Contraception Guidelines for Women with Atrial Fibrillation and Coronary Artery Disease

Contraindicated Methods

The American College of Cardiology recommends that estrogen-containing contraceptives are absolutely contraindicated in women with atrial fibrillation and coronary artery disease due to the high risk of thromboembolic events 1, 2
The 2018 ACC/AHA guidelines explicitly state that estrogen-containing contraceptives are potentially harmful for women with coronary artery disease who are at high risk of thromboembolic events, specifically including those with atrial fibrillation 1, 2
The transdermal estrogen patch should be specifically avoided due to even greater estrogen exposure than oral formulations 3

The American College of Cardiology recommends levonorgestrel-releasing IUDs as one of the preferred contraceptive methods for women at high risk of thromboembolism, including those with atrial fibrillation, due to their highly effective contraception with minimal systemic hormone exposure 1, 4
The levonorgestrel-releasing IUD provides highly effective contraception with minimal systemic hormone exposure, avoiding the thrombotic risks associated with estrogen 3
The copper IUD is equally safe and highly effective, making it an excellent alternative for patients who prefer to avoid hormones entirely, with minimal systemic effects and no hormonal risks 3
Subdermal progestin implants are highly effective with failure rates less than 1% per year and are appropriate for women with coronary artery disease, providing long-acting reversible contraception without estrogen exposure 3

Progestin-only pills may be considered but are less ideal due to higher failure rates and the need for strict adherence, and require taking pills at the same time every day, making them less forgiving than long-acting methods 1, 4, 5
Depot Medroxyprogesterone Acetate (DMPA) should be used with significant caution or avoided in women with cardiovascular disease due to fluid retention concerns, and may cause fluid retention and should be used with caution in patients with heart failure or cardiovascular disease 3, 4, 5

The American College of Cardiology recommends that tubal ligation or hysteroscopic sterilization may be considered if the patient desires permanent contraception, though surgical risks must be carefully weighed given her cardiovascular disease 1, 3, 4
Vasectomy of the male partner is often the safest permanent option when the female partner has significant cardiovascular disease, though this requires frank discussion about her prognosis 1, 3

The American College of Cardiology recommends that levonorgestrel emergency contraception is not contraindicated in women with atrial fibrillation and coronary artery disease, though acute fluid retention is a potential risk that should be discussed 1, 3
The benefits of preventing unplanned pregnancy generally outweigh the temporary risk of fluid retention, and this should be explained as an option for contraceptive failure or unprotected intercourse 1, 3

Unplanned pregnancy in patients taking cardiovascular medications poses additional serious risks due to teratogenic effects, and contraceptive counseling should occur immediately and be revisited regularly 1, 3
The American College of Cardiology recommends that contraceptive counseling should include discussion of failure rates, the specific risks of pregnancy with her cardiac conditions, and her values and preferences 1, 3