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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

II (Table 20) and be counseled regarding potential risks to mother and fetus.2,15 Pharmacokinetics of medications may be altered in pregnancy because of changes in absorption, volume of distribution, serum protein binding, extraction ratio, hepatic and renal clearance, uteroplacental flow, and fetal metabolism.7 Medication regimens should be optimized during family planning to ensure safety throughout pregnancy and lactation.2,7 Recommendations for selected cardiovascular medications during pregnancy and lactation are summarized in Table 21. 2.	 A multidisciplinary cardio-obstetrics team (Figure 10) should evaluate the patient before conception and monitor the patient throughout her pregnancy, carefully plan for labor and delivery, and provide close follow-up during the postpartum period to address medication management during lactation, monitor for cardiovascular complications, manage cardiovascular risk factors, and advise on contraception.5,16 Longitudinal registries suggest that pregnancy outcomes have improved with the introduction of multidisciplinary care teams.1 In health care settings where multidisciplinary teams are unavailable, clinicians should consider referral to relevant subspecialties as appropriate. 3.	 Statins have been contraindicated in pregnancy since

their approval in 1987. FDA guidance published in July 2021 requested removal of this contraindication from all statin labels.6 A 2015 US propensity-based

Table 21.  Safety of Cardiovascular Medications During Pregnancy and Lactation Medication Safety in Pregnancy Safety in Lactation Arrhythmias Adenosine S LD Metoprolol/propranolol S LD Digoxin S S Lidocaine S S Verapamil LD LD Diltiazem LD U Procainamide LD LD Sotalol LD U Flecainide LD LD Propafenone LD LD Amiodarone* C C Heart Failure Metoprolol S LD Carvedilol S U Furosemide S LD Bumetanide S U Dopamine S U Dobutamine S U Norepinephrine S U Hydralazine LD S Nitroglycerine LD U Isosorbide dinitrate LD U Torsemide LD U Metolazone LD U Anticoagulants Warfarin LD S Unfractionated heparin S S Enoxaparin S S Fondaparinux LD U Argatroban LD U Bivalirudin LD U Antiplatelets Aspirin (low dose) LD LD Clopidogrel LD LD Prasugrel LD U Ticagrelor LD U Thrombolytics Alteplase LD U Streptokinase LD U Hypertension Labetalol S LD Nifedipine S S Alpha-methyldopa (oral) S S Hydralazine LD S

(Continued ) Medication Safety in Pregnancy Safety in Lactation

Nitroglycerin LD U Nitroprusside LD LD Isosorbide dinitrate LD U Amlodipine LD LD Furosemide S LD Hydrochlorothiazide LD S Clonidine LD U Cautionary Use and Contraindicated in Pregnancy Atenolol C LD ACE inhibitor class† C LD ARB class C U Aldosterone antagonists C C Statin class LD C DOAC C C ERAs (eg, bosentan) C C Color key: C, contraindicated; LD, limited data, use with caution; S, considered safe; and U, conflicting data, unknown. *May be used if other therapies fail. †Captopril, benazepril, and enalapril are considered safe during lactation. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; DOAC, direct oral anticoagulants; and ERA, endothelin-receptor antagonists. Adapted with permission from Halpern DG, et al.7 Copyright 2019 American College of Cardiology Foundation.

Table 21.  Continued

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