion. In a cohort study of 18,477 women with hy- Adenosine (Food and Drug Administration
pertension in pregnancy, beta-blocker use in the Class C)
first trimester was not independently associated
Adenosine is safe for use in pregnancy and has not
with an increased risk of overall malformations or
been shown to have adverse fetal effects. Adeno-
cardiac malformations.42 Variation in risk of
sine has a very short half-life, which prevents deliv-
congenital malformation with beta-blocker dose
ery to the fetus. It is recommended as first-line
in the first trimester has not been studied.
therapy for acute termination of supraventricular
b1 selective beta-blockers are preferred in preg-
tachycardia in pregnancy if vagal maneuvers
nancy due to lower rates of IUGR and decreased
fail.46 An intravenous line should be placed in the
effects on uterine activity and peripheral vasodila-
antecubital fossa or more proximal, given the short
tion. Nonselective beta-blockers are associated
half-life. It is given as a bolus of 6 mg followed by
with higher rates of IUGR. Atenolol is the only
rapid saline flush. Two subsequent doses of 12 mg
beta-blocker listed as FDA Class D due to
can be given.12
increased risk of congenital malformations. Use
of atenolol is not recommended in pregnancy.43
Flecainide (Food and Drug Administration
A recent study by Grewal and colleagues
Class C)
analyzed the determinants of birth weight to
discern the relative impact of beta-blockers.44 Of Flecainide is a sodium channel blocker used in the
1757 pregnancies, 404 women were treated with treatment of supraventricular tachycardia, atrial
beta-blockers, most commonly metoprolol arrhythmias and CPVT. Flecainide crosses the
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Table 1
Diagnosis and management of arrhythmias in pregnancy
Arrhythmia Diagnostic Testing Treatment Clinical Pearls
Supraventricular Assess for structural Vagal maneuvers Consider antidromic SVT
tachycardia heart disease with b-blockers in differential for a
echocardiography Non-dihydropyridine regular wide complex
before antiarrhythmic calcium channel tachycardia
therapy blockers
Flecainide
Sotalol
Adenosine
DCCV
Catheter ablation
Atrial Assess for structural b-blockers Consider DCCV for
fibrillation heart disease with Non-dihydropyridine hemodynamically
and flutter echocardiography calcium channel stable AF>24 h
and/or advanced blockers AspirinArrhythmias and Pregnancy 73
placenta and is present in breast milk. It is used in ELECTROPHYSIOLOGY PROCEDURES
the treatment of both maternal and fetal arrhyth-
mias. Coadministration of atrioventricular (AV) Catheter ablation has been performed safely in
nodal blockers are recommended in patients pregnancy. Catheter ablation is considered in pa-
with AF and flutter treated with flecainide as there tients with refractory and/or life-threatening ar-
is potential for one-to-one atrioventricular conduc- rhythmias that cannot be managed with medical
tion. Flecainide should not be used in patients with therapy.20,49 If possible, catheter ablations should
coronary artery disease or structural heart be performed in the second trimester with use of
disease.47 echocardiographic guidance to minimize or elimi-
nate radiation exposure. Placement of implantable
cardiac-defibrillators (ICD) and pacemakers are
Sotalol (Food and Drug Administration Class
safe in pregnancy. ICD shocks have not been
B)
associated with adverse fetal effects.50
Sotalol is a potassium channel blocker with beta-
blocker properties. Due to its QT-prolonging ef-
fects, there is risk of torsade de pointes. Sotalol SUMMARY
exhibits reverse-use dependence on the action Arrhythmias, new-onset or exacerbation of preex-
potential. As a result, QT-prolonging effects are isting arrhythmias, are the most common cardio-
highest at reduced heart rates. Drug efficacy is vascular complication in pregnancy. A detailed
reduced at higher heart rates. evaluation should be performed in patients with ar-
rhythmias and management should be in place
Dofetilide (Food and Drug Administration outlining antepartum, intrapartum, and post-
Class C) partum care. A multidisciplinary approach with
Dofetilide is a potassium channel blocker with cardiology, maternal fetal medicine, pediatrics,
reverse-use dependence. The QT prolonging of ef- and anesthesia is of utmost importance to opti-
fects are greater when compared with sotalol. mize maternal and fetal outcomes.
Dofetilide must be initiated in an inpatient setting
with close monitoring of the electrocardiogram.47
CLINICS CARE POINTS
Providers should pay close attention to drug inter-
actions and avoid coadministration of QT- Arrhythmias are the most common cardiovas-
prolonging agents. cular complication of pregnancy, occurring in
68 per 100,000 pregnancies.
Amiodarone (Food and Drug Administration Women with a prior history of arrhythmias are
Class D) at high risk of recurrence (30%–50%) with
pregnancy.
Amiodarone is reserved for refractory and/or life-
There are no validated risk models to assess
threatening arrhythmias due to its adverse fetal ef-
risk of thromboembolic events in nonvalvular
fects which are independent of dose and duration.
AF in pregnancy. The CHA₂DS₂-VASc score
Adverse fetal effects include congenital goiter, hy-
has not been validated in pregnancy. High-
pothyroidism, neurodevelopmental abnormalities,
dose aspirin increases the risk of premature
and preterm birth. Neonatal hypothyroidism is
closure of the ductus arteriosus.
often transient and has been reported in 23% of
Ventricular tachycardia should prompt evalu-
neonates exposed to amiodarone.48 Use of amio-
ation for structural heart disease, ischemia
darone is not recommended in women
(eg, pregnancy associated myocardial infarc-
breastfeeding.
tion, coronary spasm), use of QT-prolonging
agents, and inherited channelopathies.
DIRECT CURRENT CARDIOVERSION Amiodarone is associated with adverse fetal
effects and should be reserved for refractory
Cardioversion is safe and effective in pregnancy
and life-threatening arrhythmias.
and should be performed immediately in patients
Cardioversion, catheter ablation, and implan-
with hemodynamic instability.21,22 Continuous
tation of cardioverter-defibrillators are safe in
fetal monitoring and coordination of care with
pregnancy.
maternal fetal medicine and pediatric is recom-
mended in viable pregnancies. If anticoagulation
is indicated, consideration of gestational age and DISCLOSURE
potential need for emergency delivery should
play a role in choosing the appropriate agent. The authors have nothing to disclose.
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REFERENCES 16. Salam AM, Ertekin E, van Hagen IM, et al. Atrial
fibrillation or flutter during pregnancy in patients
1. Vaidya VR, Arora S, Patel N, et al. Burden of with structural heart disease: data from the ROPAC
arrhythmia in pregnancy. Circulation 2017;135(6): (Registry on pregnancy and cardiac disease).
619–21. JACC Clin Electrophysiol 2015;1(4):284–92.
2. Abbas AE, Lester SJ, Connolly H. Pregnancy and 17. Henry D, Gonzalez JM, Harris IS, et al. Maternal
the cardiovascular system. Int J Cardiol 2005; arrhythmia and perinatal outcomes. J Perinatol
98(2):179–89. 2016;36(10):823–7.
3. Sanghavi M, Rutherford JD. Cardiovascular physi- 18. Noheria A, Shrader P, Piccini JP, et al. Rhythm Con-
ology of pregnancy. Circulation 2014;130(12): trol versus rate control and clinical outcomes in pa-
1003–8. tients with atrial fibrillation: results from the ORBIT-
4. Ekholm EM, Erkkola RU. Autonomic cardiovascular AF registry. JACC Clin Electrophysiol 2016;2(2):
control in pregnancy. Eur J Obstet Gynecol Reprod 221–9.
Biol 1996;64(1):29–36. 19. Wyse DG, Waldo AL, DiMarco JP, et al.
5. Anneken L, Baumann S, Vigneault P, et al. Estradiol A comparison of rate control and rhythm control in
regulates human QT-interval: acceleration of cardiac patients with atrial fibrillation. N Engl J Med 2002;
repolarization by enhanced KCNH2 membrane traf- 347(23):1825–33.
ficking. Eur Heart J 2016;37(7):640–50. 20. Regitz-Zagrosek V, Roos-Hesselink JW,
6. Goette A, Kalman JM, Aguinaga L, et al. EHRA/HRS/ Bauersachs J, et al. 2018 ESC Guidelines for the
APHRS/SOLAECE expert consensus on atrial car- management of cardiovascular diseases during
diomyopathies: definition, characterization, and clin- pregnancy. Eur Heart J 2018;39(34):3165–241.
ical implication. Heart Rhythm 2017;14(1):e3–40. 21. Tromp CH, Nanne AC, Pernet PJ, et al. Electrical
7. Shotan A, Ostrzega E, Mehra A, et al. Incidence of cardioversion during pregnancy: safe or not? Neth
arrhythmias in normal pregnancy and relation to pal- Heart J 2011;19(3):134–6.
pitations, dizziness, and syncope. Am J Cardiol 22. Wang YC, Chen CH, Su HY, et al. The impact of
1997;79(8):1061–4. maternal cardioversion on fetal haemodynamics. Eur
8. Marcus GM. Evaluation and management of prema- J Obstet Gynecol Reprod Biol 2006;126(2):268–9.
ture ventricular complexes. Circulation 2020; 23. Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic
141(17):1404–18. therapy for atrial fibrillation: CHEST guideline and
9. Tong C, Kiess M, Deyell MW, et al. Impact of expert panel report. Chest 2018;154(5):1121–201.
frequent premature ventricular contractions on preg- 24. Harada M, Van Wagoner DR, Nattel S. Role of
nancy outcomes. Heart 2018;104(16):1370–5. inflammation in atrial fibrillation pathophysiology
10. Chong BH, Pong V, Lam KF, et al. Frequent prema- and management. Circ J 2015;79(3):495–502.
ture atrial complexes predict new occurrence of 25. Nuotio I, Hartikainen JE, Grönberg T, et al. Time to
atrial fibrillation and adverse cardiovascular events. cardioversion for acute atrial fibrillation and throm-
Europace 2012;14(7):942–7. boembolic complications. JAMA 2014;312(6):
11. Lin CY, Lin YJ, Chen YY, et al. Prognostic signifi- 647–9.
cance of premature atrial complexes burden in pre- 26. Hellman T, Kiviniemi T, Nuotio I, et al. Intensity of an-
diction of long-term outcome. J Am Heart Assoc ticoagulation and risk of thromboembolism after
2015;4(9):e002192. elective cardioversion of atrial fibrillation. Thromb
12. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/ Res 2017;156:163–7.
AHA/HRS Guideline for the management of adult 27. Sauvé N, Rey É, Cumyn A. Atrial fibrillation in a
patients with supraventricular tachycardia: a report structurally normal heart during pregnancy: a review
of the American college of cardiology/American of cases from a registry and from the literature.
heart association task force on clinical practice J Obstet Gynaecol Can 2017;39(1):18–24.
guidelines and the heart rhythm society. J Am Coll 28. Loerup L, Pullon RM, Birks J, et al. Trends of blood
Cardiol 2016;67(13):e27–115. pressure and heart rate in normal pregnancies: a
13. Katsi V, Georgiopoulos G, Marketou M, et al. Atrial systematic review and meta-analysis. BMC Med
fibrillation in pregnancy: a growing challenge. Curr 2019;17(1):167.
Med Res Opin 2017;33(8):1497–504. 29. Belham M, Patient C, Pickett J. Inappropriate sinus
14. Chokesuwattanaskul R, Thongprayoon C, Bathini T, tachycardia in pregnancy: a benign phenomena?
et al. Incidence of atrial fibrillation in pregnancy BMJ Case Rep 2017;2017. https://doi.org/10.1136/
and clinical significance: a meta-analysis. Adv bcr-2016-217026.
Med Sci 2019;64(2):415–22. 30. Shabtaie SA, Witt CM, Asirvatham SJ. Natural history
15. Lee MS, Chen W, Zhang Z, et al. Atrial fibrillation and and clinical outcomes of inappropriate sinus tachy-
atrial flutter in pregnant women-a population-based cardia. J Cardiovasc Electrophysiol 2020;31(1):
study. J Am Heart Assoc 2016;5(4):e003182. 137–43.
Descargado para Irene Ramírez (iramirez@binasss.sa.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 08, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.Arrhythmias and Pregnancy 75
31. Ertekin E, van Hagen IM, Salam AM, et al. Ventricu- electrocardiographic monitoring for detecting ar-
lar tachyarrhythmia during pregnancy in women with rhythmias in pregnant women with symptomatic
heart disease: data from the ROPAC, a registry from arrhythmia and/or structural heart disease: a ran-
the European society of cardiology. Int J Cardiol domized clinical trial. JAMA Cardiol 2020. https://
2016;220:131–6. doi.org/10.1001/jamacardio.2019.5963.
32. Haugaa KH, Haland TF, Leren IS, et al. Arrhythmo- 42. Bateman BT, Heide-Jørgensen U, Einarsdóttir K,
genic right ventricular cardiomyopathy, clinical man- et al. b-Blocker use in pregnancy and the risk for
ifestations, and diagnosis. Europace 2016;18(7): congenital malformations: an international cohort
965–72. study. Ann Intern Med 2018;169(10):665–73.
33. Wu L, Liang E, Fan S, et al. Effect of pregnancy in 43. Tanaka K, Tanaka H, Kamiya C, et al. Beta-blockers
arrhythmogenic right ventricular cardiomyopathy. and fetal growth restriction in pregnant women with
Am J Cardiol 2020;125(4):613–7. cardiovascular disease. Circ J 2016;80(10):
34. Hodes AR, Tichnell C, Te Riele AS, et al. Pregnancy 2221–6.
course and outcomes in women with arrhythmo- 44. Grewal J, Siu SC, Lee T, et al. Impact of beta-
genic right ventricular cardiomyopathy. Heart 2016; blockers on birth weight in a high-risk cohort of
102(4):303–12. pregnant women with CVD. J Am Coll Cardiol
35. Schinkel AF. Pregnancy in women with hypertrophic 2020;75(21):2751–2.
cardiomyopathy. Cardiol Rev 2014;22(5):217–22. 45. Bateman BT, Huybrechts KF, Maeda A, et al. Cal-
36. Mazzanti A, Maragna R, Vacanti G, et al. Interplay cium channel blocker exposure in late pregnancy
between genetic substrate, QTc Duration, and and the risk of neonatal seizures. Obstet Gynecol
arrhythmia risk in patients with long QT syndrome. 2015;126(2):271–8.
J Am Coll Cardiol 2018;71(15):1663–71. 46. Costantine MM. Physiologic and pharmacoki-
37. Priori SG, Schwartz PJ, Napolitano C, et al. Risk netic changes in pregnancy. Front Pharmacol
stratification in the long-QT syndrome. N Engl J 2014;5:65.
Med 2003;348(19):1866–74. 47. January CT, Wann LS, Alpert JS, et al. 2014 AHA/
38. Ishibashi K, Aiba T, Kamiya C, et al. Arrhythmia risk ACC/HRS guideline for the management of patients
and b-blocker therapy in pregnant women with long with atrial fibrillation: executive summary: a report of
QT syndrome. Heart 2017;103(17):1374–9. the American College of Cardiology/American heart
39. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. association task force on practice guidelines and
2017 AHA/ACC/HRS Guideline for management of the heart rhythm society. Circulation 2014;130(23):
patients with ventricular arrhythmias and the preven- 2071–104.
tion of sudden cardiac death: executive summary: a 48. Lomenick JP, Jackson WA, Backeljauw PF. Amiodar-
report of the American college of cardiology/Amer- one-induced neonatal hypothyroidism: a unique
ican heart association task force on clinical practice form of transient early-onset hypothyroidism.
guidelines and the heart rhythm society. Circulation J Perinatol 2004;24(6):397–9.
2018;138(13):e210–71. 49. Driver K, Chisholm CA, Darby AE, et al. Catheter
40. Thaman R, Curtis S, Faganello G, et al. Cardiac ablation of arrhythmia during pregnancy.
outcome of pregnancy in women with a pacemaker J Cardiovasc Electrophysiol 2015;26:698–702.
and women with untreated atrioventricular conduc- 50. Miyoshi T, Kamiya CA, Katsuragi S, et al. Safety and
tion block. Europace 2011;13(6):859–63. efficacy of implantable cardioverter-defibrillator dur-
41. Sliwa K, Azibani F, Johnson MR, et al. Effectiveness ing pregnancy and after delivery. Circ J 2013;77(5):
of implanted cardiac rhythm recorders with 1166–70.
Descargado para Irene Ramírez (iramirez@binasss.sa.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 08, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.You can also read
