Effectiveness of Implanted Cardiac Rhythm Recorders With Electrocardiographic Monitoring for Detecting Arrhythmias in Pregnant Women With Symptomatic Arrhythmia and/or Structural Heart Disease

Abstract

IMPORTANCEArrhythmias are an important cause of maternal morbidity and mortality but remain difficult to diagnose. OBJECTIVE To compare implantable loop recorder (ILR) plus 24-hour Holter electrocardiographic (ECG) monitoring with standard 24-hour Holter ECG monitoring alone in terms of acceptability, ability to identify significant arrythmias, and effect on management and pregnancy outcome in women who were symptomatic or at high risk of arrythmia because of underlying structural heart disease. DESIGN, SETTING, AND PARTICIPANTS This single-center, prospective randomized clinical trial recruited 40 consecutive patients from the Cardiac Disease and Maternity Clinic at Groote Schuur Hospital in Cape Town, South Africa. Pregnant patients with symptoms of arrhythmia and/or structural heart disease at risk of arrhythmia were included. INTERVENTION Patients were randomized to standard care (SC; 24-hour Holter ECG monitoring [n = 20]) or standard care plus ILR (SC-ILR; 24-hour Holter ECG monitoring plus ILR [n = 20]). Only 17 consented to ILR insertion, and the 3 who declined ILR were allocated to the SC group. MAIN OUTCOMES AND MEASURES Arrhythmias considered included atrial fibrillation, atrial flutter, premature ventricular complexes, supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation.RESULTS Among the 40 women in this trial, the mean (SD) age was 28.4 (5.5) years. Holter monitoring detected arrhythmias in 3 of 23 patients (13%) in the SC group and 4 of 17 patients (24%) in the SC-ILR group compared with 9 of 17 patients (53%) patients who had arrhythmias detected by ILR. Seven patients (4 with supraventricular tachycardia, 1 with premature ventricular complexes, and 2 with paroxysmal atrial fibrillation recorded by ILR) did not have arrhythmias detected by 24-hour Holter monitoring. Three of these 7 patients (43%) had a change in management as a result of their ILR recordings. There were no maternal deaths. However, the SC group had a significantly lower mean (SD) gestational stage at delivery (35 [5] weeks vs 38 [2], P = .04). CONCLUSIONS AND RELEVANCEThe ILR was better than 24-hour Holter monitoring in detecting arrhythmias, which led to a change in management for a significant proportion of patients. Our findings suggest that ILR may be beneficial for pregnant women at risk of arrhythmia.

Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy

“…Women in WHO class II should be assessed during each trimester and those in class III assessed monthly or bi‐monthly. A recent randomized study on the effectiveness of implanted cardiac rhythm recorders for detecting arrhythmias in pregnant women with structural heart disease suggests that those devices could be considered in HCM facilitating early detection of arrythmia or re‐assurance of the mother and avoiding harm‐full medication 3,50 . Beta‐blockers should be continued if they are already being taken and foetal growth monitored.…”

“…A recent randomized study on the effectiveness of implanted cardiac rhythm recorders for detecting arrhythmias in pregnant women with structural heart disease suggests that those devices could be considered in HCM facilitating early detection of arrythmia or re-assurance of the mother and avoiding harm-full medication. 3,50 Beta-blockers should be continued if they are already being taken and foetal growth monitored. Beta-blockers should be started when new symptoms occur, for rate control in atrial fibrillation and to suppress ventricular arrhythmias, with verapamil as a second choice.…”

Interpreting the Need for Implantable Loop Recorder Monitoring in Pregnant Women at High Risk of Arrhythmias

“…Of these patients, 8 also had permanent implantable cardioverter-defibrillators inserted . These data show that patients with peripartum cardiomyopathy remain at high risk of arrhythmias for prolonged periods and could see considerable benefit from monitoring as described by Sliwa et al…”

“…To the Editor We congratulate Sliwa et al for their excellent analysis on the use of implantable loop recorders (ILRs) in addition to 24-hour Holter electrocardiography to improve the detection of arrhythmias in pregnant women with cardiovascular disease compared with 24-hour Holter electrocardiography alone. We believe these findings to be pertinent, as a 2019 study by Moulig et al observed 66 patients with peripartum cardiomyopathy over 5 years and found that 17% had arrhythmias, including paroxysmal supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation.…”

Rhythmusstörungen in der Schwangerschaft

“…Mittels ambulanter Langzeit-EKG-oder neuerdings intensivierter "Smart-Watch"-EKG-Aufzeichnungen sollte versucht werden, eine Korrelation zwischen Beschwerden und Rhythmusstörungen zu erzielen. In einer Vergleichsstudie an 40 Schwangeren mit Palpitationen und/oder struktureller Herzerkrankung konnten mittels Langzeit-EKG-Dokumentation bei 13-24 % Rhythmusstörungen detektiert werden, während ein implantierter Ereignisrekorder bei 9 von 17 Patientinnen (53 %) Rhythmusstörungen aufzeichnete [7]. In Einzelfällen kann eine kardiale MRT-Diagnostik sinnvoll sein, wobei Gadolinium in der Schwangerschaft vermieden werden sollte.…”