New guidelines for cardiovascular disease management during pregnancy: Risk-dependent action plans and upgraded recommendations of catheter ablation

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New guidelines for the management of cardiovascular diseases during pregnancy, including upgraded recommendations of catheter ablation and risk-dependent action plans, were presented by Carina Blomström-Lundqvist, Uppsala University, Uppsala, Sweden, at the European Society of Cardiology Congress (ESC; 25–29 August, Munich, Germany).

According to Blomström-Lundqvist, atrial fibrillation (AF) and paroxysmal supraventricular tachycardia (PSVT) are the most frequent arrhythmias in pregnancy; however, both are usually benign and can be treated effectively.

Regarding pre-pregnancy recommendations, Blomström-Lundqvist stressed their importance, noting that risk assessments and counselling should be offered to all women with known or suspected congenital or acquired cardiovascular and aortic disease, as an implantable cardioverter defibrillator (ICD) or ablation may need to be considered. Furthermore, she stated that risk assessments are recommended in all women with cardiac diseases of childbearing age after conception. She emphasised that once the women become pregnant, it is important to plan for the medication treatment during pregnancy—especially in relation to channelopathies.

Discussing the acute management of supraventricular tachycardia (SVT) and AF for PSVT, Blomström-Lundqvist noted that the class 1 recommendation is for vagal manoeuvres, followed by adenosine if these are to fail. Additionally, for tachycardias that are haemodynamically unstable, including patients with pre-excited AF, electrical cardioversion is the first line of choice. The method is seen as safe, as foetal blood flow is not compromised, there is a low risk of foetal arrhythmia, and foetal heart rate should be controlled after the cardioversion.

If the first line of drugs fail, beta-1-selective blockers should be considered for acute conversion of PSVT (class IIa indication), while in selected cases, ibutilide or flecainide may be considered for termination of atrial flutter and AF in stable patients with structurally normal hearts.

In relation to long-term management of SVT and AF, beta-blockers or calcium channel blockers are recommended for the prevention of SVT, provided the patient has no pre-excitation on resting ECG. Flecainide or propafenone are recommended for the prevention of SVT in patients with Wolff-Parkinson-White syndrome. Blomström-Lundqvist acknowleged that although beta-blockers would be first choice, diagoxin and verapamil (unless there is preexcitation on ECG) could be used for rate control of atrial tachycardia or AF, as well as catheter ablation, provided the centre has a high level of expertise using the electroanatomical system for cases of drug-refractory and poorly tolerated SVT.

Regarding the acute management of ventricular tachyarrhythmias (VT), electrical cardioversion is again preferred for both unstable and stable VT. ICD is preferably recommended prior to pregnancy for patients with a clinical indication in the long-term management of VT or ventricular fibrillation, but is also possible during pregnancy—preferably using echo-cardio-graphic guidance or mapping. Beta-blocking agents are recommended to be continued during pregnancy and post-partum in patients with long QT syndrome or catecholaminergic polymorphic VT.

With respect to the new 2018 guidelines, Blomström-Lundqvist stated that they have upgraded the recommendation of catheter ablation for SVT. Specifically, common types such as atrioventricular nodal re-entrant tachycardia and tricuspid atrial flutter have been upgraded from IIb to IIa.

During the presentation, Blomström-Lundqvist pointed to surveillance levels at time of delivery in women with arrhythmias. She explained that physicians should first classify the patient within the three levels of risk for arrhythmia (low, medium or high), given the provided definitions, then take action dependent on the surveillance level; another new recommendation included in the guidelines. She gives the example: if a patient belongs to the low-risk group, physicians should consult a cardiologist, whereas if the patient belongs to the medium or high risk, a consultation with a multidisciplinary team including arrhythmologists at a specialised centre should be arranged. Furthermore, caesarean delivery is recommended if a patient has a very high risk, as well as arterial line.

Other examples included that medium to high-risk patients should undergo an intravenous administration of a beta-blocker, as well as the potential delivery at a thoracic operating theatre, and even preparations for transfer to a cardiac intensive care unit post-partum (for high-risk patients) if necessary.

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