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2023 HRS Expert Consensus Statement on Management of Arrhythmias During Pregnancy

Clinical Quick Reference — SVT, AF, VT, and Drug Safety in Pregnant Patients

Published: Heart Rhythm, Volume 20, No. 10 (October 2023)
Societies: HRS, ACC, ACOG, AHA, PACES, LAHRS, SMFM, EHRA, APHRS
DOI: 10.1016/j.hrthm.2023.05.017
View Full Guideline PDF

Overview & Epidemiology

Arrhythmias are common in pregnancy due to physiologic and autonomic changes. Most are benign.

Pearl: Pregnancy increases sympathetic tone and heart rate (10–20 bpm), creating an arrhythmogenic substrate. However, most arrhythmias are benign and resolve after delivery.

Overarching Principles

General Management

  • 1 Maintain treatment during pregnancy, delivery, and postpartum; use drugs with longest safety record; lowest effective dose
  • 1 Inform patients of regulatory precautions, drug interactions, and fetal risks

Team-Based Care & Shared Decision-Making

Multidisciplinary Team

  • 1 Cardio-obstetrics team includes: maternal-fetal medicine, cardiologist/EP, pediatric EP, anesthesiologist, neonatologist
  • 1 Consultation with EP expertise recommended, preferably with pregnancy experience

Genetic Testing

Inherited Arrhythmia Syndromes

  • 1 For family history of IAS or ACM: clinical evaluation and genetic counseling recommended, ideally by cardiac genetics team

Cardioversion During Pregnancy

Recommendations

  • 1 For unstable SVT/VT: direct current synchronized cardioversion with standard energy dosing
  • 1 For stable, refractory SVT: elective cardioversion with fetal evaluation
  • 1 Place electrodes avoiding breast tissue for optimal current delivery

Safety: Safe in all trimesters; no adverse fetal effects from standard energy; fetal monitoring advised.

Radiation Exposure During Cardiac Procedures

Recommendations

  • 1 Maternal benefit from controlling tachycardia prioritized; minimize fetal radiation to as low as reasonably achievable (ALARA)
  • 1 Techniques (3D mapping, zero fluoroscopy) recommended to minimize radiation
  • 1 Cardio-obstetrics team for high-risk procedures to manage complications
  • 3 Pelvic lead apron provides no substantial fetal protection; not recommended

Dose: Typical catheter ablation <50 mGy; teratogenicity threshold >100 mGy.

Anesthesia Considerations

Recommendations

  • 1 General anesthesia preferred for hemodynamic instability
  • 1 Left lateral tilt in late pregnancy (>26 weeks) to minimize aortocaval compression
  • 1 Review medications to avoid exacerbating arrhythmias
  • 1 Intraprocedural fetal monitoring recommended for hemodynamically unstable patients
Avoid QT-prolonging drugs: Ondansetron, droperidol, quinolones, macrolides, antihistamines, sympathomimetics.

Delivery & Lactation

Recommendations

  • 1 Mode of delivery determined by obstetric factors; continue antiarrhythmic therapy
  • 1 Adequate pain control (neuraxial anesthesia preferred) to prevent catecholamine surges
  • 1 Breastfeeding safe with most antiarrhythmic agents
  • 1 For life-threatening arrhythmias refractory to other therapy: amiodarone use requires shared decision-making weighing fetal/neonatal toxicity vs. maternal benefit

Diagnosis of Palpitations

Diagnostic Approach

  • 1 Sinus tachycardia/extrasystoles with normal evaluation: reassure without further testing
  • 1 New-onset syncope (especially first trimester): enhanced evaluation with echo + close monitoring
  • 1 Detailed history, exam, 12-lead ECG, targeted blood work for all palpitations
  • 2a Implantable cardiac monitor (ICM) reasonable for unexplained palpitations with syncope or structural disease suspicion
  • 3 EPS not recommended as first-line diagnostic test without documented arrhythmia

Diagnosis & Management of Syncope

Syncope Evaluation

  • 1 Initial evaluation: detailed history, orthostatic vitals, 12-lead ECG, targeted labs
  • 1 New-onset syncope (especially first trimester): enhanced evaluation with echo + monitoring
  • 1 Cardiac origin suspected: additional imaging per cardiology/EP evaluation
  • 1 Recurrent unexplained syncope: ICM recommended
  • 3 Reflex-mediated with normal exam/ECG: further testing not beneficial
  • 3 EPS not indicated without cardiac disease

Management

Management of Supraventricular Tachycardia (SVT)

Acute SVT

Acute Management

  • 1 Vagal maneuvers first-line (Valsalva, ice to face)
  • 1 IV adenosine for stable patients; safe, short-acting (t½ <10 sec)
  • 1 Synchronized cardioversion for unstable patients
  • 2a IV beta-blocker (metoprolol/propranolol) if adenosine fails/contraindicated
  • 2b IV calcium channel blocker (verapamil/diltiazem) or IV procainamide as alternatives

Chronic SVT

Prophylaxis

  • 1 Beta-blockers (metoprolol/propranolol) or digoxin first-line; verapamil second-line
  • 1 For WPW: oral flecainide or propafenone recommended
  • 2a For refractory: flecainide, propafenone, or sotalol reasonable
  • 2a Catheter ablation reasonable if medication-refractory
Pearl: Adenosine is first-line for hemodynamically stable SVT in pregnancy; safe short-acting profile; can repeat if needed.

Management of Atrial Fibrillation & Flutter

Acute Management

  • 1 Hemodynamic compromise: direct current cardioversion with standard energy
  • 1 Rate control: IV beta-blockers first-line; digoxin or calcium channel blockers second-line
  • 1 Persistent symptoms/RVR: elective cardioversion with anticoagulation
  • 1 High thromboembolic risk: anticoagulation recommended

Anticoagulation Strategy

Use low-dose warfarin (<5 mg daily) throughout pregnancy if anticoagulation indicated; transition to LMWH/UFH near delivery. Avoid DOACs.

Use CHA₂DS₂-VASc Calculator and HAS-BLED Calculator to stratify risk.

Chronic AF/AFL

Management of Ventricular Tachycardia

Acute & Chronic VT

  • 1 Hemodynamic compromise: synchronized cardioversion
  • 1 Idiopathic VT (stable): IV beta-blockers or adenosine first-line
  • 1 Hemodynamically stable: IV procainamide recommended
  • 1 Refractory: cardioversion with standard energy
  • 1 ICD indicated: placement recommended with radiation minimization
  • 1 Chronic recurrent: beta-blockers +/− other agents
  • 1 Refractory VT: flecainide, sotalol, or mexiletine
  • 2a Catheter ablation reasonable if medications fail

Antiarrhythmic Drug Safety

Drug Safety Matrix: Pregnancy & Breastfeeding

Drug Pregnancy Breastfeeding
Propranolol Safe Safe
Metoprolol Safe Safe
Nadolol Safe Safe
Atenolol Risk (fetal growth restriction) Caution
Digoxin Safe Safe
Flecainide Safe (avoid if SHD) Safe
Propafenone Safe (avoid if SHD) Safe
Mexiletine Caution Safe
Sotalol Safe Safe
Amiodarone Caution (use only if life-threatening) Requires shared decision-making
Avoid atenolol in pregnancy: Associated with fetal growth restriction. Use propranolol or metoprolol instead.

Breastfeeding Drug Safety

Safe agents: Digoxin, propranolol, metoprolol, nadolol, quinidine, sotalol, flecainide, propafenone have minimal breast milk excretion.

Higher excretion: Mexiletine and amiodarone accumulate in breast milk; monitor infant drug levels in selected cases.

For detailed breastfeeding information, consult LactMed (NCBI).

Related Calculators

Use these tools to support clinical decisions:

Corrected QT (QTc)

Monitor QT intervals during antiarrhythmic therapy to screen for drug-induced prolongation.

CHA₂DS₂-VASc Score

Assess stroke risk in pregnant patients with atrial fibrillation for anticoagulation decisions.

HAS-BLED Score

Evaluate bleeding risk in pregnant patients with AF on anticoagulation therapy.