Cardiovascular Drugs during Pregnancy
“Bert” Bertis Britt Little in Drugs and Pregnancy, 2022
Procainamide is an amide compound similar to lidocaine used to treat ventricular tachycardia. This drug’s pharmacokinetics during pregnancy were reported in a case report; fetal levels were approximately one-fourth maternal levels (Garite and Briggs, 1987). No reports are published of procainamide use during the first trimester of pregnancy and congenital anomalies. The safety profile of a closely related drug, lidocaine, suggests procainamide probably does not pose a great risk when used during pregnancy (Little and Gilstrap, 1989). However, as always, the absence of evidence is not evidence of absence. Breastfeeding is not contraindicated in mothers on procainamide (American Academy of Pediatrics, 2001). A rare complication of chronic use of procainamide is a lupus-like syndrome (serious rash) may occur. Prolonged use should be avoided, unless necessary for life threatening conditions (Rotmensch et al., 1987). It is an old FDA category C drug under the old system. No infants in the Swedish Birth Defects Registry were exposed to procainamide (Kallen, 2019).
Cardiac diseases in pregnancy
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
Predictors of adverse maternal outcomes in these patients include a reduced mitral valve area (less than 1.5cm2) and the NYHA functional class before pregnancy (45). Mortality among pregnant women with minimal symptoms is less than 1% (15). Severe mitral stenosis with NYHA class III–IV symptoms has a 4% to 5% maternal mortality and 30% fetal mortality (46). The mortality is even higher if atrial fibrillation is present (47). Improved diagnostic techniques, better prenatal management, and effective cardiac drugs have improved the outcome of these patients. Development of atrial fibrillation requires prompt treatment, including cardioversion. Beta blockers and digoxin can be safely used for rate control. Antiarrhythmic drugs preferred are beta blockers (sotalol, atenolol) or flecainide. Procainamide is another safe alternative, while mexiletine and amiodarone have also been used with success in small numbers of patients in the acute setting with success (48). Anticoagulant therapy is indicated in patients with mitral stenosis and atrial fibrillation is indicated to decrease the risk of systemic embolism (49,50). Anticoagulation in pregnancy is discussed separately. In patients who present with severe symptoms during pregnancy, successful percutaneous balloon mitral valvuloplasty, performed during the second trimester, has been associated with normal subsequent deliveries and excellent fetal outcomes (51). The maternal and perinatal benefits of the procedure probably outweigh the small risk of fetal exposure to the radiation. Open cardiac surgery has been performed during pregnancy for severe mitral stenosis. Maternal outcomes are approximately the same as those among nonpregnant, but there is fetal loss in 10% to 30% of cases (52). See also Figure 3.
Cardiovascular drugs
Bev-Lorraine True, Robert H. Dreisbach in Dreisbach’s HANDBOOK of POISONING, 2001
Procainamide is used for the treatment of cardiac irregularities. As little as 200 mg (2 ml of 10% solution) intravenously has caused death as a result of either hypersensitivity or rapid injection. At least four fatalities have been reported from procainamide poisoning. The rapid administration of procainamide causes irregularities of ventricular contraction, including tachycardia or fibrillation. Agranulocytosis from procainamide is apparently a hypersensitivity reaction.
Management of Wolff-Parkinson-White syndrome in a patient with peripartum cardiomyopathy
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Snigdha Bendaram, Sherif Elkattawy, Muhammad Atif Masood Noori, Hardik Fichadiya, Sarah Ayad, Parminder Kaur, Raja Pullatt, Fayez Shamoon
Amiodarone is effective but has significant side effects; thus, it can be employed in patients where other therapies failed or are not feasible. As per 2014 AHA guidelines, for patients with pre-excitation and rapid ventricular rate, management involves intravenous procainamide in hemodynamically stable patients and synchronized cardioversion in unstable ones. In a small, non-randomized trial containing a subset of patients with AVRT, ten patients treated with a combination of propafenone and beta-blocker therapy had no recurrence at >9 months after discharge [9]. Cardioversion can be performed during any week of pregnancy; although there is a theoretical risk of triggering an arrhythmia in the fetus, the risk is supposed to be small due to the small amount of energy directly reaching the fetus itself [10,11]. However, there have been cases reported of fetal arrhythmias requiring emergent C-section after cardioversion, and hence monitoring fetal heart rhythm is recommended [12].
Brugada syndrome clinical update
Published in Hospital Practice, 2021
Rhadames Rojas, Risheek Kaul, Daniel Frenkel, Ethan G Hoch, Sei Iwai, Jason T Jacobson, Wilbert S. Aronow
Frequently, variations in the EKG pattern can occur in a patient including complete absence of the BrS pattern. Repositioning the right precordial leads from the traditional location in the 4th intercostal space to more a cranial position in the 2nd or 3rd intercostal space may increase the ability to detect Brugada pattern EKG given its proximity to the right ventricular outflow tract (RVOT) [14]. Sodium channel blocking drugs (such as those listed in Table 1) can also be used to unmask the Type 1 EKG pattern and establish the diagnosis [15,16]. During a drug challenge, continuous EKG monitoring along with full resuscitative equipment is necessary for every test. The drug challenge must be stopped when the diagnosis has been established, or alternatively if there is prolongation of the QRS width to 130% of baseline, or presence of frequent premature ventricular stimuli. The drug challenge is typically performed when there is a clinical suspicion for the disease based on the patient’s history and presentation. Drug-induced tests can have false negatives 14–32% of the time especially when using procainamide and flecainide [1,17,18]. If the history is highly suggestive, a repeat test using intravenous ajmaline should be considered if available. In the United States, only intravenous procainamide is routinely available. In countries where intravenous sodium channel blockers are not available, there are limited data to support the use of oral flecainide [19].
Current pharmacotherapeutic strategies for cardiac arrhythmias in heart failure
Published in Expert Opinion on Pharmacotherapy, 2020
Ashish Correa, Yogita Rochlani, Wilbert S. Aronow
In the absence of hemodynamic instability, appropriate intravenous drug therapy can be given. Appropriate therapy for proven or presumed sustained VT is intravenous infusion of an anti-arrhythmic agent. While procainamide is the preferred option in most patients without HF (in the absence of QT prolongation), it should be avoided in HF patients due to its potent negative inotropic effects [78]. Intravenous amiodarone or sotalol are preferred agents in HF. (Refer to Table 2) Sotalol should be used cautiously in patients with a prolonged QT interval. Both these agents have been found to be superior to lidocaine [79,80], which is a second-line agent. When used, lidocaine is given as an intravenous bolus followed by a maintenance infusion of 1 to 4 mg/min (Refer to Table 2).