Antiarrhythmic Drug Use in Pregnancy: Considerations and Safety Profiles
Abstract
:1. Introduction
2. Type of Arrhythmias
- Premature ventricular complex (PVC), which is usually benign.
- Idiopathic VT, particularly arising from the right ventricular outflow tract.
- Inherited arrhythmia syndromes: Brugada syndrome and arrhythmogenic right ventricular cardiomyopathy (ARVC) are well-tolerated during pregnancy. Long QT syndrome shows a low risk of cardiac events during pregnancy, which is increased for 9 months postpartum compared to the healthy population [12]. For catecholaminergic polymorphic ventricular tachycardia (CPVT), beta-blockers and close monitoring are recommended.
- Drug-induced: certain medications, including some antiarrhythmic drugs, can cause QT interval prolongation and potentially lead to ventricular arrhythmias [13].
- Arrhythmia related to structural heart disease: Conditions such as ischemic heart disease, cardiomyopathy, congenital heart disease, myocarditis, or valvular heart disease can predispose pregnant women to ventricular arrhythmias.
3. Potential Risks Associated with the Use of AADs
4. Dealing with the Maternal-Fetal Cardiovascular System and Changes in Pharmacokinetics
5. Classification of Antiarrhythmic Drugs (Vaughan Williams Classification)
- Class Ia: These medications, including quinidine, procainamide, and disopyramide, moderately block sodium channels and have some impact on potassium channels, without affecting atrio-ventricular conduction. As a result, they are helpful for treating atrial and ventricular arrhythmias by slowing conduction velocity, prolonging the action potential duration, and increasing the effective refractory period. Quinidine and procainamide are considered second-line therapies for hemodynamically stable ventricular tachycardia. There is evidence supporting the effectiveness and safety of quinidine in preventing ventricular arrhythmias associated with Brugada syndrome due to periods of increased vagal tone [27].
- Class Ib: These drugs (e.g., lidocaine, mexiletine, and phenytoin) weakly block sodium channels and have minimal effects on action potential duration. They mainly prolong the post-repolarization refractoriness in ventricular cells, making them a suitable therapy for VT, particularly in the context of acute myocardial infarction or ischemia.
- Class Ic: These medications, including flecainide, propafenone, and moricizine, powerfully inhibit sodium channels while having little to no effect on the duration of action potentials. They decrease conduction velocity but only minimally affect the refractory period. These agents are employed in the treatment of atrial and ventricular arrhythmias, but caution should be exercised in patients with structural heart disease due to the risk of arrhythmia. Flecainide and similar drugs are recommended as initial treatment to terminate SVT in patients with known pre-excitation or a history of Wolf–Parkinson–White syndrome, as well as for long-term arrhythmia control.
Safety Profiles of Antiarrhythmic Drugs in Pregnancy
6. Discussion
7. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Safety | Vaughan Williams Class | Drugs | FDA Category | Placental Transfer | Fetal Risk | Use in Fetal Treatment |
---|---|---|---|---|---|---|
- | Adenosine | C | Unknown | Minor | No | |
IB | Lidocaine | B | Yes | Minor | No | |
- | Digoxin | C | Yes | Minor | Yes | |
II | Metoprolol/Propranolol | C | Yes | Minor | No | |
IA | Procainamide | C | Yes | Minor | No | |
IA | Quinidine | C | Yes | Minor | No | |
IB | Mexiletine | C | Yes | Minor | No | |
IC | Flecainide | C | Yes | Minor | Yes | |
IC | Propafenone | C | Yes | Minor | No | |
III | Sotalol | B | Yes | Minor | Yes | |
IV | Verapamil | C | Yes | Moderate | No | |
IV | Diltiazem | C | No | Moderate | No | |
II | Atenolol | D | Yes | Major | No | |
III | Amiodarone | D | Yes | Major | No |
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Mariani, M.V.; Pierucci, N.; La Fazia, V.M.; Cipollone, P.; Micillo, M.; D’Amato, A.; Fanisio, F.; Ammirati, G.; Salagundla, N.; Lavalle, C.; et al. Antiarrhythmic Drug Use in Pregnancy: Considerations and Safety Profiles. J. Cardiovasc. Dev. Dis. 2024, 11, 243. https://doi.org/10.3390/jcdd11080243
Mariani MV, Pierucci N, La Fazia VM, Cipollone P, Micillo M, D’Amato A, Fanisio F, Ammirati G, Salagundla N, Lavalle C, et al. Antiarrhythmic Drug Use in Pregnancy: Considerations and Safety Profiles. Journal of Cardiovascular Development and Disease. 2024; 11(8):243. https://doi.org/10.3390/jcdd11080243
Chicago/Turabian StyleMariani, Marco Valerio, Nicola Pierucci, Vincenzo Mirco La Fazia, Pietro Cipollone, Marco Micillo, Andrea D’Amato, Francesca Fanisio, Giuseppe Ammirati, Nethuja Salagundla, Carlo Lavalle, and et al. 2024. "Antiarrhythmic Drug Use in Pregnancy: Considerations and Safety Profiles" Journal of Cardiovascular Development and Disease 11, no. 8: 243. https://doi.org/10.3390/jcdd11080243