Arrhythmias during pregnancy. PDF
Preview Arrhythmias during pregnancy.
Arrhythmias in Pregnancy Dr Leisa Freeman Norfolk & Norwich University Hospital NHS Foundation Trust Disclosures – support from Pfizer for this meeting. Norfolk & Norwich University Hospital UK Heart rate awareness in pregnancy: normal hearts • Awareness of ↑ HR common – esp 3rd Tr • “palpitations” usually sinus tachycardia (25%) or ectopic beats/N.S arrhythmias (50%) • Reassurance best approach. • Sustained tachycardia – only 0.3% Adamson D, Nelson-Piercy C, Holter in <40 yrs pregnant women. Heart 2007; 93: 1630-6 Uebing, A. et al. BMJ 2006;332:401-406 Norfolk & Norwich University Hospital UK De Novo or predisposed? (normal hearts) • Pregnant state unlikely to generate new arrhythmias – but may expose • Atrial stretch, oestrogen & ßHCG (effect on ion channel expression), ↑sympathetic tone; ↑ EDV – bigger heart can sustain re-entry • Careful hx often reveals previous episodes. • AVRT & AVNRT – more common in ♀ • Symptomatic Long QT & drug induced TdP – more common in ♀ • “lone” AFib 70% ♂ ; rare in pregnancy. But T4 ↑; M.Sten or structural heart dis predispose • WPW 60-70% ♂ but preg ♀ have increased episodes during pregnancy Norfolk & Norwich University Adamson D, Nelson-Piercy C, Hospital UK Heart 2007; 93: 1630-6 Frequency of arrhythmias in normal heart pregnancy • SVT • 34% increase in the risk of new onset SVT & 29% exacerbation during pregnancy * • 24/100,000 admissions:SVT – most 3rd Trimester** • VT • RVOT tachycardia, Catecholaminergic VT, Mahaim pathway – (monomorphic, lbbb inferior axis) Rx BB • RBBB VT from LV Rx Verapamil • Long QT – increased risk seems to be post partum but not peri pregnancy*** continue BB post partum • Long QT Pre P% Preg % PPartum% • ∆ known 0.9 4.5 9.1*** New onset 0 1.8 9.0*** Tawanet et al Am J Card 1993 * * ** Li J,et al Clin Cardiol. 2008 ;31(11):538-41. *** Rashba et al Circ 1998 Norfolk & Norwich University Hospital UK Pre existing arrhythmias • 73 women, 87 pregnancies with previous arrhythmias.* • 44% had reccurrence during pregnancy, delivery or early post partum • 36 PSVT 50% recurrence • 23 PAF or A fl 52% recurrence • 22 VT 27% recurrence • **Ablate if possible pre conception or before next pregnancy** • *Silverside CK et al AJC 2006: 1206-1212 Norfolk & Norwich University Hospital UK • Congenital Long QT • Acquired Long QT • ♀predominance • Correct electrolytes increased risk post inc Mg partum • Removal of Class 1 & • Beta blocker III drugs associated with • Macrolide antibiotics decrease risk of • Antidepressants cardiac events – • Some antipsychotics continue post partum • ICD for aborted SCD Norfolk & Norwich University Hospital UK Structural heart conditions: arrhythmia in pregnancy • Palliated CHD – associated with re-entrant tachycardia or volume/pressure overload eg ASD, dTGA, ToF, TCPC circulation • Unpalliated CHD – eg Ebstein, ccTGA, or valvar lesions (eg bicuspid Ao or Pul valves) • Acquired valvular HD 2o Rh fever – especially Mitral stenosis or 2o endocarditis (inc TV IVDA) • Cardiomyopathy – eg ARVC, COCM, HOCM Norfolk & Norwich University Hospital UK • 62 pregnant women with HD / 599 pregnancies* – Cardiac lesions: • – congenital 445 (74%), acquired 127 (22%) – arrhythmic 27 (4.5%) • 13% cardiac event during pregnancies; 55% occurred prepartum (pul oedema & arrhythmia • DC cardioversion was performed in 2 patients • **8/90 pregnant women with HD: 2 SVT • 6VT (all tx BB) • *Circulation: 2001: 104: 515-521 • ** Khairy et al 2008 Norfolk & Norwich University Hospital UK 27/599 (4.5%) pre preg arrhythmias (risk score 1 for future events) In 14/80 pts with events (11.2%) were arrhythmias . 10 SVT, 2VT; 1 bradycardia Siu et al Circulation: 2001: 104: 515-521 Norfolk & Norwich University Hospital UK Single centre university hospital pregnancy outcomes from patients reviewed in maternal cardiology clinic. Rafiq I, Rekhraj S, Parthasarathy H, FREEMAN L, Stanley K. Heart 2008:94(Suppl II):A89 24/95 with arrhythmias in pregnancy 22 SVT; 2 VT 13 had „normal heart‟ arrhythmias 11 – structural heart disease 9 SVT 2 - VT (1 cocm; 1 PA/VSD) No deaths 95 pregnancies in 79 women 2000-2006 seen in maternal cardiology Grown up Congenital heart Diseases (GUCH) clinic Cardiomyopathy Arrhythmais Ischaemic heart disease Miscellaneous Norfolk & Norwich University Hospital UK
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