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Circulation. 2018;138:e272–e391. DOI: 10.1161/CIR.0000000000000549 September 25, 2018 e339 CLINICAL STATEMENTS AND GUIDELINES pregnancy to ensure ongoing beta-blocker therapy. The risk of SCA or SCD is significantly higher during the 9 months after delivery, most notably among women with LQT2.S10.2-1,S10.2-6,S10.2-7 A large retrospective analysis from the long QT syndrome registry demonstrated an odds ratio of 40.8 for syncope, SCA, or SCD among women with long QT syndrome in the 9 months’ postpartum; treatment with beta blockers during pregnancy was independently associated with decreased risk.S10.2-7 Overall arrhythmic events during pregnancy are not increased among women receiving beta-blocker therapy.S10.2-1,S10.2-6,S10.2-7 In a casecontrol study, women with LQT1 who did not receive beta blockers during pregnancy, particularly those with prior syncope, were at significantly increased risk of SCA or syncope.S10.2-8 Frequency of events returned to prepregnancy levels after 9 months.S10.2-1 Maternal use of beta blockers during pregnancy is associated with decreased newborn birth weight and hypoglycemia,S10.2-9 but it is not associated with increased risk of miscarriage.S10.2-8,S10.2-10 Fetal bradycardia is associated with fetal long QT syndrome and should not independently provoke discontinuation of beta-blocker therapyS10.2-11–S10.2-14; these infants are at increased risk of death and require careful neonatal monitoring and treatment.S10.2-13 As 50% of offspring may be affected with long QT syndrome, with highest risk of adverse events in infancy and childhood, screening of the newborn at birth and during infancy for long QT syndrome is important.S10.2-8 2. Available data on electrical fields associated with properly applied AED patches suggest that the fetus is safe; no observational data are available to the contrary. Anterolateral defibrillator pad placement is preferred with the lateral pad/paddle placed under the breast tissue, which is an important consideration in the pregnant patient. 3. The ICD in pregnant women is safe and effective.S10.2-4 For the rare circumstance of pregnant women with an immediate indication for an ICD, or less common indications for VT ablation during pregnancy, the radiation risk to the fetus is minimal.S10.2-5,S10.2-15 The procedure is usually performed after the first trimester unless there are circumstances that demand an earlier procedure. Wearable cardioverter-defibrillators have been used in peripartum cardiomyopathy while awaiting repeat assessment of recovery of ventricular function.S10.2-16 The subcutaneous implantable cardioverter-defibrillator is a potential alternative to conventional ICDs, although data are unavailable to support a recommendation. 10.3 Older Patients With Comorbidities Recommendation for Older Patients With Comorbidities See Systematic Review Report.S10.3-1 COR LOE Recommendation IIa B-NRSR 1. For older patients and those with significant comorbidities, who meet indications for a primary prevention ICD, an ICD is reasonable if meaningful survival of greater than 1 year is expected.S10.3-1 SR indicates systematic review. Synopsis Refer to the “Systematic Review for the 2017 ACC/ AHA/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” for the complete systematic evidence review for additional data and analyses.S10.3-1 The results from the question “What is the impact of ICD implantation for primary prevention in older patients and patients with significant comorbidities? (Part 2)” and the writing committee’s review of the totality of the literature were used to frame our decision-making. Recommendations are based on a body of evidence that includes the systematic review conducted by the ERC and are denoted by the superscript SR (eg, LOE: B-RSR). Comorbidities included various combinations of renal disease, chronic obstructive pulmonary disease, atrial fibrillation, and heart disease, among others. Recommendation-Specific Supportive Text 1. Older age is defined as ≥75 years. The ERC’s analyses are helpful in clearly demonstrating that neither age nor comorbidities alone should be exclusions for an ICD. However, the data included in the analysis are limited. Firstly, most data are from nonrandomized studies and “both selection and unidentified confounding biases can never be fully adjusted for.” It is likely that the more frail patients are already appropriately not offered ICDs and are thus not included. Secondly, because most of the studies are nonrandomized, these findings signify only an association and not causality. Also, older adults are prone to higher complication rates, shorter life expectancies (and thus, fewer years during which they could derive benefit from an ICD), and varying preferences.S10.3-2 For these reasons, it is important to take a particularly nuanced and patientcentered approach to treating these patients. 10.4 Chronic Kidney Disease Patients with chronic kidney disease (CKD) are at an increased risk of SCD compared with the general popula- Downloaded from http://ahajournals.org by on October 7, 2026