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Article* "Development of the European Network in Orphan Cardiovascular Diseases" „Rozszerzenie Europejskiej Sieci Współpracy ds Sierocych Chorób Kardiologicznych” Title: Supraventricular arrhytmias in pregnancy RCD code: VII-V Author: Grzegorz Kopeć Affiliation: Department of Cardiac and Vascular Diseases, Centre for Rare Cardiovascular Diseases, John Paul II Hospital, Krakow, Poland Date: 2014.04.10 [* The article should be written in Englis John Paul II Hospital in Kraków Jagiellonian University, Institute of Cardiology 80 Prądnicka Str., 31-202 Kraków; tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88 e-mail: [email protected] www.crcd.eu Exacerbation of supraventricular tachycardia (SVT) can develop in 20-40% of women who had SVT before pregnancy. Atrioventricular nodal reentry tachycardia (AVNRT) and atrioventricular reentry tachycardia (AVRT) can usually be terminated by vagal maneuvers. When they are ineffective adenosine is a drug of choice. Metoporol iv can be used if SVT persists despite adenosine infusion. Pharmacological prophylaxis should only be used when arrhytmia is not tolerated. Digoxin and metoprolol are of first choice and sotalol, flekainid and propafenon are of second choice. If preexcitation is evident from the surface ECG drugs which slow atrioventricular conduction are contraindicated. Ablation can be considered only in selected patients especially in whom SVT is associated with hemodynamic instability. In every case of hemodynamically unstable arrhythmia electrical cardioversion should be used promptly. Atrial focal tachycardia (AFT) is usually resistant to pharmacotherapy in pregnancy and frequently associated with structural heart disease. The main aim is to control the ventricular rate with use of beta blockers or digoxin to prevent tachyarrhytmic cardiomyopathy. To prevent AFT sotalol, flecainid and propafenon can be used. Amiodaron can be used only if other drugs are ineffective. Electrical cardioversion is usually not indicated due to high rate of recurrence of arrhythmia. Atrial fibrillation (AFib) and atrial flutter (AFl) in pregnancy usually develop due to hyperthyroidism or structural heart disease. In case of hemodynamic instability electrical cardioversion is indicated without delay. In stable patients without structural heart disease ibutilid and flekainid should be used as a first choice for cardiovarsion. The second choice is propafenon or vernacalant but there is no evidence on their use for cardioversion of AFib in pregnancy. The third choice is amiodaron which however can be toxic for the child. If cardioversion is planned and AFib or AFl lasts for more than 48 hours 3 week anticoagulation is necessary before the procedure and 4 weeks or longer after cardioversion. Stratification of cardioembolic risk in AFib or AFl is similar as in nonpregnant patients and is based on the CHA2DS2VASC criteria. Vitamin K antagonists are recommended in the second trimester and in the third trimester until 36 week. In the first trimester and last month of pregnancy low molecular weight heparin in therapeutic doses adjusted to body weight should be used. New oral anticoagulants should not be used due to the risk for the child. If cardioversion is not John Paul II Hospital in Kraków Jagiellonian University, Institute of Cardiology 80 Prądnicka Str., 31-202 Kraków; tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88 e-mail: [email protected] www.crcd.eu considered the rhythm should be controlled with beta blockers (first choice drug) or digoxin which however does not reduce heart rate during exercise. Werapamil is a second choice drug. In case of severe symptoms of recurrent AFib or AFl pharmacological prevention with sotalol or flecainide or propafenon can be used. Flecainide and propafenon need to be combined with beta blockers. Dronedarone should not be used in pregnancy. It has been underscored that atenolol should not be used in pregnancy due to the risk of hypospadias when used in the I trimester and the risk of congenital defects, low birth weight, bradycardia and hypoglicemia in child when used in II or III trimester. References 1. Elkayam U, Goodwin TM. Adenosine therapy for supraventricular tachycardia during pregnancy. Am J Cardiol 1995;75:521–523. 2. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF, Antman EM, Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO Jr, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol 2003;42: 1493–1531. 3. Kockova R, Kocka V, Kiernan T, Fahy GJ. Ibutilide-induced cardioversion of atrial fibrillation during pregnancy. J Cardiovasc Electrophysiol 2007;18:545–547. 4. Rathore SS, Wang Y, Krumholz HM. Sex-based differences in the effect of digoxin for the treatment of heart failure. N Engl J Med 2002;347:1403–1411. 5. European Society of Gynecology (ESG); Association for European Paediatric Cardiology (AEPC); German Society for Gender Medicine (DGesGM), Regitz-Zagrosek V, Blomstrom John Paul II Hospital in Kraków Jagiellonian University, Institute of Cardiology 80 Prądnicka Str., 31-202 Kraków; tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88 e-mail: [email protected] www.crcd.eu Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JS, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AH, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U, Torracca L; ESC Committee for Practice Guidelines. 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 Dec;32(24):3147-97 ……………………………………….. Author’s signature** John Paul II Hospital in Kraków Jagiellonian University, Institute of Cardiology 80 Prądnicka Str., 31-202 Kraków; tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88 e-mail: [email protected] www.crcd.eu [** Signing the article will mean an agreement for its publication] John Paul II Hospital in Kraków Jagiellonian University, Institute of Cardiology 80 Prądnicka Str., 31-202 Kraków; tel. +48 (12) 614 33 99; 614 34 88; fax. +48 (12) 614 34 88 e-mail: [email protected] www.crcd.eu