Batra AS, Silka MJ, Borquez A, Cuneo B, Dechert B, Jaeggi E, Kannankeril PJ, Tabulov C, Tisdale JE, Wolfe D; American Heart Association Clinical Pharmacology Committee of the Council on Clinical Cardiology, Council on Basic Cardiovascular Sciences, Council on Cardiovascular and Stroke Nursing, Council on Genomic and Precision Medicine, and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Circulation. 2024 Mar 5;149(10):e937-e952. doi: 10.1161/CIR.0000000000001206. Epub 2024 Feb 5.PMID: 38314551 Free article. Review.
Take home points:
- This AHA statement updates the diagnosis and pharmacologic treatment of the fetus and neonate with both tachyarrhythmia and bradyarrhythmia.
- Future directions for aspects with inadequate research are also presented
Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Fetal Cardiology Journal Watch:
Clinically significant fetal and neonatal arrhythmias including SVT, atrial flutter, and AV block are common and an important cause of morbidity and mortality. Evidence-based algorithms for management are limited, so this scientific statement was written to identify best practices, provide indications and types of pharmacologic treatment, and limit potential toxic exposures.
The authors begin by defining the various arrhythmias, as well as provide echo Doppler images for fetal arrhythmias. Another diagnostic (e.g. tumors, cardiomyopathies, diverticula) and etiologic reasons (e.g. Graves’ disease, LQTS, anti-Ro/SSA, etc.) for the arrhythmias are discussed.
Detailed pharmacologic information was listed and treatment algorithms for SVT/atrial flutter (Figure 2) and AV block (Figure 3) provided. For the former, based on more recent data and meta-analysis, in fetuses without hydrops, flecainide for fetal SVT and sotalol for fetal atrial flutter are superior as a monotherapy in conversion to sinus rhythm. For the latter, the authors discuss the use of home handheld monitoring for the progression of sinus rhythm to AV block to allow for treatment within a window that may have a clinical impact. This is important given the limited evidence of efficacy of treatment after complete heart block develops, and the potential adverse effects of these medications on the fetus and mother. A section on co-management with cardio-obstetric subspecialists and maternal fetal medicine/OB was very useful, given the maternal and delivery issues that are important in management decisions. Given the achievable goal of a vaginal delivery of a term, nonhydropic fetus in sinus rhythm, the authors write that the preterm birth rate should be no higher than 7.6% as there are significantly higher risks of morbidity and mortality in fetuses born preterm.
Postnatal recurrence, first-time neonatal arrhythmia management, pharmacology, and role of nursing are discussed at the end of the statement. They also mention changes from the 2014 scientific statement, including a greater appreciation of bradycardia, treatment instead of delivery of the near-term fetus with SVT, and weaning of antiarrhythmics after sustained conversion to sinus rhythm, even during the fetal period.