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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e107

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

especially cardioselective beta blockers, for treatment of AF need not be avoided when indicated, especially in patients with less than severe COPD. However, beta blockers can exacerbate reactive airway disease and are generally avoided in that setting, such as in patients with asthma. 2.	 Atrial arrhythmias are common in PH with pulmonary

vascular disease (PHPVD; hemodynamically defined as PH with increased pulmonary vascular resistance and normal left heart filling pressures, typical of World Health Organization group 1 but also of groups 3 and 4). Right atrial contraction accounts for a significantly greater proportion of total right heart function in patients with PHPVD than in normal subjects,18 and the onset of atrial arrhythmia is frequently associated with clinical deterioration.4–12 Restoration of sinus rhythm results in improvement, whereas persistent arrhythmia or recurrence is associated with mortality.4,8,9 Pharmacological rhythm control and cardioversion have both been used, although negative inotropy may limit antiarrhythmic drug therapy. Catheter ablation of typical AFL has been well described in patients with PHPVD, with acceptable results and safety, as well as improvement in clinical and hemodynamic parameters.5,7,12 LA ablation has also been described, although the possibility of creating a right-to-left shunt should always be considered when planning transseptal puncture. Anesthetic management is also complex, and these patients are best cared for by centers with extensive clinical expertise in these conditions.

10.13 Pregnancy

Recommendations for Pregnancy Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In pregnant patients with AF, DCCV is safe to the

patient and fetus and should be performed in the same manner as in patients who are not pregnant.1

2b C-LD 2 In pregnant individuals with structurally normal hearts and

hemodynamically stable AF, pharmacological cardioversion with agents with history of safe use in pregnancy, such as intravenous procainamide, may be considered.1,2

2a C-LD 3 In pregnant individuals with AF and without structural

heart disease, antiarrhythmic agents with history of safe use in pregnancy (eg, flecainide and sotalol) are reasonable for maintenance of sinus rhythm.1,2

2a B-NR 4 In pregnant individuals with persistent AF, rate-control

agents with a record of safety in pregnancy, such as beta blockers (eg, propranolol or metoprolol) and digoxin, either alone or in combination with beta blockers, are reasonable as first-line agents.1,2

2b C-LD 5 Pregnant individuals with AF and elevated risk of

stroke may be considered for anticoagulation with the recognition that no anticoagulation strategy is completely safe for both the mother and fetus, and an SDM discussion should take place regarding risks to both mother and fetus (Table 28).3 Synopsis The incidence of atrial arrhythmias is rising in pregnancy, and data from the national inpatient sample suggest that this is largely driven by increasing incidence of AF, with a reported frequency of 27 per 100 000 hospitalizations.4 The incidence of AF/AFL in pregnant patients with heart disease is 1.3%, with a peak occurrence between 23 and 30 weeks gestation.5,6 Hospitalizations during pregnancy for arrhythmias are associated with an increased risk of maternal and fetal adverse outcomes. AF during pregnancy is associated with increased maternal mortality (OR, 13.13 [95% CI, 7.77-22.21]; P<0.0001).9

Atrial arrhythmias may manifest for the first time during pregnancy; however, AF is usually associated with underlying structural or CHD. Factors associated with an increased incidence of AF in pregnant individuals include advanced maternal age,6 African American race, lower socioeconomic status, and left-sided obstructive lesions.4,5 Obesity is associated with the development of hypertensive disorders of pregnancy, which is also a known risk factor for AF.7 Another potential mechanism for development of AF in pregnancy is the cardiogastric interaction that occurs with elevated progesterone levels, leading to gastroesophageal reflux disease.8 In patients deemed to be at high risk of stroke, recommendations for anticoagulation in pregnancy are extrapolated from experience in managing VHD. DOACs are contraindicated during pregnancy and during breastfeeding because of a lack of data to support their safety and efficacy in this patient population. Recommendation-Specific Supportive Text 1.	 Rapid atrioventricular conduction may have serious hemodynamic consequences for both mother and fetus.9 DCCV of AF in pregnant individuals is safe for both mother and fetus and should be performed within 48 hours of presentation to minimize risk of stroke.1 Appropriate sedation should be provided to the pregnant individuals before DCCV. Fetal monitoring is generally used during and directly after DCCV. 2.	 Antiarrhythmic drugs are used in pregnancy for

both maternal and fetal conditions; therefore, their mechanisms and adverse effect profile must be tolerable to both mother and fetus. These medications should be avoided if possible during the first trimester, and initiation of the drug should be attempted at the lowest dose with involvement of an electrophysiologist or cardiologist skilled in the management of arrhythmias in pregnancy.10 Intravenous ibutilide has been used effectively in pregnant women with refractory AF, although published reports included a very small number of patients. In a pregnant patient presenting with AF and manifest preexcitation, intravenous procainamide is also an option.11

3 In pregnant individuals with structurally normal

hearts and AF, rhythm-control strategies may include

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