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................................................................................................................................................... 9. Arrhythmias

9.1 Introduction

Tachyarrhythmias, particularly AF,318,319 may manifest for the first time and become more frequent during pregnancy, especially in older women318,320 and in women with congenital heart disease.41,321 AF (27/100 000) and paroxysmal supraventricular tachycardia (PSVT) (22 - 24/100 000) are, apart from premature beats, the most frequent arrhythmias.318 Symptomatic exacerbations of PSVT322 are usually benign and can be medically treated effectively.12 Life-threatening VT and ventricular fibrillation are very rare during pregnancy,318 as are bradyarrhythmias and conduction disturbances. The current background information and detailed discussion of the data for the following section of these Guidelines can be found in ESC CardioMed.

9.2 Maternal risk

AF is associated with an increased mortality risk318 [odds ratio (OR) 13.13, 95% CI 7.77–22.21; P <0.0001], and a rapid ventricular response can lead to serious haemodynamic consequences for both the mother and the foetus. Diagnosis and treatment of underlying conditions are the first priorities. Patients with a known history of any symptomatic supraventricular tachycardia (SVT) or VT should be considered for catheter ablation prior to pregnancy. SCD is recognized as an increasing risk factor in pregnancy and therefore cascade screening for channelopathies with genetic counselling2,3,72 is important. Women with congenital LQTS are at substantial risk of cardiac events during the post-partum period.323 New-onset VT warrants the exclusion of underlying structural heart disease,324 as it is associated with increased risk of SCD for the mother (OR 40.89, 95% CI 26.08–64.1; P <0.0001).318 Bradyarrhythmias and conduction disturbances usually have a favourable outcome in the absence of underlying heart disease.

9.3 Obstetric and offspring risk

Pregnant PSVT subjects have worse obstetric and foetal outcomes, with higher adjusted ORs (1.54–3.52) for severe maternal morbidity, caesarean delivery, low birth weight, pre-term labour, foetal stress, and foetal abnormalities than those without PSVT.325 Women with congenital heart disease are more likely to die during admission for delivery than those without (OR 6.7), arrhythmia being the most frequent cardiovascular event.321 Recommendations for optimal surveillance levels during delivery for women with arrhythmias are outlined in ‘Recommendations for the management of arrhythmias’.

9.4 Supraventricular tachycardia

Recommendations for acute termination of PSVT (AV nodal re-entry tachycardia and AV re-entry tachycardia)326 are outlined in ‘Recommendations for the management of arrhythmias’ below. The i.v. administration of adenosine is recommended as the first drug of choice for acute conversion of PSVT (see table ‘Recommendations for the management of arrhythmias’).

For the prevention of PSVT, beta-blockers (except atenolol) or verapamil are first-line agents, except for patients with Wolff–Parkinson–White syndrome (see section 12).12,32,327,328 The use of preventive drug therapy should be related to the severity of symptoms and haemodynamic compromise during tachycardia. Focal atrial tachycardia (AT) can be associated with drug resistance and tachycardia-induced cardiomyopathy. Adenosine may aid in diagnosis and terminates focal AT in 30% of cases. AV nodal blocking drugs are recommended for long-term rate control. Flecainide, propafenone (in the absence of ischaemic heart disease), or sotalol should be considered for rhythm control if these agents fail (see Table 7).12

9.5 Atrial fibrillation and atrial flutter

Electrical cardioversion is recommended whenever ongoing AF is haemodynamically unstable or a considerable risk for the mother or the foetus.306 Delivery of i.v. butilide or flecainide may be considered for the termination of atrial flutter and AF in stable patients with structurally normal hearts.12,329 Cardioversion should generally be preceded by anticoagulation (see below).306 The use of i.v. betablockers is recommended for rate control. Rhythm control should be considered as the preferred treatment strategy during pregnancy, starting with a beta-blocker as the first option.306 In the case of a rate control strategy, an oral beta-blocker is recommended (see Table 7). Episodes of atrial flutter are usually not well tolerated in patients with congenital heart disease and electrical cardioversion should therefore be performed to restore sinus rhythm.12 Beta-blockers, class I antiarrhythmic drugs, and sotalol should be used with caution if systemic ventricular function is impaired (see section 8).

9.5.1 Anticoagulation The same rules for stroke risk stratification should be used as in nonpregnant patients.306 Non-vitamin K oral anticoagulation drugs are prohibited during pregnancy (see Table 7).

9.6 Ventricular tachycardia

Inherited arrhythmogenic disorders should always be looked for with appropriate diagnostic tests during or after pregnancy.72 PPCM should be ruled out in the case of new-onset VT during the last 6 weeks of pregnancy or in the early post-partum period.266 Recommendations for acute termination of VT72 are outlined in ‘Recommendations for the management of arrhythmias’. The choice of prophylactic antiarrhythmic drug therapy relates to the presence of underlying structural heart disease and LV function Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026