CaseReportsinWomen’sHealth24(2019)e00153
Contents lists available atScienceDirect
Case
Reports
in
Women’s
Health
j o u r n a l h o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / c r w h
Invited
Editorial
Supraventricular
tachycardia
and
the
menstrual
cycle
Keywords:
Arrhythmia
Sexhormones
Menstrualcycle
Diagnostics
Overthemenstrualperiod,variousconditions,suchasmigraine, asthmaandepilepsy,canbeexacerbatedbythevariationsin hor-monelevels[1].Femalesexhormoneshaveamultitudeofeffects onthecardiovascularsystemthroughseveralmechanisms,ranging fromestradiol-inducedvasodilationassociatedwithfluctuationsin bloodpressuretoincreasedelasticityofaorticsmoothmusclecells afterexposuretohigherlevelsofestradiolandprogesterone[2,3]. Althoughitisknownthatboth estrogenandprogesteronehave electrophysiologicalproperties,onlyafewstudieshaveassessed theeffectofthemenstrualcycleonarrhythmia.Ingeneral,women lessoftendevelopventriculararrhythmiathanmen;however,they haveanincreasedriskoflong-QT-inducedtorsadesdepointesand long-QT-associateddrug-inducedventriculararrhythmia[4]. Clini-callysignificantvariationsinQTintervaldurationhavebeenlinked tothe menstrualcycle and fluctuations in sexhormone levels, soanassociationbetweenphasesofthemenstrualcycleandthe occurrenceofventriculartachycardiawouldbequitepossible[5]. However,toourknowledge,nostudieshavebeenpublishedonthis topic.
Thiseditorialgivesabriefoverviewofthecurrentknowledgeof theeffectofchangingovarianhormonelevelsacrossthemenstrual cycleinwomenwithsupraventriculartachycardia(SVT)andits possiblediagnosticandtherapeuticconsequences.
Themenstrualcyclecanbedividedinseveralphases.Thefirst phase, starting withthefirstdayof menstruation,is knownas thefollicularphase,when estradiolandprogesteronelevelsare low. Mid-cycle,atovulation, estradiol shows asharp surge but progesterone is still low. Finally, in thepremenstrual or luteal phase,estradiolandprogesteronelevelsareinitiallyhighbutthen decrease(solevelsarelowagainatthenextmenstruation).
Bothestradiolandprogesteroneinfluenceheartrateinwomen, viaseveralpathways.Itisreportedthatestradiolhasadirect neg-ativechronotropiceffectbysuppressingT-typecalciumchannels andbyitsinfluenceonthecardiacautonomicnervoussystem[6,7]. Progesterone,ontheotherhand,activatestherenin-angiotensin system,leadingtofluidretentionandconsequentlyanincreasein circulatingbloodvolumeandincreasedheartrate[8].
A study of 49 healthy premenopausal women with a regu-larmenstrualcyclefoundasignificantlyloweraverageheartrate (−2.33bpm),butanincreasedheartratevariability,duringthe fol-licular(menstrual)phasecomparedwiththeluteal(premenstrual) phase. Thisimpliesthatestradiol andprogesteronefluctuations affectcardiacautonomicregulation[9].
Basedontheseresults,onemightexpectmostepisodesof tachy-cardiatooccurduringthepremenstruallutealphase.Indeed,in a studyof 26 premenopausalwomen witharegular menstrual cycleandparoxysmalSVT,whounderwentweekly48-h ambula-toryelectrocardiographicmonitoringduringonemenstrualcycle, significantlymoreepisodesofparoxysmalSVTwererecordedin thepremenstrualdaysthaninthemenstrualdays.Moreover,an inversecorrelationbetweenfrequencyandduration ofepisodes ofparoxysmalSVTandestradiollevelwasfound[10].Inastudy of42premenopausalwomenwithsymptomaticparoxysmalSVT, 40%ofthepatientsreportedaclusteringofSVTepisodesinthe premenstrualperiod[11].Moreover,thisstudyshowedthatthe cyclicincreasedsensitivityforepisodesofSVThasclinical conse-quencesfordiagnostictesting.Allwomenunderwentdiagnostic electrophysiological testing, including provocation with isopro-terenol, which wasperformedto induceepisodesof SVT.First, electrophysiologicaltestswereperformedmid-cycle.Sixpatients inwhomepisodesofSVTwerenotinducibleduringtheinitialtest underwentasecondelectrophysiologicaltestinthepremenstrual period.Allsixwomenwhoinitiallyhadanegative electrophysi-ologicalmid-cycletesthadinducedepisodesofparoxysmalSVT duringtherepeattestinthepremenstrualphase.Therefore, per-formingelectrophysiological proceduresin women withSVTin theirpremenstrualperiodmaylead tomore accuratediagnosis [11].
The influence of the menstrual cycle on the occurrence of arrhythmia has been investigated in only a few studies, with smallsamples.Asindicatedabove,takingthemenstrualcycleinto accountwhenschedulingdiagnostictestssuchasambulatory elec-trocardiographic(ECG)monitoringandelectrophysiologicaltests mightleadtomoreaccuratediagnoses.ItisrecommendedthatECG monitoringbeperformedduringthepremenstrualphase,asthe occurrenceofarrhythmiasishighestwhenestradiollevelsarelow andprogesteronelevelsarehigh.Ifpremenstrual-related arrhyth-miaisdiagnosed,itwouldbeinterestingtoinvestigatewhether treatmentcanbetailoredaroundthemenstrualphase.Researchis neededtoevaluatewhetheradjustingthedosageof antiarrhyth-micdrugsindifferentphasesofthemenstrualcyclewillleadto
https://doi.org/10.1016/j.crwh.2019.e00153
2214-9112/©2019TheAuthors.PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.
2 InvitedEditorial/CaseReportsinWomen’sHealth24(2019)e00153
lesssymptomaticarrhythmiainpremenopausalwomen.Another optionwouldbetolearnmoreabouttheeffectofcontinuous estra-dioltreatmentbytestingiftheoralcontraceptivepill(withoutthe often-usedweekofinterruption)decreasesthenumberofepisodes ofSVT.However,themostexcitingdirectionwillbetorevealthe precisepathwaysbywhichsexhormonesaffectSVTandto mod-ulatetheseinamoresophisticatedfashion,whichmightleadto newantiarrhythmictreatmentoptions,notonlyforpremenopausal womenbutalsoforpostmenopausalwomenandmen.
Contributors
M.M.Schreudercontributedtotheliteraturesearchandwrote thefirstdraftofthemanuscript.
M.Sunamuracontributedtotheliteraturesearchandrevision ofthemanuscript.
J.E.RoetersvanLennepcontributedtotheliteraturesearchand revisionofthemanuscript.
Conflictofinterest
Theauthorhasnoconflictofinterestregardingthepublication ofthiseditorial.
Funding
Nofundingwassoughtorsecuredinrelationtothiseditorial.
Provenanceandpeerreview
This editorial was commissioned and not externally peer reviewed.
References
[1]A.M.Case,R.L.Reid,Effectsofthemenstrualcycleonmedicaldisorders,Arch. Intern.Med.158(1998)1405–1412.
[2]E.J.Adkisson,D.P.Casey,D.T.Beck,A.N.Gurovich,J.S.Martin,R.W.Braith, Cen-tral,peripheralandresistancearterialreactivity:fluctuatesduringthephases ofthemenstrualcycle,Exp.Biol.Med.(Maywood)235(2010)111–118.
[3]R.W.Chow,D.J.Handelsman,NgM.K.Minireview,Rapidactionsofsexsteroids intheendothelium,Endocrinology151(2010)2411–2422.
[4]B.M.Gowd,P.D.Thompson,Effectoffemalesexoncardiacarrhythmias,Cardiol. Rev.20(2012)297–303.
[5]J.E.Salem,J.Alexandre,A.Bachelot,C.Funck-Brentano,Influenceofsteroid hormonesonventricularrepolarization,Pharmacol.Ther.167(2016)38–47.
[6]T.M.Saleh,B.J.Connell,Roleofoestrogeninthecentralregulationofautonomic function,Clin.Exp.Pharmacol.Physiol.34(2007)827–832.
[7]F.Marni,Y.Wang,M.Morishima,T.Shimaoka,T.Uchino,M.Zheng,T.Kaku,K. Ono,17beta-estradiolmodulatesexpressionoflow-voltage-activatedCa(V)3.2 T-typecalciumchannelviaextracellularlyregulatedkinasepathwayin car-diomyocytes,Endocrinology150(2009)879–888.
[8]N.S.Stachenfeld,H.S.Taylor,Progesteroneincreasesplasmavolume indepen-dentofestradiol,J.Appl.Physiol.2005(98)(1985)1991–1997.
[9]P.S.McKinley,A.R.King,P.A.Shapiro,I.Slavov,Y.Fang,I.S.Chen,L.D.Jamner,R.P. Sloan,Theimpactofmenstrualcyclephaseoncardiacautonomicregulation, Psychophysiology46(2009)904–911.
[10]G.M.Rosano,F.Leonardo,P.M.Sarrel,C.M.Beale,F.DeLuca,P.Collins,Cyclical variationinparoxysmalsupraventriculartachycardiainwomen,Lancet347 (1996)786–788.
[11]R.J.Myerburg,M.M.Cox,A.InterianJr.,R.Mitrani,I.Girgis,J.Dylewski,A. Castellanos,Cyclingofinducibilityofparoxysmalsupraventricular tachycar-diainwomenanditsimplicationsfortimingofelectrophysiologicprocedures, Am.J.Cardiol.83(1999)1049–1054.
M.M.Schreuder DepartmentofInternalmedicine,VascularMedicine, ErasmusMedicalCentre,Rotterdam,theNetherlands M.Sunamura CapriCardiacRehabilitationCenter,Departmentof CardiologyFranciscus,Rotterdam,theNetherlands J.E.RoetersvanLennep∗ DepartmentofInternalmedicine,VascularMedicine, ErasmusMedicalCentre,Rotterdam,theNetherlands
∗Correspondingauthorat:Dr.Molenwaterplein40,
3015GD,Rotterdam,Postbus2040,3000CA, Rotterdam,Room:Rg-531,theNetherlands. E-mailaddress:j.roetersvanlennep@erasmusmc.nl (J.E.RoetersvanLennep) 30September2019
