The ESC Textbook of Cardiovascular Medicine (3 edn)
Cite
This chapter provides the background information and detailed discussion of the data for the following current ESC Guidelines on: 
management of cardiovascular diseases during pregnancy - https://dbpia.nl.go.kr/eurheartj/article/39/34/3165/5078465#135911105
Summary
Pregnant women with pre-existing cardiovascular disease may require drug therapy during their pregnancy and lactation period. There are no uniform recommendations for selection of medications, dosing, and timing of treatment. Possible adverse or teratogenic effects of the drugs on the fetus must be weighed against the maternal indication of drug treatment. This chapter gives an overview of medical treatment options for cardiovascular diseases in pregnancy. Furthermore, sources of evidence which can be used for risk classification of drugs applied during pregnancy are shown.
General principles
There are no uniform recommendations for selection of medications, dosing, and timing of treatment. Possible adverse or teratogenic effects of the drugs on the fetus must be weighed against the maternal indication of drug treatment.
Different sources of evidence can be used for risk classification of drugs applied during pregnancy. Box 53.10.1 shows the classification of the US Department of Health and Human Services (Food and Drug Administration).
Category A (safest).
Category B: either animal reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal reproduction studies have shown an adverse effect that was not confirmed in controlled studies in women.
Category C: either studies in animals have revealed adverse effects on the fetus and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if potential benefits justify the potential risk to the fetus.
Category D: there is evidence of human fetal risk, but the benefits from use in pregnant woman may be acceptable despite the risk (e.g. treatment of life-threatening conditions).
Category X: studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant.
There are also various Internet databases where information is given on the use of drugs in pregnancy (Box 53.10.2).
http://www.embryotox.de—a German database of the Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie of the Berliner Betrieb für Zentrale Gesundheitliche Aufgabe. Recommendations are based on a combination of scientific sources and expert opinions, mainly based on observational data.
http://www.safefetus.com—an English database, arranged comparably to the German database.
Recommendations for drug treatment for specific indications
Treatment of heart failure
Heart failure during pregnancy should be treated according to guidelines on acute and chronic heart failure.2 Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and renin inhibitors are contraindicated because of fetotoxicity.3,4
Nitrates can be used instead of ACE inhibitors/angiotensin II receptor blockers for afterload reduction. Dopamine and levosimendan can be used if inotropic drugs are needed.
When ACE inhibitors are needed during breastfeeding, benazepril, captopril, or enalapril should be preferred.
Beta-blocker treatment is indicated for patients with heart failure.5 Beta1-selective beta blockers, such as metoprolol, are preferred. Most are excreted in breast milk but they are generally well tolerated, although a decrease in fetal heart rate can be observed. Atenolol is classified as a category D agent by the Food and Drug Administration, related to growth retardation in babies receiving atenolol in the first trimester and a higher prevalence of preterm delivery.6
In women suffering from hypertrophic cardiomyopathy, delivery with beta-blocker protection is recommended. Newborns should be supervised for 24–48 h after delivery to exclude hypoglycaemia, bradycardia, and respiratory depression.
Diuretics should only be used if pulmonary congestion is present since they may decrease blood flow over the placenta.7 Furosemide and hydrochlorothiazide are most frequently used.
Aldosterone antagonists should be avoided.4 Spironolactone can be associated with antiandrogenic effects in the first trimester. Eplerenone is more specific for the mineralocorticoid receptor. The knowledge about effects on the human fetus is insufficient and its use is not recommended.
Digoxin may be used in pregnancy. Measurements of blood serum levels are subject to errors in pregnancy and are unlikely to be helpful.8
Treatment of hypertension
Women with pre-existing hypertension are advised to continue their current medication except for ACE inhibitors, angiotensin II antagonists, and direct renin inhibitors (see Chapter 44.7).9,10
Alpha-methyldopa is the drug of choice for long-term treatment of hypertension during pregnancy.11 No teratogenic effects have been documented and alpha-methyldopa has been well tolerated by the fetus.12 The alpha/beta blocker labetalol has comparable efficacy to methyldopa, but is not available in all countries in Europe. If beta blockers are used, metoprolol is recommended.
Calcium channel blockers such as nifedipine (orally) or isradipine (intravenously) are drugs of second choice for hypertension treatment.13
Urapidil is the drug of choice for hypertensive emergencies, where it is applied intravenously under continuous infusion.
Magnesium sulphate intravenously is the drug of choice for treatment of seizures and prevention of eclampsia.
Diuretics should be avoided for hypertension treatment because they may decrease blood flow over the placenta. They are not recommended in preeclampsia.
Antiarrhythmic drugs
For drug dosing information we refer to the published European Society of Cardiology Guidelines on the management of patients with atrial fibrillation, supraventricular arrhythmias, ventricular arrhythmias, and heart failure.2,14,15,16
Vaughan Williams class I antiarrhythmic agents:
Flecainide appears to be relatively safe during pregnancy.17 It passes the placenta well, particularly during the third trimester, explaining the successful treatment of fetal arrhythmias by giving medication to the mother. Teratogenic effects have not been described. The experience with propafenone is limited, although no adverse effects to the fetus have been reported when taken during the third trimester.18
Adverse effects have been described for quinidine.19 Only a few reports are available on the use of lidocaine and mexiletine. Lidocaine is well tolerated by the mother and fetus, although it increases uterine tone and decreases blood flow in the placenta (Table 53.10.1). Less experience is available for mexiletine.20 Teratogenic effects have not been described with these drugs.
Procainamide is considered to be well tolerated and appears to be relatively safe for short-term therapy.21
| Drug | Classification (Vaughan Williams for antiarrhythmic agents) | FDA category | Placenta permeable | Transfer to breast milk (fetal dose) | Adverse effects |
|---|---|---|---|---|---|
Abciximab | Monoclonal antibody with antithrombotic effects | C | Unknown | Unknown | Inadequate human studies; should be given only if the potential benefit outweighs the potential risk to the fetus |
Acenocoumarol | Vitamin K antagonist | X | Yes | Yes (no adverse effects reported) | Embryopathy (mainly 1st trim), bleeding |
Acetylsalicylic acid (low dose) | Antiplatelet drug | B | Yes | Well tolerated | No teratogenic effects known |
Adenosine | Antiarrhythmic | C | No | No | No fetal adverse effects reported (limited human data) |
Aliskiren | Renin inhibitor | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown | Unknown |
Amiodarone | Antiarrhythmic (class III) | D | Yes | Yes | Thyroid insufficiency (9%), hyperthyroidism, goitre, bradycardia, growth retardation, premature birth |
Atenolol | β-blocker (class II) | D | Yes | Yes | Hypospadias (1st trim); birth defects, low birth weight, bradycardia and hypoglycaemia in fetus (2nd, 3rd trim) |
Benazepril | ACE inhibitor | C (1st trim)/D (2nd,3rd trim) | Yes | Yesa (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Bisoprolol | β-blocker (class II) | C | Yes | Yes | Bradycardia and hypoglycaemia in fetus |
Candesartan | Angiotensin II receptor blocker | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown; not recommended | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Captopril | ACE inhibitor | C (1st trim)/D (2nd, 3rd trim) | Yes | Yesa (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Clopidogrel | Antiplatelet drug | C | Unknown | Unknown | No information during pregnancy available |
Colestipol | Lipid-lowering drug | C | Unknown | Yes—lowering fat-soluble vitamins | May impair absorption of fat-soluble vitamins, e.g. vitamin K → cerebral bleeding (neonatal) |
Danaparoid | Anticoagulant | B | No | No | No side effects (limited human data) |
Digoxin | Cardiac glycoside | C | Yes | Yesa | |
Diltiazem | Calcium channel blocker (class IV) | C | No | Yesa | Possible teratogenic effects |
Disopyramide | Antiarrhythmic (class IA) | C | Yes | Yesa | Uterus contraction |
Enalapril | ACE inhibitor | C (1st trim)/D (2nd, 3rd trim) | Yes | Yesa (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Eplerenone | Aldosterone antagonist | C | Unknown | Unknown | Unknown |
Fenofibrate | Lipid-lowering drugs | C | Yes | Yes—potentially carcinogenic | No adequate human data |
Flecainide | Antiarrhythmic (class IC) | C | Yes | Yesa | Unknown |
Fondaparinux | Anticoagulant | B | Yes (max 10%) | No | No side effects (limited human data) |
Furosemide | Diuretic | C | Yes | Well tolerated; milk production can be reduced | Oligohydramnios |
Gemfibrozil | Lipid-lowering drugs | B | Yes | Unknown | Structural brain anomalies, Pierre Robin syndrome |
Glyceryl trinitrate | Nitrate | B | Unknown | Unknown | Bradycardia |
Heparin (low molecular weight) | Anticoagulant | B | No | No | Long-term application: seldom osteoporosis and markedly less thrombocytopenia than unfractonated heparin |
Heparin (unfractionated) | Anticoagulant | B | No | No | Long-term application: osteoporosis and thrombocytopenia |
Hydralazine | Vasodilator | C | Yes | Yesa (1%) | Maternal side effect: lupus-like symptoms; fetal tachyarrhythmias (maternal use) |
Hydrochloro- thiazide | Diuretic | B | Yes | Yes; milk production can be reduced | Oligohydramnios |
Irbesartan | Angiotensin II receptor blocker | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Isosorbide dinitrate | Nitrate | B | Unknown | Unknown | Bradycardia |
Isradipine | Calcium channel blocker | C | Yes | Unknown | Potential synergism with magnesium sulphate may induce hypotension |
Labetalol | α-blocker/β-blocker | C | Yes | Yesa | Intrauterine growth retardation (2nd, 3rd trim), neonatal bradycardia and hypotension (used near term) |
Lidocaine | Antiarrhythmic (class IB) | C | Yes | Yesa | Fetal bradycardia, acidosis, central nervous system toxicity |
Methyldopa | Central α-agonist | B | Yes | Yesa | Mild neonatal hypotension |
Metoprolol | β-blocker (class II) | C | Yes | Yesa | Bradycardia and hypoglycaemia in fetus |
Mexiletine | Antiarrhythmic (class IB) | C | Yes | Yesa | Fetal bradycardia |
Nifedipine | Calcium channel blocker | C | Yes | Yesa (max 1.8%) | Tocolytic; sublingual application and potential synergism with magnesium sulphate may induce hypotension (mother) and fetal hypoxia |
Phenprocoumon | Vitamin K antagonist | X | Yes | Yes (max 10%), well tolerated as inactive metabolite | Coumarin-embryopathy, bleeding |
Procainamide | Antiarrhythmic (class IA) | C | Yes | Yes | Unknown |
Propafenone | Antiarrhythmic (class IC) | C | Yes | Unknown | Unknown |
Propranolol | β-blocker (class II) | C | Yes | Yesa | Bradycardia and hypoglycaemia in fetus |
Quinidine | Antiarrhythmic (class IA) | C | Yes | Yesa | Thrombopenia, premature birth, VIIIth nerve toxicity |
Ramipril | ACE inhibitor | C (1st trim)/D (2nd, 3rd trim) | Yes | Yes (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Sotalol | Antiarrhythmic (class III) | B | Yes | Yesa | Bradycardia and hypoglycaemia in fetus |
Spironolactone | Aldosterone antagonist | D | Yes | Yes (1.2%); milk production can be reduced | Antiandrogenic effects, oral clefts (1st trim) |
Statins, e.g. simvastatin, pravastatin, atorvastatin, fluvastatin | Lipid-lowering drugs | X | Yes | Unknown | Congenital anomalies |
Ticlopidine | Antiplatelet | B | Unknown | Unknown | Unknown |
Valsartan | Angiotensin II receptor blocker | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Verapamil | Calcium channel blocker (Class IV) | C | Yes | Yesa | Bradycardia, atrioventricular block, hypotension |
Warfarin | Vitamin K antagonist | X | Yes | Yes (max 10%), well tolerated as inactive metabolite | Coumarin-embryopathy, bleeding |
| Drug | Classification (Vaughan Williams for antiarrhythmic agents) | FDA category | Placenta permeable | Transfer to breast milk (fetal dose) | Adverse effects |
|---|---|---|---|---|---|
Abciximab | Monoclonal antibody with antithrombotic effects | C | Unknown | Unknown | Inadequate human studies; should be given only if the potential benefit outweighs the potential risk to the fetus |
Acenocoumarol | Vitamin K antagonist | X | Yes | Yes (no adverse effects reported) | Embryopathy (mainly 1st trim), bleeding |
Acetylsalicylic acid (low dose) | Antiplatelet drug | B | Yes | Well tolerated | No teratogenic effects known |
Adenosine | Antiarrhythmic | C | No | No | No fetal adverse effects reported (limited human data) |
Aliskiren | Renin inhibitor | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown | Unknown |
Amiodarone | Antiarrhythmic (class III) | D | Yes | Yes | Thyroid insufficiency (9%), hyperthyroidism, goitre, bradycardia, growth retardation, premature birth |
Atenolol | β-blocker (class II) | D | Yes | Yes | Hypospadias (1st trim); birth defects, low birth weight, bradycardia and hypoglycaemia in fetus (2nd, 3rd trim) |
Benazepril | ACE inhibitor | C (1st trim)/D (2nd,3rd trim) | Yes | Yesa (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Bisoprolol | β-blocker (class II) | C | Yes | Yes | Bradycardia and hypoglycaemia in fetus |
Candesartan | Angiotensin II receptor blocker | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown; not recommended | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Captopril | ACE inhibitor | C (1st trim)/D (2nd, 3rd trim) | Yes | Yesa (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Clopidogrel | Antiplatelet drug | C | Unknown | Unknown | No information during pregnancy available |
Colestipol | Lipid-lowering drug | C | Unknown | Yes—lowering fat-soluble vitamins | May impair absorption of fat-soluble vitamins, e.g. vitamin K → cerebral bleeding (neonatal) |
Danaparoid | Anticoagulant | B | No | No | No side effects (limited human data) |
Digoxin | Cardiac glycoside | C | Yes | Yesa | |
Diltiazem | Calcium channel blocker (class IV) | C | No | Yesa | Possible teratogenic effects |
Disopyramide | Antiarrhythmic (class IA) | C | Yes | Yesa | Uterus contraction |
Enalapril | ACE inhibitor | C (1st trim)/D (2nd, 3rd trim) | Yes | Yesa (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Eplerenone | Aldosterone antagonist | C | Unknown | Unknown | Unknown |
Fenofibrate | Lipid-lowering drugs | C | Yes | Yes—potentially carcinogenic | No adequate human data |
Flecainide | Antiarrhythmic (class IC) | C | Yes | Yesa | Unknown |
Fondaparinux | Anticoagulant | B | Yes (max 10%) | No | No side effects (limited human data) |
Furosemide | Diuretic | C | Yes | Well tolerated; milk production can be reduced | Oligohydramnios |
Gemfibrozil | Lipid-lowering drugs | B | Yes | Unknown | Structural brain anomalies, Pierre Robin syndrome |
Glyceryl trinitrate | Nitrate | B | Unknown | Unknown | Bradycardia |
Heparin (low molecular weight) | Anticoagulant | B | No | No | Long-term application: seldom osteoporosis and markedly less thrombocytopenia than unfractonated heparin |
Heparin (unfractionated) | Anticoagulant | B | No | No | Long-term application: osteoporosis and thrombocytopenia |
Hydralazine | Vasodilator | C | Yes | Yesa (1%) | Maternal side effect: lupus-like symptoms; fetal tachyarrhythmias (maternal use) |
Hydrochloro- thiazide | Diuretic | B | Yes | Yes; milk production can be reduced | Oligohydramnios |
Irbesartan | Angiotensin II receptor blocker | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Isosorbide dinitrate | Nitrate | B | Unknown | Unknown | Bradycardia |
Isradipine | Calcium channel blocker | C | Yes | Unknown | Potential synergism with magnesium sulphate may induce hypotension |
Labetalol | α-blocker/β-blocker | C | Yes | Yesa | Intrauterine growth retardation (2nd, 3rd trim), neonatal bradycardia and hypotension (used near term) |
Lidocaine | Antiarrhythmic (class IB) | C | Yes | Yesa | Fetal bradycardia, acidosis, central nervous system toxicity |
Methyldopa | Central α-agonist | B | Yes | Yesa | Mild neonatal hypotension |
Metoprolol | β-blocker (class II) | C | Yes | Yesa | Bradycardia and hypoglycaemia in fetus |
Mexiletine | Antiarrhythmic (class IB) | C | Yes | Yesa | Fetal bradycardia |
Nifedipine | Calcium channel blocker | C | Yes | Yesa (max 1.8%) | Tocolytic; sublingual application and potential synergism with magnesium sulphate may induce hypotension (mother) and fetal hypoxia |
Phenprocoumon | Vitamin K antagonist | X | Yes | Yes (max 10%), well tolerated as inactive metabolite | Coumarin-embryopathy, bleeding |
Procainamide | Antiarrhythmic (class IA) | C | Yes | Yes | Unknown |
Propafenone | Antiarrhythmic (class IC) | C | Yes | Unknown | Unknown |
Propranolol | β-blocker (class II) | C | Yes | Yesa | Bradycardia and hypoglycaemia in fetus |
Quinidine | Antiarrhythmic (class IA) | C | Yes | Yesa | Thrombopenia, premature birth, VIIIth nerve toxicity |
Ramipril | ACE inhibitor | C (1st trim)/D (2nd, 3rd trim) | Yes | Yes (max 1.6%) | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Sotalol | Antiarrhythmic (class III) | B | Yes | Yesa | Bradycardia and hypoglycaemia in fetus |
Spironolactone | Aldosterone antagonist | D | Yes | Yes (1.2%); milk production can be reduced | Antiandrogenic effects, oral clefts (1st trim) |
Statins, e.g. simvastatin, pravastatin, atorvastatin, fluvastatin | Lipid-lowering drugs | X | Yes | Unknown | Congenital anomalies |
Ticlopidine | Antiplatelet | B | Unknown | Unknown | Unknown |
Valsartan | Angiotensin II receptor blocker | C (1st trim)/D (2nd, 3rd trim) | Unknown | Unknown | Renal or tubular dysplasia, oligohydramnios, growth retardation, ossification disorders of skull, lung hypoplasia, contractures, large joints, anaemia, intrauterine fetal death |
Verapamil | Calcium channel blocker (Class IV) | C | Yes | Yesa | Bradycardia, atrioventricular block, hypotension |
Warfarin | Vitamin K antagonist | X | Yes | Yes (max 10%), well tolerated as inactive metabolite | Coumarin-embryopathy, bleeding |
Vaughan Williams class II antiarrhythmic agents:
Beta-blocking agents: oral medication with selective beta-blocking agents is generally considered to be safe.
Vaughan Williams class III antiarrhythmic agents:
Sotalol seems to be well tolerated during pregnancy22 and side effects are mainly related to its non-selective beta-blocking effects. Experience with sotalol during pregnancy is limited, however, so caution is still advised.
Amiodarone can have deleterious effects on the fetus.23 Hence, amiodarone, a category D agent, if given during the whole pregnancy, should be restricted to treating arrhythmias that are life-threatening or causing haemodynamic instability.23,24 There is no reported experience of dofetilide or dronedarone use during pregnancy. Dronedarone is assigned category X by the Food and Drug Administration and its use is considered contraindicated.
Vaughan Williams class IV antiarrhythmic agents:
Calcium antagonists: the use of verapamil intravenously may be associated with a greater risk of hypotension and subsequent fetal hypoperfusion. Oral verapamil is usually well tolerated, but there is limited experience during pregnancy. Beside hypotension of the mother and fetus, side effects affecting the fetus may include bradycardia, atrioventricular block, and decrease of myocardial contractility.
Multichannel blockers: there is no experience of use of vernakalant in pregnancies.
Others:
Digoxin: the experience with digoxin is extensive, and it is considered to be the safest antiarrhythmic drug during pregnancy.
Adenosine: significant side effects for mother and fetus have not been described, although most of the experiences with this drug were in the second and third trimesters.25
Antithrombotic therapy
A formal indication for antiplatelet drugs in pregnant women is rare and hence the evidence regarding benefits and risks is scarce.26,27,28
Acetylsalicylic acid is used during pregnancy mainly to prevent preeclampsia, preterm death, and perinatal mortality in women at risk for these complications.26,29 No evidence of teratogenicity is observed in large trials.30,31
Thienopyridines have not been studied in pregnant women and should be avoided unless essential (as in percutaneous transluminal coronary angiography, see Chapter 5.7).
Unfractionated heparin and low-molecular weight heparin do not cross the placental barrier and do not cause embryopathy, but may lead to retroplacental bleeding. Both can be used during pregnancy if anticoagulation is necessary.
Phenprocoumon, warfarin, or other vitamin K antagonists are considered contraindicated in pregnancy by the manufacturer and are listed in the Food and Drug Administration category D, because of fetal risk of coumarin embryopathy and bleeding. Yet as stated for category D, the benefit from use in pregnant woman may be acceptable despite the risk.
References
1. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
2. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Strömberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K; ESC Committee for Practice Guidelines.
3. Schaefer C.
4. Cooper WO, Hernandez-Diaz S, Arbogast PG, Dudley JA, Dyer S, Gideon PS, Hall K, Ray WA.
5. Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology.
6. Lydakis C, Lip GY, Beevers M, Beevers DG.
7. Sliwa K, Fett J, Elkayam U.
8. Ijiri Y, Hayashi T, Kamegai H, Ohi K, Suzuki K, Kitaura Y, Takenaka H.
9. Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, Menzies J, Sanchez JJ, Ganzevoort W, Helewa M, Lee SK, Lee T, Logan AG, Moutquin JM, Singer J, Thornton JG, Welch R, Magee LA.
10. Seely EW, Ecker J.
11. Cockburn J, Moar VA, Ounsted M, Redman CW.
12. Redman CW.
13. Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P.
14. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH.
15. Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF.
16. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL.
17. Simpson JM, Sharland GK.
18. Capucci A, Boriani G.
19. Joglar JA, Page RL.
20. Lownes HE, Ives TJ.
21. Allen NM, Page RL.
22. Oudijk MA, Ruskamp JM, Ververs FF, Ambachtsheer EB, Stoutenbeek P, Visser GH, Meijboom EJ.
23. Magee LA, Downar E, Sermer M, Boulton BC, Allen LC, Koren G.
24. Bartalena L, Bogazzi F, Braverman LE, Martino E.
25. Elkayam U, Goodwin TM.
26. Duley L, Henderson-Smart DJ, Meher S, King JF.
27. Tang CH, Wu CS, Lee TH, Hung ST, Yang CY, Lee CH, Chu PH.
28. Rodger MA, Hague WM, Kingdom J, Kahn SR, Karovitch A, Sermer M, Clement AM, Coat S, Chan WS, Said J, Rey E, Robinson S, Khurana R, Demers C, Kovacs MJ, Solymoss S, Hinshaw K, Dwyer J, Smith G, McDonald S, Newstead-Angel J, McLeod A, Khandelwal M, Silver RM, Le Gal G, Greer IA, Keely E, Rosene-Montella K, Walker M, Wells PS; TIPPS Investigators.
29. Bujold E, Roberge S, Lacasse Y, Bureau M, Audibert F, Marcoux S, Forest JC, Giguère Y.
30. Kozer E, Nikfar S, Costei A, Boskovic R, Nulman I, Koren G.
31. Xu TT, Zhou F, Deng CY, Huang GQ, Li JK, Wang XD.
32. American Academy of
Further reading
Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF.
Bujold E, Roberge S, Lacasse Y, Bureau M, Audibert F, Marcoux S, Forest JC, Giguère Y.
Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).
Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, Menzies J, Sanchez JJ, Ganzevoort W, Helewa M, Lee SK, Lee T, Logan AG, Moutquin JM, Singer J, Thornton JG, Welch R, Magee LA.
Rodger MA, Hague WM, Kingdom J, Kahn SR, Karovitch A, Sermer M, Clement AM, Coat S, Chan WS, Said J, Rey E, Robinson S, Khurana R, Demers C, Kovacs MJ, Solymoss S, Hinshaw K, Dwyer J, Smith G, McDonald S, Newstead-Angel J, McLeod A, Khandelwal M, Silver RM, Le Gal G, Greer IA, Keely E, Rosene-Montella K, Walker M, Wells PS; TIPPS Investigators.
Seely EW, Ecker J.
Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology.
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL.
