CardioNerd (Amit Goyal), cardioobstetrics series co-chair Dr. Natalie Stokes, Cardionerds Duke University CardioNerds Ambassador and episode lead fellow, Dr. Kelly Arps, join Dr. Andrea Russo, Director of Electrophysiology and Arrhythmia Services at Cooper Medical School of Rowan University and immediate past president Heart Rhythm Society, for a discussion about pregnancy and arrhythmia. Stay tuned for a message from Dr. Sharonne Hayes about WomenHeart. Audio editing by Gurleen Kaur.
Dr. Russo’s disclosures: Johnson and Johnson, Medtronic, Inc., Boston Scientific Corporation, Kestra, Medilynx, Up-to-Date, and ABIM.
Pregnant patients may have exacerbation of underlying arrhythmic syndromes or unmasking of previously undiagnosed arrhythmic syndromes. Management of atrial and ventricular tachyarrhythmias should proceed with increased urgency in pregnant patients due to risk of adverse hemodynamic events in the mother and fetus. Cardioversion of atrial and ventricular arrhythmias is safe in pregnancy. Preferred antiarrhythmic agents in pregnant patients include metoprolol, propranolol, verapamil, flecainide, propafenone, sotalol, procainamide, and lidocaine. Management of arrhythmias in pregnancy should include collaboration with obstetrics and maternal-fetal medicine teams.
- Pre-conception counseling is a shared decision making process; include obstetrics and maternal-fetal medicine colleagues in challenging cases.
- Have a high sense of urgency for acute arrhythmias in pregnancy due to risk of impaired fetal perfusion. Goals of acute arrhythmic management should include rapid treatment while avoiding hypotension.
- In scenarios when beta blockers are indicated, metoprolol and propranolol are first choice. Avoid atenolol as this drug has the highest risk of fetal bradycardia and intra-uterine growth retardation in the class.
- Lidocaine or procainamide should be first line for ventricular arrhythmias in pregnancy. Amiodarone is potentially teratogenic and should not be used in pregnant patients unless all other options have been exhausted.
1. What are the expected electrophysiologic changes associated with pregnancy?
- Increase in resting heart rate which peaks in third trimester
- PR shortening
- ECG axis shift leftward and upward
- Non-specific ST and T wave changes
These changes, along with increased cardiac output and volume with increased stretch in all chambers, increase the risk of re-entrant arrhythmias in those who are predisposed.
↑ atrial volume -> ↑ stretch -> ↑ ectopy -> ↑ risk for re-entrant arrhythmias
2. What is the approach to pre-conception counseling for patients with known arrhythmias or arrhythmic syndromes?
- Anticipate frequency and potential severity of adverse arrhythmic outcomes during pregnancy and post-partum period
- Consider available options for rhythm control and anticoagulation therapy, as appropriate, during the pre-conception, pregnancy, and post-partum periods
- Consider catheter ablation prior to pregnancy, particularly for curable arrhythmias such as Wolff-Parkinson-White (WPW) and AVNRT
- Offer genetic counseling about hereditary risk to fetus for inherited arrhythmias such as Brugada syndrome and Long QT syndrome
3. What is the management of SVT in pregnancy?
Consider the increased risk of tachyarrhythmias in pregnancy:
Typically benign arrhythmias can lead to more rapid decompensation in mother due to increased baseline cardiac output.
Typically benign arrhythmias can lead to rapid danger to the fetus due to maternal hypotension and shortened diastolic filling time, both of which contribute to impaired fetal perfusion.
Treatment algorithm is identical to that of non-pregnant patients
- Attempt vagal maneuvers
- Adenosine is safe
- Cardioversion is safe: monitor the fetus during and after cardioversion
- In stable arrhythmias, choose nodal blocking agents with the best safety profile: metoprolol, propranolol, and verapamil.
Evaluation of the pregnant patient with new onset SVT
Have a high index of suspicion for underlying structural heart disease such as peripartum cardiomyopathy in a pregnant women with new diagnosis of SVT – presence of structural heart disease significantly increases the risk of maternal morbidity and mortality.
Pregnancy can be the first presentation of inherited arrhythmia syndromes that commonly present in young adults such as WPW, Brugada Syndrome, Catecholaminergic Polymorphic VT (CPVT), Long QT Syndrome (LQTS), Arrhythmogenic Right Ventricular Cardiomyopathy / Dysplasia (ARVC/D), and Hypertrophic Cardiomyopathy (HCM).
4. What are some special considerations for acute management of VT in pregnancy?
Cardioversion is safe.
First line pharmacologic therapy: lidocaine or procainamide
- Lidocaine has been associated fetal bradycardia but has been used safely without reported teratogenic effect
- Brugada syndrome: consider quinidine in Brugada syndrome
- Fascicular VT: use verapamil
- Only use amiodarone if absolutely necessary, and after the first trimester
5. What is the approach to chronic arrhythmia management in pregnancy?
Preferred rate control agents:
AVOID: atenolol (increased risk of fetal bradycardia and intrauterine growth restriction; note that this risk is present with all beta blockers*)
Preferred rhythm control agents:
- Flecainide (if no structural heart disease)
- Propafenone (if no structural heart disease)
AVOID: amiodarone; use only in a patient with refractory unstable arrhythmias after the first trimester (due to fetal thyroid and neurodevelopmental issues)
AVOID: dronedarone; Category X in pregnancy
Catheter ablation in the pregnant patient
- Best delayed until late in pregnancy or after delivery
- Maternal-fetal medicine colleagues should be involved in procedural planning
- Minimize fluoroscopic time
- Shield the pelvis during fluoroscopy and use electroanatomic mapping
*Surveillance for pregnant patients on beta blockers:
- Serial growth ultrasounds in the third trimester
- Antenatal testing of for bradycardia and hypoglycemia
- Postnatal monitoring for:
- Growth retardation
- Postnatal monitoring for:
6. What is the approach to antiarrhythmic therapy in the breastfeeding patient?
All antiarrhythmic drugs are passed into breast milk
- Preferred rate control agents: metoprolol, propranolol (watch for fetal bradycardia)
- Rhythm control agents: weigh risks and benefits; read dosing adjustments on prescribing instructions carefully
7. What is the approach to anticoagulation in pregnancy and breastfeeding?
Use the CHAD2S2-VASc score to estimate stroke risk for pregnant patients with AF and AL
Risk of stroke with AF and AFL in pregnancy are uncertain, as women of childbearing age were minimally represented in large studies evaluating prophylactic antithrombotic drug treatment.
- Low molecular weight heparin is preferred in the first trimester and around the time of delivery.
- Warfarin should be avoided during the first trimester (especially at doses >5 mg daily), but may be used in the second and beginning of the third trimester.
- Avoid DOACs
- Use warfarin or LMWH
AVOID: DOACs may be excreted in breast milk and should not be used during breast feeding.
8. What is the approach to specific arrhythmic syndromes?
AVNRT: recommend catheter ablation prior to conception if prior diagnosis. Manage acute events if they occur during pregnancy.
WPW: recommend catheter ablation prior to conception if prior diagnosis. Use procainamide for acute arrhythmic events and avoid nodal blocking agents.
LQTS:recommend beta blockers (metoprolol or propranolol) through pregnancy and at least through the post -partum period
CPVT: recommend beta blockers (metoprolol or propranolol) through pregnancy and at least through the post-partum period
9. What is the approach to management of cardiac arrest in the pregnant patient?
ACLS should be performed per ACLS guidelines, including chest compressions and defibrillation.
Positioning: aim to avoid IVC compression and impaired venous return to the heart in the supine pregnant patient.
- Patients with a pulse: left lateral decubitus
- No pulse: Manually displace the uterus to the left
- All patients: place IVs above the diaphragm
Be prepared for difficult airway in mother due to airway edema Call OB and neonatal teams immediately to determine need for emergency C-section if no ROSC within the first several minutes.
European Society of Gynecology (ESG); Association for European Paediatric Cardiology (AEPC); German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147-3197. doi:10.1093/eurheartj/ehr218
Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2018 Oct 2;72(14):1760]. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e232-3]. Circulation. 2016;133(14):e471-e505. doi:10.1161/CIR.0000000000000310
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2014 Dec 2;130(23):e272-4]. Circulation. 2014;130(23):e199-e267. doi:10.1161/CIR.0000000000000041
Dr. Andrea Russo is Professor of Medicine at Cooper Medical School of Rowan University, where she is also Director of the Clinical Cardiac Electrophysiology Fellowship Program, as well as Director of Electrophysiology and Arrhythmia Services at Cooper University Hospital and Director of Research at Cooper Heart Institute. She is the immediate past president of the Heart Rhythm Society. She’s also had numerous leadership positions in HRS, the American College of Cardiology, American Heart Association, American Board of Internal Medicine, National Quality Forum, and the American Board of Medical Specialties. Dr. Russo is currently serving as a member of the ACC Cardiovascular Disease in Women Committee and the ABIM Cardiovascular Board. She’s written extensively in the field of electrophysiology, with a focus on sex differences in arrhythmias, ICDs and subcutaneous cardiac devices, atrial fibrillation, digital health, and performance improvement activities. She has been on the steering committee for trials including UNTOUCHED and the Apple Heart Study and contributed to multiple guideline and consensus statements including as first author of the 2013 multisociety Appropriate Use Criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy and senior author of the ACC / AHA Guidance for Cardiac Electrophysiology During the COVID-19 Pandemic. In addition to her academic achievements, Dr. Russo has been recognized many times as a “Top Doctor” in Philadelphia and Southern New Jersey.
Kelly completed medical school at Emory University and residency at Johns Hopkins Hospital, where she served as editor-in-chief for the 2018 Osler Medicine Survival Guide. She is currently is a clinical cardiology fellow at Duke University and served on the 2019-2020 ACC FIT website editorial board in the education section. Kelly is planning to pursue a career in cardiac electrophysiology with a focus on ventricular arrhythmias in heart failure and infiltrative cardiomyopathies.