ABC | Volume 114, Nº5, May 2020

Statement Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020 Arq Bras Cardiol. 2020; 114(5):849-942 Table 42 – Recommendations for intravenous vasodilators in acute heart failure Vasodilator Posology Adjustments Nitroglycerin Initial: 10 to 20 mcg/min Maximum: 200 mcg/min Every 15 min Increase: 10 to 20 mcg/min Sodium nitroprusside Initial: 0.3 mcg/kg/min Maximum: 5 mcg/kg/min Every 15 min Increase: 0.3 to 0.5 mcg/kg/min Table 43 – Posology of inotropic and vasoconstrictor drugs Inotropic Posology Maximum dose Dobutamine 2.5 mcg/kg/min Evaluate adjustment every 15 min Hemodynamic effect in up to 2 h 10 to 20 mcg/kg/min Milrinone Initial: 0.375 mcg/kg/min Adjustment every 4 h 0.75 mcg/kg/min 0.5 mcg/kg/min* Levosimendan 0.1 mcg/kg/min Adjustment of 0.05 mcg/kg/min every 4 h Infusion for 24 h 0.15 mcg/kg/min Norepinephrine Initial: 0.1 to 0.2 mcg/kg/min Adjustment every 15 min 1 mcg/kg/min * Dose for patients with renal insufficiency. effects inherent to catecholamines in mind. A recent study has demonstrated a beneficial effect of levosimendan (at a dose of 0.1 mcg/kg/min) in relation to improvements in ventricular function and systemic congestion in pregnant women with AHF due to PPCM. 385 Norepinephrine is indicated in the occurrence of significant arterial hypotension or cardiogenic shock, because, in addition to its vasoconstrictor effect that modulates vasoplegia and redistributes blood flow, it also has an effect on cardiac output. In refractory patients, who do not respond to pharmacological measures, success has been described with the use of temporary mechanical circulatory assist devices, such as intra-aortic balloon (IAB) and extracorporeal membrane oxygenation (ECMO). 386 5.7.2. Arrhythmia The main consideration in practice for poorly tolerated arrhythmias with hemodynamic impact is to prioritize the mother’s life. Nonetheless, treatment should also be weighed in relation to the side effects of antiarrhythmic drugs on maternal cardiac output and uteroplacental flow, oxytocic effects, and proarrhythmogenic effects on the fetus. For these reasons, antiarrhythmic medication, maintenance, discontinuation, or dose optimization should be individualized depending on the type of arrhythmia, gestational period, maternal structural disease, and risk of sudden death. 387 Nodal reentry tachycardia is the most common SVT, followed by atrioventricular tachycardia. Its occurrence is more frequently observed during pregnancy; its treatment in the emergency room, however, does not present modifications in relation to non-pregnant women. In stable patients, the vagal maneuver is the first choice, followed by the use of adenosine, which does not pass the placental barrier, in a bolus (6 mg, followed by 12 mg if it persists). Regarding CCB, verapamil is a good, safe option. In patients with signs of pre-excitation on resting ECG, there is a formal contraindication to the use of beta-blockers. In patients with hemodynamic instability, synchronized electrical cardioversion is indicated. 388 There are no contraindications to cardioversion, and, other than choosing the most appropriate form of sedation, there are no additional precautions. 74 Indication for catheter ablation may be considered during pregnancy, using electromechanical mapping in refractory cases. AF, atrial flutter, and atrial tachycardia are uncommon during gestation in patients without structural cardiac injury. In situations of accelerated ventricular response, there is a risk of hemodynamic degeneration in both the mother and the fetus. In all patients, it is necessary to rule out association with infection, anemia, and thyrotoxicosis. 389 In order to control AF frequency in patients with high ventricular response, lanatoside-C, verapamil, or metoprolol are used. Under hemodynamic instability that might be attributable to tachycardia, synchronized electrical cardioversion is indicated. Patients with AF and heart valve disease have a precise indicated for anticoagulation. In cases that are more clinically stable, when opting for rhythm control, electrical cardioversion is preferable to chemical cardioversion, considering the teratogenic effect of amiodarone and the scarcity of evidence in relation to the safety of high doses of propafenone. In cases where time since onset of arrhythmia exceeds 48 hours, it is necessary to perform transesophageal echo. 390 For patients with flutter, cardioversion is preferable, given its high reversibility rate, observing less than 48 hours of onset or after performance of transesophageal echo to rule out the presence of intracavitary thrombi. The occurrence of VT during gestation is rare, but it may occur in high-risk patients, especially those with structural disease and ventricular dysfunction. Electrical cardioversion is indicated when the maternal clinical picture is unstable. In patients without hemodynamic instability, lidocaine is safe, 919