Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

Characterization of cardiac arrhythmias and maternal-fetal outcomes in pregnant women: A prospective cohort study

INTRODUCTION AND OBJECTIVES

Cardiovascular disease is a common cause of morbidity and mortality in pregnant women. Arrhythmias are common complications during pregnancy; however, the data are limited. Our goal was to characterize the epidemiology, clinical presentation, and impact of cardiac arrhythmias on maternal-fetal outcomes.

METHODS

A prospective cohort study from the Colombian Registry of Pregnancy and Cardiovascular Disease was carried out from 2016 to 2019. All patients with tachyarrhythmia or bradyarrhythmia and a minimum follow-up of six months after delivery were included. The primary outcome was a composite of cardiac events defined as pulmonary edema, symptomatic sustained arrhythmia requiring specific therapy, stroke, cardiac arrest, or maternal death. Secondary outcomes were other cardiac, neonatal, and obstetric events.

RESULTS

Arrhythmias were the most common cause of referral to our dedicated cardio-obstetric clinic. A total of 92 patients were included, mean age 27±6 years; 8.7% had previous structural heart disease, and cardiology consultation was delayed in 79.4%. The most common arrhythmias were premature ventricular contractions (33%) and paroxysmal reentrant supraventricular tachycardias (15%); 11 patients (12%) had cardiac implantable electronic devices. Cardiac events occurred in 18.4% of patients, obstetric events occurred in 6.5%, and one caesarean was indicated in the context of symptomatic severe mitral stenosis. Adverse neonatal outcomes were observed in 24.3% of newborns.

CONCLUSIONS

Arrhythmias were the most common cause of referral to a dedicated cardio-obstetric clinic; most had a benign course. Adverse maternal cardiovascular outcomes were significant and there was a high rate of obstetric and neonatal adverse events, underlining the importance of multidisciplinary care.

Gastric electrical stimulation is safe during pregnancy and delivery: Results from a French cohort

BACKGROUND

Gastric electrical stimulation (GES) is an effective therapy in medically refractory chronic nausea and vomiting. GES is assumed to be a contraindication for pregnancy. We examined the safety of GES during pregnancy and its clinical impact on vomiting symptoms.

METHODS

A retrospective study was performed in two tertiary centers including all female patients of childbearing age implanted with GES. Patients without pregnancy while on GES were asked about their desire and concerns about pregnancy. Patients who were pregnant while on GES therapy were interviewed about the course of the pregnancy and labor, as well as the health of the children.

KEY RESULTS

Among 91 patients implanted at childbearing age, 54 patients without pregnancy answered the questionnaire. Nine patients (16.7%) reported a desire for pregnancy and five patients (7.4%) reported worries about the safety of GES during pregnancy. Sixteen pregnancies were reported in 10 patients. All pregnancies ended in a live birth with premature birth in 12 pregnancies (75.0%). No health concern was currently noted in these children. No severe GES-related complications occurred during pregnancy with only pain at the implantation site reported during 3 pregnancies (18.8%). The severity and frequency of nausea and vomiting significantly increased during the first trimester (p = 0.04 and p = 0.005, respectively) and decreased after the delivery, becoming lower than before the pregnancy (p = 0.044 and p = 0.011, respectively).

CONCLUSION & INFERENCES

Patients are concerned regarding pregnancy while being treated with GES. No serious maternal or fetal complications related to GES were noted in our cohort.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Management of Complete Heart Block in a Pregnant Woman with Systemic Lupus Erythematosus-Associated Complications: Treatment Considerations and Pitfalls

We present a case of a pregnant woman with systemic lupus erythematosus (SLE) who was diagnosed with asymptomatic complete heart block (CHB) during pregnancy. To evaluate possible risks and benefits of pacemaker (PM) implantation, a multidisciplinary counselling board was held. Its recommendation was to perform PM implantation to prevent intra-uterine growth restriction from insufficient cardiac output using a fluoroscopic protective shield. The procedure was performed without complications and established permanent pacing on onwards ECG examinations. The patient subsequently gave birth to a healthy newborn. After a retrospective clinical case evaluation and review of relevant literature, a presumptive association between CHB and the primary diagnosis was proposed. Above that, pregnant women with SLE who develop hypertension are commonly treated with methyldopa, which may cause conduction abnormalities. Clinical recommendations for young female patients expecting pregnancy are lacking in this area. Careful diagnostic and treatment approaches should be used in the management of possible SLE-related complications in women of child-bearing age, focusing on preventable events.

Pregnancy maternal fetal outcomes among pregnancies complicated with atrioventricular block

Background

Atrioventricular block (AVB) during pregnancy is rare. Case study for pregnancy with AVB have been reported but a consensus guideline for peripartum management has not been established. This study aimed to investigate cardiac and obstetric complications and outcomes in our pregnant women with AVB and share our management experience.

Methods

This was a retrospective study. We reviewed a total of 74 pregnant women with AVB who delivered at our tertiary care center in the past 10 years. The patients were categorized into four groups according to the degree of block. The data were analyzed and compared among the four groups of patients.

Results

Regarding the cardiac complications, the cardiac function level showed significant difference among patient groups. The higher NYHA class were observed in patients with higher degree AVB. Pacemaker was placed before delivery in 32/33 patients with III° AVB, 8/25 patients with II° AVB, and 0/16 patient with I° AVB. Other types of arrhythmias except AVB were present in all groups of patients but more frequently observed in type I patients with II° AVB. No other heart abnormalities were observed among the patient groups. Obstetric complications were found in 21 women (28.4%), including premature labor, premature rupture of membranes (PROM), gestational diabetes mellitus (GDM), preeclampsia, etc. The incidence rate of fetal cardiac abnormalities was 6.58%. But no statistical difference was detected among four groups of patients for fetal and maternal complications and fetal cardiac abnormalities (P>0.05). Caesarean section was performed more in patients with high-degree AVB than in patients with low-degree AVB. No maternal or neonatal death in our cases.

Conclusions

Most women with AVB could achieve successful pregnancy and delivery. Patients with II° AVB type II and III° AVB should be monitored vigilantly during pregnancy and post-partum. Temporary pacing before delivery appeared to be beneficial for women with III°AVB, and accurate diagnosis and care by a multidisciplinary team was recommended.

Pregnancy with complete heart block

Pregnancy with complete heart block is rare, its management is not streamlined and requires a multidisciplinary team approach involving the obstetrician, cardiologist, anaesthesiologist and neonatologist. High index of suspicion in a woman with slow heart rate and electrocardiographic examination will ensure the diagnosis of this condition. Such patient can be managed conservatively or may require temporary or permanent pacemaker implantation. We present a 26-year-old primigravida with complete heart block at term pregnancy. She was asymptomatic throughout her pregnancy with pulse rate between 50 and 60 beats per minute. Vaginal delivery was planned under continuous ECG monitoring. Isoprenaline drip and temporary pacemaker were kept stand-by. However, for obstetric reasons caesarean section was performed successfully under spinal anaesthesia without a pacemaker. Method of anaesthesia was planned to keep the haemodynamics stable and drugs causing bradycardia were avoided.

Arrhythmias in Pregnancy

Increasing maternal mortality and incidence of arrhythmias in pregnancy have been noted over the past 2 decades in the United States. Pregnancy is associated with a greater risk of arrhythmias, and patients with a history of arrhythmias are at significant risk of arrhythmia recurrence during pregnancy. The incidence of atrial fibrillation in pregnancy is rising. This review discusses the management of tachyarrhythmias and bradyarrhythmias in pregnancy, including management of cardiac arrest. Management of fetal arrhythmias are also reviewed. For patients without structural heart disease, β-blocker therapy, especially propranolol and metoprolol, and antiarrhythmic drugs, such as flecainide and sotalol, can be safely used to treat tachyarrhythmias. As a last resort, catheter ablation with minimal fluoroscopy can be performed. Device implantation can be safely performed with minimal fluoroscopy and under echocardiographic or ultrasound guidance in patients with clear indications for devices during pregnancy. Because of rising maternal mortality in the United States, which is partly driven by increasing maternal age and comorbidities, a multidisciplinary and/or integrative approach to arrhythmia management from the prepartum to the postpartum period is needed.

Diagnosis and management of arrhythmias in pregnancy

Arrhythmias are the most common cardiac complications occurring in pregnancy. Although the majority of palpitations in pregnancy may be explained by atrial or ventricular premature complexes, the full spectrum of arrhythmias can occur. In this article, we establish a systematic approach to the evaluation and management of arrhythmias in pregnancy. Haemodynamically unstable arrhythmias warrant urgent cardioversion. For mild cases of benign arrhythmia, treatment is usually not needed. Symptomatic but haemodynamically stable arrhythmic patients should first undergo a thorough evaluation to establish the type of arrhythmia and the presence or absence of structural heart disease. This will ultimately determine the necessity for treatment given the potential risks of anti-arrhythmic pharmacotherapy in pregnancy. We will discuss the main catalogue of anti-arrhythmic medications, which have some established evidence of safety in pregnancy. Based on our appraisal, we provide a treatment algorithm for the tachyarrhythmic pregnant patient.

Management of pregnancy and delivery in women with transposition of the great arteries after atrial switch operation: A 16-year single-center experience

AIM

This study aimed to summarize cases of successful pregnancy and delivery in patients with transposition of the great arteries (TGA) after atrial switch operation (ASO), to provide management, clinical experience, and maternal and fetal outcomes.

METHODS

During a 16-year period (2004-2019), we experienced 30 pregnancies in 15 patients after ASO at our institution. We retrospectively reviewed the medical records of the patients.

RESULTS

In 30 pregnancies, there were 21 (70%) live births, five (17%) miscarriages, and four (13%) artificial abortions. There were no maternal or neonatal deaths. Cardiac complications occurred in nine (43%) patients: deterioration of right ventricular (RV) function in one, symptomatic heart failure (HF) in three, supraventricular tachyarrhythmia requiring electrical cardioversion in two, sick sinus syndrome that required pacemaker implantation in two, and hemoptysis in one. Obstetric complications occurred in five (24%). Neonatal complications were premature births (delivery at <37 weeks of gestation) in 15 (71%), and birthweight <2500 g in 18 (86%). The mode of delivery consisted of vaginal delivery (VD) in five (24%), and cesarean section (CS) in 16 (76%).

CONCLUSION

A high incidence of preterm CS and cardiac complications including deterioration of RV function was observed in patients who had undergone ASO for TGA.

Arrhythmias and Pregnancy: Management of Preexisting and New-Onset Maternal Arrhythmias

Arrhythmias are the most common cardiovascular complication of pregnancy in women with and without structural heart disease. Appropriate maternal diagnosis and management is of utmost importance to optimize maternal and fetal outcomes. A multidisciplinary care approach with cardiology, maternal fetal medicine, anesthesia, and pediatrics is important for preconceptional, pregnancy, and delivery planning.

Atrioventricular Block in Pregnancy: 15.8 Seconds of Asystole

Atrioventricular (AV) block in pregnancy is infrequently encountered and there is little management guidance available. We present a case of a 24-year-old G3P1011 at 24 weeks' gestation who presented to the obstetrics and gynecology clinic complaining of palpitations, fatigue, and dyspnea on exertion. Cardiology workup including an electrocardiogram (ECG) and Holter monitor detected second-degree type II (Mobitz) AV block with the longest asystole event lasting 15.8 seconds. 

A St. Jude's dual-chamber pacemaker (Abbott Laboratories, Abbott Park, IL) was implanted immediately. Standard radiation precautions were taken with additional shielding for the fetus. The patient experienced significant improvement in her symptoms. The patient went into labor at 37 3/7 weeks. Due to non-reassuring fetal heart tones, a cesarean section was performed, and a healthy baby girl was born. 

The management of heart block in pregnancy can be divided into involving those who are symptomatic and those who are asymptomatic. Symptoms of heart block can include palpitations, fatigue, dyspnea, and/or syncope; the presence of these symptoms warrants the placement of a pacemaker, preferably during pre-pregnancy or during the first two trimesters, as high-grade heart block is associated with significant mortality. Those who are in their last trimester or postpartum should consider the use of a temporary pacemaker as heart block could be due to pregnancy-related cardiovascular changes. 

For women with heart block, labor and delivery could result in worsening of bradycardia due to uterine contractions displacing blood into the central circulation. Most women with heart block do well in labor and delivery and having a pacemaker is not necessarily an indication for a cesarean section.

The anesthetist as cardiologist: a case of heart block identified in the peripartum period

We describe a case of undiagnosed heart block which was detected during the postpartum surgical repair of a vaginal tear, and the subsequent investigations that confirmed diagnosis of atrio-ventricular heart block.

Predicting postpartum cardiac events in pregnant women with complete atrioventricular block

BACKGROUND

Women with complete atrioventricular block (CAVB) can tolerate hemodynamic changes during pregnancy; however, the incidence of cardiac events in women with CAVB may increase after delivery. The aim of this study was to investigate predictive factors for postpartum cardiac events in pregnant women with CAVB.

METHODS AND RESULTS

Pregnant women with CAVB who received perinatal management at a tertiary cardiac center from 1981 to 2015 were retrospectively reviewed. Univariate and multivariate logistic analyses of postpartum cardiac events were performed. Postpartum cardiac event was defined as cardiopulmonary arrest, cardiac failure, or the need for permanent pacemaker implantation (p-PMI) within 3 months after delivery. A total of 63 pregnancies in 36 women with CAVB were included in this study; 25 had undergone p-PMI before pregnancy. Regardless of p-PMI status, women with CAVB had no further increases in heart rate during the second and third trimesters. No heart failure was found during pregnancy and delivery. Postpartum cardiac events occurred in 9 pregnancies (14.3%) in 8 women with CAVB; 3 had cardiac failure and p-PMI, 3 had cardiac failure, 2 required p-PMI, and 1 had cardiopulmonary arrest. Multivariate analysis showed that perinatal ventricular pause (odds ratio 11.60, 95% confidence interval 1.90-82.18, p<0.01) and family history of CAVB (odds ratio 10.59, 95% confidence interval 1.36-90.56, p=0.03) were associated with postpartum cardiac events.

CONCLUSIONS

All cardiac events occurred during the postpartum period among women with CAVB, and ventricular pause during the perinatal period and a family history of CAVB were predictors of postpartum cardiac events. Close follow-up should be considered during the postpartum period for women with high-risk CAVB.

Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.

Complete Heart Block in Pregnancy: A Report of Emergency Caesarean Section in a Parturient without Pacemaker

Management of women with Complete Heart Block (CHB) presenting without pacing, during pregnancy and labour is debatable. Temporary pacemakers have been routinely inserted for labour and birth probably to withstand any haemodynamic variations. However, due to lack of large scale prospective studies, the necessity of this procedure has not been objectively assessed. Also, the most appropriate anaesthetic technique for caesarean section in women with CHB is yet to be clarified. We report herein the case of a pregnant woman with CHB who had uneventful emergency caesarean delivery under spinal anaesthesia without temporary pacing. She was an unbooked case detected with congenital CHB first time during active labour; echocardiography showed no structural cardiac disease and her heart rate increased with atropine. We suggest further research so that guidelines could be established to prevent unnecessary morbidity and expense of temporary pacemaker insertion. Newly diagnosed cases of asymptomatic CHB in late pregnancy should be worked up for chronotropic responsiveness using atropine and responsive cases may be managed without pacemaker.

Complete atrioventricular block in pregnancy: report of seven pregnancies in a patient without pacemaker

Obstetric management of a woman with a permanent pacemaker in situ is well reported in the literature; but those who present without pacing are still debatable. The necessity for setting the optimal timing or rate of temporary artificial pacing, specifically for labour, has not been objectively assessed. Temporary pacing in most cases reported in the literature might be to withstand the variations in haemodynamic status during delivery and labour. We report a case of a patient with complete heart block without any pacing who had seven pregnancies without any significant changes in haemodynamic status during labour and delivery. Managing a pregnancy without pacing might be an appropriate alternative for women without any underlying cardiac disorder, as it will not lead to significant changes in the haemodynamic system.

Management of complete heart block during pregnancy

A 22-year-old second gravida presented to the antenatal clinic at 28 weeks of gestation with frequent fainting attacks (2-3 episodes/day), palpitations and dyspnea (New York Heart Association Functional Classification II). Her pulse rate was 40 b.p.m. A 12-lead electrocardiogram and 24-h Holter revealed complete heart block. A transvenous permanent pacemaker (ventricular demand rate-responsive), paced at a rate of 60 pulses/min, was successfully implanted. A multidisciplinary approach was taken and the patient delivered a healthy baby boy of 2.8 kg at 38 weeks. She remained asymptomatic and was discharged in good condition. Management varies from expectant management to temporary pacemaker insertion to permanent pacing during pregnancy. In a young patient with sinus bradycardia, the primary criterion for a pacemaker is the concurrent observation of a symptom (e.g., syncope) with bradycardia (e.g., heart rate 35-40 b.p.m. or asystole for 3 s). Symptomatic pregnant women should always be counseled for a permanent pacemaker.