Pharmacotherapeutic strategies for atrial fibrillation in pregnancy

ABSTRACT

Introduction: Atrial fibrillation (AF) is rare during pregnancy but its incidence is expected to rise in parallel to increasing age of women in pregnancy and fraction of pregnant women with structural heart disease.

Areas covered: The authors provide a review of the contemporary evidence on diagnostic work-up and optimal pharmacotherapeutic management of AF in pregnancy. The authors have performed a systematic search for relevant articles using MEDLINE, the COCHRANE LIBRARY, and ClinicalTrials.gov.

Expert opinion: New-onset AF during pregnancy is usually an indication of underlying heart disease and should lead to hospital admission. Patients should be evaluated by an experienced cardiologist or an electrophysiologist. Direct cardioversion is highly effective and safe in pregnant women and should be prioritized over pharmacologic cardioversion with intravenous ibutilide or flecainide. Amiodarone should be avoided if possible. Digoxin and beta-blockers are the rate-control pharmaceutic agents with the widest experience of use. Catheter ablation during pregnancy should be considered in selected cases of atrial flutter refractory to medication and only performed using fluoroless techniques, preferably during the second trimester. Vitamin K antagonists (VKAs) can be used after the first trimester, while low molecular weight heparin should be accompanied by periodic evaluation of anti-Xa factor. Non-VKA oral anticoagulants should be avoided because of limited experience in pregnancy.

KEYWORDS:

• Atrial fibrillation
• pregnancy
• women
• supraventricular arrhythmias
• management

Article highlights

• AF increases mortality and morbidity of the mother and fetus if not treated promptly and must be hospitalized

• AF in pregnancy is usually an indication of underlying heart disease

• Direct cardioversion of AF is effective, safe and preferred over pharmacologic cardioversion in pregnancy

• If pharmacologic cardioversion is selected, ibutilide and flecainide have shown to be effective, while digoxin and beta-blockers are favored if rate control is needed

• Tools currently used for prediction of stroke risk in non-pregnant patients with AF have not been validated in pregnancy

• In the first trimester and after gestational week 36 avoid VKAs and use heparin, preferably low molecular weight heparin under periodic evaluation of anti-Xa factor; after the first trimester and till gestational week 36 use VKAs or low molecular weight heparin

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.