101
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Wu S, Xu X, He Q, Qin Y, Wang R, Chen J, Chen C, Wu C, Liu S. Incidence and outcomes of acute high-risk chest pain diseases during pregnancy and puerperium. Front Cardiovasc Med 2022; 9:968964. [PMID: 36035949 PMCID: PMC9403474 DOI: 10.3389/fcvm.2022.968964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/14/2022] [Indexed: 11/26/2022] Open
Abstract
Aim To investigate the incidence and outcomes of acute high-risk chest pain diseases, including acute myocardial infarction (AMI), aortic dissection (AD), and pulmonary embolism (PE) during pregnancy and puerperium. Methods The National Inpatient Sample was queried to identify pregnancy-related hospitalizations from January 1, 2008 to December 31, 2017. Temporal trends in the incidence and mortality of AMI, AD and PE were extracted. Results Among 41,174,101 hospitalizations, acute high-risk chest pain diseases were diagnosed in 40,285 (0.098%). The incidence increased from 79.92/100,000 in 2008 to 114.79/100,000 in 2017 (Ptrend < 0.0001). The most frequent was PE (86.5%), followed by AMI (9.6%) and AD (3.3%). The incidence of PE in pregnancy decreased after 2014 and was lower than AMI and AD, while its incidence in puerperium was higher than AMI and AD consistently (Ptrend < 0.0001). Subgroup analysis showed the incidence of these diseases was higher in black women, lowest-income households, and elderly parturients (Ptrend < 0.0001). The mortality decreased from 2.24% in 2008 to 2.21% in 2017 (Ptrend = 0.0240), exhibiting 200-fold higher than patients without these diseases. The following factors were significantly associated with these diseases: aged ≥ 45 years (OR, 4.25; 95%CI, 3.80–4.75), valvular disease (OR, 10.20; 95%CI, 9.73–10.70), and metastatic cancer (OR, 9.75; 95%CI, 7.78–12.22). The trend of elderly parturients increased from 14.94% in 2008 to 17.81% in 2017 (Ptrend < 0.0001), while no such up-trend was found in valvular disease and metastatic cancer. Conclusion The incidence of acute high-risk chest pain diseases, especially PE in puerperium, increased consistently. Although mortality has shown a downward trend, it is still at a high level. We should strengthen monitoring and management of acute high-risk pain diseases in pregnancy and puerperium, especially for black women, lowest-income households, and elderly parturients in the future.
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Affiliation(s)
- Shengyong Wu
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Xudong Xu
- Department of Cardiology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Qian He
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Rui Wang
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Jun Chen
- Department of Gynecology and Obstetrics, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Chenxin Chen
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Cheng Wu
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
- *Correspondence: Cheng Wu,
| | - Suxuan Liu
- Department of Cardiology, Changhai Hospital, Navy Medical University, Shanghai, China
- Suxuan Liu,
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102
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Mok T, Woods A, Small A, Canobbio MM, Tandel MD, Kwan L, Lluri G, Reardon L, Aboulhosn J, Lin J, Afshar Y. Delivery Timing and Associated Outcomes in Pregnancies With Maternal Congenital Heart Disease at Term. J Am Heart Assoc 2022; 11:e025791. [PMID: 35943056 PMCID: PMC9496287 DOI: 10.1161/jaha.122.025791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Current recommendations for delivery timing of pregnant persons with congenital heart disease (CHD) are based on expert opinion. Justification for early-term birth is based on the theoretical concern of increased cardiovascular stress. The objective was to evaluate whether early-term birth with maternal CHD is associated with lower adverse maternal or neonatal outcomes. Methods and Results This is a retrospective cohort study of pregnant persons with CHD who delivered a singleton after 37 0/7 weeks gestation at a quaternary care center with a multidisciplinary cardio-obstetrics care team between 2013 and 2021. Patients were categorized as early-term (37 0/7 to 38 6/7 weeks) or full-term (≥39 0/7) births and compared. Multivariable logistic regression was conducted to calculate the adjusted odds ratio for the primary outcomes. The primary outcomes were composite adverse cardiovascular, maternal obstetric, and adverse neonatal outcome. Of 110 pregnancies delivering at term, 55 delivered early-term and 55 delivered full-term. Development of adverse cardiovascular and maternal obstetric outcome was not significantly different by delivery timing. The rate of composite adverse neonatal outcomes was significantly higher in early-term births (36% versus 5%, P<0.01). After adjusting for confounding variables, early-term birth remained associated with a significantly increased risk of adverse neonatal outcomes (adjusted odds ratio 11.55 [95% CI, 2.59-51.58]). Conclusions Early-term birth for pregnancies with maternal CHD was associated with an increased risk of adverse neonatal outcomes, without an accompanying decreased rate in adverse cardiovascular or obstetric outcomes. In the absence of maternal or fetal indications for early birth, induction of labor before 39 weeks for pregnancies with maternal CHD should be reserved for routine obstetrical indications.
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Affiliation(s)
- Thalia Mok
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology University of California Los Angeles CA
| | - Allison Woods
- Department of Anesthesiology and Perioperative Medicine University of California Los Angeles CA
| | - Adam Small
- Division of Cardiology, Department of Medicine New York University Langone Health New York NY
| | - Mary M Canobbio
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center University of California Los Angeles CA.,UCLA School of Nursing University of California Los Angeles CA
| | - Megha D Tandel
- Department of Urology University of California Los Angeles CA
| | - Lorna Kwan
- Department of Urology University of California Los Angeles CA
| | - Gentian Lluri
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center University of California Los Angeles CA
| | - Leigh Reardon
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center University of California Los Angeles CA
| | - Jamil Aboulhosn
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center University of California Los Angeles CA
| | - Jeannette Lin
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center University of California Los Angeles CA
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology University of California Los Angeles CA
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103
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Denoble AE, Goldstein SA, Wein LE, Grotegut CA, Federspiel JJ. Comparison of severe maternal morbidity in pregnancy by modified World Health Organization Classification of maternal cardiovascular risk. Am Heart J 2022; 250:11-22. [PMID: 35526569 PMCID: PMC9836743 DOI: 10.1016/j.ahj.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/15/2022] [Accepted: 04/29/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND To compare rates of severe maternal morbidity (SMM) for pregnant patients with a cardiac diagnosis classified by the modified World Health Organization (mWHO) classification to those without a cardiac diagnosis. METHODS This retrospective study using the 2015-2019 Nationwide Readmissions Database identified hospitalizations, comorbidities, and outcomes using diagnosis and procedure codes. The primary exposure was cardiac diagnosis, classified into low-risk (mWHO class I and II) and moderate-to-high-risk (mWHO class II/III, III, or IV). The primary outcome was SMM or death during the delivery hospitalization; secondary outcomes included cardiac-specific SMM during delivery hospitalizations and readmissions after the delivery hospitalization. RESULTS A weighted national estimate of 14,995,122 delivery admissions was identified, including 46,541 (0.31%) with mWHO I-II diagnoses and 37,330 (0.25%) with mWHO II/III-IV diagnoses. Patients with mWHO II/III-IV diagnoses experienced SMM at the highest rates (22.8% vs 1.6% for no diagnosis; with adjusted relative risk (aRR) of 5.67 [95% CI: 5.36-6.00]). The risk of death was also highest for patients with mWHO II/III-IV diagnoses (0.3% vs <0.1% for no diagnosis; aRR 18.07 [95% CI: 12.25-26.66]). Elevated risk of SMM and death persisted to 11 months postpartum for those patients with mWHO II/III-IV diagnoses. CONCLUSIONS In this nationwide database, SMM is highest among individuals with moderate-to-severe cardiac disease based on mWHO classification. This risk persists in the year postpartum. These results can be used to enhance pregnancy counseling.
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Affiliation(s)
- Anna E Denoble
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT.
| | - Sarah A Goldstein
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Lauren E Wein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Chad A Grotegut
- Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC; Department of Gynecology and Obstetrics, The Johns Hopkins School of Medicine, Baltimore, MD
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104
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Bond RM, Phillips K, Ivy KN, Ogueri V, Parapid B, Miller SC, Ansong A. Cardiovascular Health of Black Women Before, During, and After Pregnancy: A Call to Action and Implications for Prevention. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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105
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Sierra-Galan LM, Bhatia M, Alberto-Delgado AL, Madrazo-Shiordia J, Salcido C, Santoyo B, Martinez E, Soto ME. Cardiac Magnetic Resonance in Rheumatology to Detect Cardiac Involvement Since Early and Pre-clinical Stages of the Autoimmune Diseases: A Narrative Review. Front Cardiovasc Med 2022; 9:870200. [PMID: 35911548 PMCID: PMC9326004 DOI: 10.3389/fcvm.2022.870200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Autoimmune diseases (ADs) encompass multisystem disorders, and cardiovascular involvement is a well-known feature of autoimmune and inflammatory rheumatic conditions. Unfortunately, subclinical and early cardiovascular involvement remains clinically silent and often undetected, despite its well-documented impact on patient management and prognostication with an even more significant effect on severe and future MACE events as the disease progresses. Cardiac magnetic resonance imaging (MRI), today, commands a unique position of supremacy versus its competition in cardiac assessment and is the gold standard for the non-invasive evaluation of cardiac function, structure, morphology, tissue characterization, and flow with the capability of evaluating biventricular function; myocardium for edema, ischemia, fibrosis, infarction; valves for thickening, large masses; pericardial inflammation, pericardial effusions, and tamponade; cardiac cavities for thrombosis; conduction related abnormalities and features of microvascular and large vessel involvement. As precise and early detection of cardiovascular involvement plays a critical role in improving the outcome of rheumatic and autoimmune conditions, our review aims to highlight the evolving role of CMR in systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), systemic sclerosis (SSc), limited sclerosis (LSc), adult-onset Still's disease (AOSD), polymyositis (PM), dermatomyositis (DM), eosinophilic granulomatosis with polyangiitis (EGPA) (formerly Churg-Strauss syndrome), and DRESS syndrome (DS). It draws attention to the need for concerted, systematic global interdisciplinary research to improve future outcomes in autoimmune-related rheumatic conditions with multiorgan, multisystem, and cardiovascular involvement.
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Affiliation(s)
- Lilia M. Sierra-Galan
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Mona Bhatia
- Department of Imaging, Fortis Escorts Heart Institute, New Delhi, India
| | | | - Javier Madrazo-Shiordia
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Carlos Salcido
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Bernardo Santoyo
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Eduardo Martinez
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Maria Elena Soto
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
- Immunology Department of the National Institute of Cardiology, “Ignacio Chavez”, Mexico City, Mexico
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106
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Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease. Reprod Sci 2022; 29:3007-3014. [PMID: 35819577 PMCID: PMC9537116 DOI: 10.1007/s43032-022-00978-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/18/2022] [Indexed: 11/11/2022]
Abstract
Cardiovascular disease is the leading cause of pregnancy mortality. Socioeconomic and racial disparities in pregnancy are well established. Despite this, little is known about the impact of social determinants of health in pregnant patients with heart disease. This study aims to determine whether pregnant patients with heart disease living in lower income neighborhoods and managed at cardio-obstetrics programs have higher rates of cardiac events or preterm deliveries compared with those living in higher income neighborhoods. This is a retrospective cohort study of 206 patients between 2010 and 2020 at a quaternary care hospital in Northern California. The exposure was household income level based on neighborhood defined by the US Census data. Patients in lower income neighborhoods (N = 103) were 45% Hispanic, 34% White, and 14% Asian versus upper income neighborhoods (N = 103), which were 48% White, 31% Asian, and 12% Hispanic (p < 0.001). There was no significant difference in the rates of intrapartum cardiac events (10% vs. 4%; p = 0.16), postpartum cardiac events (14% vs. 17%; p = 0.7), and preterm delivery (24% vs. 17%; p = 0.23). The rates of antepartum hospitalization were higher for lower income neighborhoods (42% vs 22%; p = 0.004). While there is no significant difference in cardiac events and preterm delivery rates between patients from low versus high income neighborhoods, patients from lower income neighborhoods have higher antepartum hospitalization rates. Earlier identification of clinical deterioration provided by a cardio-obstetrics team may contribute to increased hospitalizations, which might mitigate socioeconomic disparities in outcomes for these pregnant patients with heart disease.
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107
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Wichert-Schmitt B, D'Souza R, Silversides CK. Reproductive Issues in Patients With the Fontan Operation. Can J Cardiol 2022; 38:921-929. [PMID: 35490924 DOI: 10.1016/j.cjca.2022.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 01/09/2023] Open
Abstract
Patients with the Fontan operation have a unique circulation, with a limited ability to increase cardiac output, and high central venous pressure. They may have diastolic and/or systolic ventricular dysfunction, arrhythmias, thromboembolic complications, or multiorgan dysfunction. All of these factors contribute to reproductive issues, including menstrual irregularities, infertility, recurrent miscarriage, and complications during pregnancy. Although atrial arrhythmias are the most common cardiac complications during pregnancy, patients can develop heart failure and thromboembolic events. Obstetric bleeding, including postpartum hemorrhage, is common. In addition to maternal complications, adverse fetal and neonatal events, such as prematurity and low birthweight, are very common. Counselling about these reproductive issues should begin early. For those who become pregnant, care should be provided by a multidisciplinary cardio-obstetric team familiar with the specific issues and needs of the Fontan population. In this review, we discuss infertility, contraception, and pregnancy in patients with the Fontan operation.
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Affiliation(s)
- Barbara Wichert-Schmitt
- Department of Cardiology and Medical Intensive Care, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz, Austria.
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto, Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
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108
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O’Kelly AC, Ludmir J, Wood MJ. Acute Coronary Syndrome in Pregnancy and the Post-Partum Period. J Cardiovasc Dev Dis 2022; 9:jcdd9070198. [PMID: 35877560 PMCID: PMC9319853 DOI: 10.3390/jcdd9070198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.
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109
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Pham A, Polic A, Nguyen L, Thompson JL. Statins in Pregnancy: Can We Justify Early Treatment of Reproductive Aged Women? Curr Atheroscler Rep 2022; 24:663-670. [PMID: 35699821 DOI: 10.1007/s11883-022-01039-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Statins are the pillar of secondary prevention in reducing cardiovascular disease in high-risk adults. However, statin discontinuation is the standard recommendation in pregnant and lactating patients. This review evaluates whether we can justify the early treatment of reproductive aged women with statin therapy. RECENT FINDINGS Statins have several potential benefits including its antioxidant, anti-inflammatory, and anti-thrombogenic properties that may prevent the worsening of atherosclerosis in high-risk women. Nevertheless, most studies on statins and teratogenicity have a limited sample size and the effects of long-term statin use on fetal and neonatal health remain unknown. Not all statins may be safe and pravastatin's cholesterol-lowering properties may be too limited to provide much maternal benefit in pregnancy. While emerging evidence supports the use of pravastatin in pregnancy, we need to better assess the risk of early cardiovascular disease and acute progression of atherosclerosis before and during pregnancy to better understand the risks and benefits of statin use.
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Affiliation(s)
- Amelie Pham
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Medical Center North, 1161 21stAvenue, South B-1100, Nashville, TN, 37212, USA
| | - Aleksandra Polic
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Medical Center North, 1161 21stAvenue, South B-1100, Nashville, TN, 37212, USA
| | - Lynsa Nguyen
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Medical Center North, 1161 21stAvenue, South B-1100, Nashville, TN, 37212, USA
| | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Medical Center North, 1161 21stAvenue, South B-1100, Nashville, TN, 37212, USA.
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110
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Kim B, Moon JY, Shin JY, Jeon HR, Oh SY, Kim SY. Effect of smartphone app-based health care intervention for health management of high-risk mothers: a study protocol for a randomized controlled trial. Trials 2022; 23:486. [PMID: 35698156 PMCID: PMC9190453 DOI: 10.1186/s13063-022-06425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The 4th Industrial Revolution with the advent of the smart era, in which artificial intelligence, such as big data analysis and machine learning, is expected, and the provision of healthcare services using smartphones has become a reality. In particular, high-risk mothers who experience gestational diabetes, gestational hypertension, and prenatal and postpartum depression are highly likely to have adverse effects on the mother and newborn due to the disease. Therefore, continuous observation and intervention in health management are needed to prevent diseases and promote healthy behavior for a healthy life. METHODS This randomized controlled trial will provide mothers 18 years of age or older with health care information collected based on evidence-based literature data using a smartphone app for 6 weeks. About 500 mothers will be selected in consideration of the dropout rate due to the characteristics of mothers. The study group and control group will be computer-generated in a 1:1 ratio through random assignment. The research group will receive health management items through the app, and health management information suitable for the pregnancy cycle is pushed to an alarm. The control group will receive the health management information of the paper. We also followed the procedure for developing mobile apps using the IDEAS framework. DISCUSSION These results show the effectiveness of smart medical healthcare services and promote changes in health behaviors throughout pregnancy in high-risk mothers. TRIAL REGISTRATION Clinical trial registration information for this study has been registered with WHO ICTRP and CRIS (Korea Clinical Research Information Service, CRIS). Clinical trial registration information is as follows: Study of development of integrated smart health management service for the whole life cycle of high-risk mothers and newborns based on community, KCT0007193 . Registered on April 14, 2022, prospectively registered. This protocol version is Version 1.0. April 14, 2022.
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Affiliation(s)
- Bora Kim
- Department of Preventive Medicine, Gachon University College of Medicine, Incheon, Republic of Korea.,Center for Public Health, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea.,Department of Literature and Art Therapy, Konkuk University, Seoul, Republic of Korea
| | - Jong Youn Moon
- Department of Preventive Medicine, Gachon University College of Medicine, Incheon, Republic of Korea. .,Center for Public Health, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea. .,Artificial Intelligence and Big-Data Convergence Center, Gachon University Gil Medical Center, Incheon, 21565, Republic of Korea.
| | - Jae Yong Shin
- Department of Preventive Medicine & Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Rin Jeon
- Department of Obstetrics and Gynecology, Gachon University of Gil Medical Center, Incheon, 21565, Republic of Korea
| | - So Yeon Oh
- Department of Social & Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Suk Young Kim
- Department of Obstetrics and Gynecology, Gachon University of Gil Medical Center, Incheon, 21565, Republic of Korea.
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111
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Abstract
Cardiovascular complications of pregnancy have risen substantially over the past decades, and now account for the majority of pregnancy-induced maternal deaths, as well as having substantial long-term consequences on maternal cardiovascular health. The causes and pathophysiology of these complications remain poorly understood, and therapeutic options are limited. Preclinical models represent a crucial tool for understanding human disease. We review here advances made in preclinical models of cardiovascular complications of pregnancy, including preeclampsia and peripartum cardiomyopathy, with a focus on pathological mechanisms elicited by the models and on relevance to human disease.
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Affiliation(s)
- Zolt Arany
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Denise Hilfiker-Kleiner
- Institute of Cardiovascular Complications in Pregnancy and in Oncologic Therapies, Philipps University Marburg, Germany (D.H.-K.)
| | - S Ananth Karumanchi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (S.A.K.)
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112
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Morgan J, Bauer S, Whitsel A, Combs CA. Society for Maternal-Fetal Medicine Special Statement: Postpartum visit checklists for normal pregnancy and complicated pregnancy. Am J Obstet Gynecol 2022; 227:B2-B8. [PMID: 35691408 DOI: 10.1016/j.ajog.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Rising maternal morbidity and mortality rates, widening healthcare disparities, and increasing focus on cardiometabolic risk modification in at-risk patients have together catalyzed a shift in the postpartum care paradigm. What was once a single office visit in the 6 weeks after delivery is now being reimagined as a continuum of care that transitions patients from pregnancy to life-long health optimization. However, this shift in postpartum care also comes with increased visit complexity and additional provider burden, particularly when patients have had significant pregnancy complications or have chronic diseases. To ensure that the comprehensive needs of both healthy and medically complex people are consistently met under this revised postpartum care paradigm, a postpartum visit checklist for uncomplicated postpartum patients and another checklist for those with major medical or obstetric morbidities are presented. These checklists are designed to ensure that essential elements of physical and mental well-being are routinely considered, that adequate follow-up or specialty referrals are made, and that relevant future health risks are appropriately reviewed and discussed.
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113
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Marshall V WH, Gee S, Lim W, Lastinger LT, Cackovic M, Benza RL, Daniels CJ, Bradley EA, Rajpal S. Maternal and fetal outcomes in pregnant women with pulmonary hypertension: The impact of left heart disease. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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114
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Nappi RE, Chedraui P, Lambrinoudaki I, Simoncini T. Menopause: a cardiometabolic transition. Lancet Diabetes Endocrinol 2022; 10:442-456. [PMID: 35525259 DOI: 10.1016/s2213-8587(22)00076-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
Menopause is often a turning point for women's health worldwide. Increasing knowledge from experimental data and clinical studies indicates that cardiometabolic changes can manifest at the menopausal transition, superimposing the effect of ageing onto the risk of cardiovascular disease. The menopausal transition is associated with an increase in fat mass (predominantly in the truncal region), an increase in insulin resistance, dyslipidaemia, and endothelial dysfunction. Exposure to endogenous oestrogen during the reproductive years provides women with protection against cardiovascular disease, which is lost around 10 years after the onset of menopause. In particular, women with vasomotor symptoms during menopause seem to have an unfavourable cardiometabolic profile. Early management of the traditional risk factors of cardiovascular disease (ie, hypertension, obesity, diabetes, dyslipidaemia, and smoking) is essential; however, it is important to recognise in the reproductive history the female-specific conditions (ie, gestational hypertension or diabetes, premature ovarian insufficiency, some gynaecological diseases such as functional hypothalamic amenorrhoea, and probably others) that could enhance the risk of cardiovascular disease during and after the menopausal transition. In this Review, the first of a Series of two papers, we provide an overview of the literature for understanding cardiometabolic changes and the management of women at midlife (40-65 years) who are at higher risk, focusing on the identification of factors that can predict the occurrence of cardiovascular disease. We also summarise evidence about preventive non-hormonal strategies in the context of cardiometabolic health.
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Affiliation(s)
- Rossella E Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Peter Chedraui
- Instituto de Investigación e Innovación en Salud Integral and Laboratorio de Biomedicina, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
| | - Irene Lambrinoudaki
- Menopause Unit, 2nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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115
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Jiang L, Liang WX, Yan Y, Wang SP, Dai L, Chen DJ. Thrombotic pulmonary embolism of inferior vena cava during caesarean section: A case report and review of the literature. World J Clin Cases 2022; 10:4226-4235. [PMID: 35665114 PMCID: PMC9131231 DOI: 10.12998/wjcc.v10.i13.4226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/21/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thrombotic pulmonary embolism (TPE) is one of the most critical diseases in obstetrics but is rarely reported in caesarean section (CS) because TPE patients in CS have a high risk of death and are difficult to diagnose. This case report of TPE during CS was recorded by transthoracic echocardiography (TTE) and can provide a reference for the differential diagnosis of critical illnesses in CS.
CASE SUMMARY A 37-year-old pregnant woman with rheumatic heart disease (RHD), gravida 5 and para 1 (G5P1), presented for emergency CS at 33 wk and 3 d of gestation under general anesthesia because of acute heart failure, pulmonary hypertension and arrhythmia. After placental removal during CS, TTE revealed a nascent thrombus in the inferior vena cava (IVC) that elongated, detached and fragmented leading to acute thromboembolic events and acute TPE. This report presents the whole process and details of TPE during CS and successful rescue without any sequelae in the patient. This case gives us new ideas for the diagnosis of death or cardiovascular accidents during CS in pregnant women with heart disease and the detailed presentation of the rapid development of TPE may also elucidate new ideas for treatment. This case also highlighted the importance of prophylactic anticoagulation in the management of heart disease during pregnancy.
CONCLUSION Pregnancy with heart failure could trigger inferior vena cava (IVC)-origin TPE during CS. Detection and timely treatment can avoid serious consequences.
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Affiliation(s)
- Lan Jiang
- Department of Medical Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Wei-Xiang Liang
- Department of Medical Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Yi Yan
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Shou-Ping Wang
- Department of Anesthesiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510015, Guangdong Province, China
| | - Li Dai
- Department of Medical Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, Guangdong Province, China
| | - Dun-Jin Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510015, Guangdong Province, China
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116
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 650] [Impact Index Per Article: 325.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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117
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Cardiac disease in pregnancy. Best Pract Res Clin Anaesthesiol 2022; 36:191-208. [PMID: 35659955 DOI: 10.1016/j.bpa.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. The cardiovascular system is not only significantly challenged by physiological alterations in pregnancy but also by obstetric medication. Depending upon the severity of the underlying condition, pregnant women with cardiovascular disease should be managed by a multidisciplinary heart team in which anaesthesiologists play an important role. Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.
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118
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Bello NA, Agrawal A, Davis MB, Harrington CM, Lindley KJ, Minissian MB, Sharma G, Walsh MN, Park K. Need for Better and Broader Training in Cardio-Obstetrics: A National Survey of Cardiologists, Cardiovascular Team Members, and Cardiology Fellows in Training. J Am Heart Assoc 2022; 11:e024229. [PMID: 35435011 PMCID: PMC9238459 DOI: 10.1161/jaha.121.024229] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Team-based models of cardio-obstetrics care have been developed to address the increasing rate of maternal mortality from cardiovascular diseases. Cardiovascular clinician and trainee knowledge and comfort with this topic, and the extent of implementation of an interdisciplinary approach to cardio-obstetrics, are unknown. Methods and Results We aimed to assess the current state of cardio-obstetrics knowledge, practices, and services provided by US cardiovascular clinicians and trainees. A survey developed in conjunction with the American College of Cardiology was circulated to a representative sample of cardiologists (N=311), cardiovascular team members (N=51), and fellows in training (N=139) from June 18, 2020, to July 29, 2020. Knowledge and attitudes about the provision of cardiovascular care to pregnant patients and the prevalence and composition of cardio-obstetrics teams were assessed. The widest knowledge gaps on the care of pregnant compared with nonpregnant patients were reported for medication safety (42%), acute coronary syndromes (39%), aortopathies (40%), and valvular heart disease (30%). Most respondents (76%) lack access to a dedicated cardio-obstetrics team, and only 29% of practicing cardiologists received cardio-obstetrics didactics during training. One third of fellows in training reported seeing pregnant women 0 to 1 time per year, and 12% of fellows in training report formal training in cardio-obstetrics. Conclusions Formalized training in cardio-obstetrics is uncommon, and limited access to multidisciplinary cardio-obstetrics teams and large knowledge gaps exist among cardiovascular clinicians. Augmentation of cardio-obstetrics education across career stages is needed to reduce these deficits. These survey results are an initial step toward developing a standard expectation for clinicians' training in cardio-obstetrics.
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Affiliation(s)
- Natalie A. Bello
- Department of CardiologySmidt Heart InstituteCedars‐Sinai Medical CenterLos AngelesCA
| | - Akanksha Agrawal
- Emory Heart and Vascular CenterEmory Women’s Heart CenterEmory University School of MedicineAtlantaGA
| | - Melinda B. Davis
- Division of Cardiovascular MedicineUniversity of MichiganAnn ArborMI
| | - Colleen M. Harrington
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts School of MedicineWorcesterMA
| | - Kathryn J. Lindley
- Cardiovascular DivisionDepartment of MedicineWashington University in St LouisMO
| | - Margo B. Minissian
- Barbra Streisand Women’s Heart CenterCedars‐Sinai Smidt Heart Institute and the Geri and Richard Brawerman Nursing InstituteCedars‐Sinai Medical CenterLos AngelesCA
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular DiseaseJohns Hopkins University School of MedicineBaltimoreMD
| | | | - Ki Park
- Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleFL
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119
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Ijäs P. Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke. Front Neurol 2022; 13:833215. [PMID: 35481266 PMCID: PMC9035801 DOI: 10.3389/fneur.2022.833215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Pregnancy is a female-specific risk factor for stroke. Although pregnancy-associated stroke (PAS) is a rare event, PAS leads to considerable maternal mortality and morbidity. It is estimated that 7.7–15% of all maternal deaths worldwide are caused by stroke and 30–50% of surviving women are left with persistent neurological deficits. During last decade, several studies have reported an increasing incidence of PAS. The objective of this review is to summarize studies on time trends of PAS in relation to trends in the prevalence of stroke risk factors in pregnant women. Seven retrospective national healthcare register-based cohort studies from the US, Canada, UK, Sweden, and Finland were identified. Five studies from the US, Canada, and Finland reported an increasing trend of PAS. Potential biases include more sensitive diagnostics and improved stroke awareness among pregnant women and professionals toward the end of the study period. However, the concurrent increase in the prevalence of several stroke risk factors among pregnant women, particularly advanced age, hypertensive disorders of pregnancy, diabetes, and obesity, indicate that the findings are likely robust and should be considered seriously. To reduce stroke in pregnancy, increased awareness among all medical specialties and pregnant women on the importance of risk-factor management during pregnancy and stroke symptoms is necessary. Important preventive measures include counseling for smoking cessation and substance abuse, treatment of hypertensive disorders of pregnancy, use of aspirin in women at high risk for developing preeclampsia, and antithrombotic medication and pregnancy surveillance for women with high-risk conditions. Epidemiological data from countries with a high risk-factor burden are largely missing. National and international registries and prospective studies are needed to increase knowledge on the mechanisms, risk factors, management, and future implications for the health of women who experience this rare but devastating complication of pregnancy.
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120
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 754] [Impact Index Per Article: 377.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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121
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Development of delivery plans for women with complex heart disease. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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122
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Screening for Cardiovascular Disease in Pregnancy: Is There a Need? J Cardiovasc Dev Dis 2022; 9:jcdd9030089. [PMID: 35323636 PMCID: PMC8953180 DOI: 10.3390/jcdd9030089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Maternal mortality in the United States has been on the rise. Every year, about 700 women die from pregnancy-related complications. Cardiovascular disease (CVD) accounts for a large majority of pregnancy-related deaths driven by the lack of recognition and delays in diagnosis due to the overlap of normal pregnancy symptoms with those of CVD. Risk factors for CVD including race, advanced maternal age, hypertension, diabetes, obesity, socioeconomic status, and geographic region play an important role in CVD-related deaths. Several risk assessment models are available to stratify women with a known diagnosis of CVD. However, most women who die from CVD during pregnancy or the postpartum period do not have a prior diagnosis of CVD, and cardiomyopathy is an important contributor. The California Maternal Quality Care Collaborative (CMQCC) developed an algorithm to screen all pregnant and postpartum women to allow stratification into low or high risk for CVD. The algorithm has been validated in diverse patient populations. We propose universal CVD screening for all women in the antepartum and postpartum period to identify women at risk and to provide education and awareness for both patients and healthcare providers. This screening tool would work to reduce the increasing rates of severe maternal mortality and morbidity while having a significant impact on healthcare costs in the United States.
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123
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Enomoto N, Yamashita T, Furuta M, Tanaka H, Ng ESW, Matsunaga S, Sakurai A. Effect of maternal positioning during cardiopulmonary resuscitation: a systematic review and meta-analyses. BMC Pregnancy Childbirth 2022; 22:159. [PMID: 35216559 PMCID: PMC8881850 DOI: 10.1186/s12884-021-04334-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Although rare, cardiac arrest during pregnancy is the leading cause of maternal death. Recently, its incidence has been increasing worldwide because more pregnant women have risk factors. The provision of early, high-quality cardiopulmonary resuscitation (CPR) plays a major role in the increased likelihood of survival; therefore, it is important for clinicians to know how to manage it. Due to the aortocaval compression caused by the gravid uterus, clinical guidelines often emphasise the importance of maternal positioning during CPR, but there has been little evidence regarding which position is most effective. Methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and OpenGrey (updated on April 3, 2021). We included clinical trials and observational studies with reported outcomes related to successful resuscitations. Results We included eight studies from the 1,490 screened. The eight studies were simulation-based, crossover trials that examine the quality of chest compressions. No data were available about the survival rates of mothers or foetuses/neonates. The meta-analyses showed that resuscitation of pregnant women in the 27°–30° left-lateral tilt position resulted in lower quality chest compressions. The difference is an 19% and 9% reduction in correct compression depth rate and correct hand position rate, respectively, compared with resuscitations in the supine position. Inexperienced clinicians find it difficult to perform chest compressions in the left-lateral tilt position. Conclusions Given that manual left uterine displacement allows the patient to remain supine, the resuscitation of women in the supine position using manual left uterine displacement should continue to be supported. Further research is needed to fill knowledge gaps regarding the effects of maternal positioning on clinical outcomes, such as survival rates following maternal cardiac arrest.
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Affiliation(s)
- Naosuke Enomoto
- Department of Obstetrics and Gynaecology, Graduate School of Medicine, Mie University / Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tomoyuki Yamashita
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Marie Furuta
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynaecology, Graduate School of Medicine, Mie University / Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Edmond S W Ng
- London School of Hygiene & Tropical Medicine, London, UK
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynaecology, Saitama Medical Centre, Saitama Medical University, Saitama, Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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124
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Abstract
As populations age worldwide, the burden of valvular heart disease has grown exponentially, and so has the proportion of affected women. Although rheumatic valve disease is declining in high-income countries, degenerative age-related causes are rising. Calcific aortic stenosis and degenerative mitral regurgitation affect a significant proportion of elderly women, particularly those with comorbidities. Women with valvular heart disease have been underrepresented in many of the landmark studies which form the basis for guideline recommendations. As a consequence, surgical referrals in women have often been delayed, with worse postoperative outcomes compared with men. As described in this review, a more recent effort to include women in research studies and clinical trials has increased our knowledge about sex-based differences in epidemiology, pathophysiology, diagnostic criteria, treatment options, outcomes, and prognosis.
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Affiliation(s)
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA
| | - Rebecca T. Hahn
- Division of Cardiology, New York Presbyterian Columbia Heart Valve Center, Columbia University Medical Center, New York, NY
| | - Judy W. Hung
- Division of Cardiology and Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Francesca N. Delling
- Division of Cardiology, University of California San Francisco, San Francisco, CA
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125
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Adedinsewo DA, Pollak AW, Phillips SD, Smith TL, Svatikova A, Hayes SN, Mulvagh SL, Norris C, Roger VL, Noseworthy PA, Yao X, Carter RE. Cardiovascular Disease Screening in Women: Leveraging Artificial Intelligence and Digital Tools. Circ Res 2022; 130:673-690. [PMID: 35175849 PMCID: PMC8889564 DOI: 10.1161/circresaha.121.319876] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease remains the leading cause of death in women. Given accumulating evidence on sex- and gender-based differences in cardiovascular disease development and outcomes, the need for more effective approaches to screening for risk factors and phenotypes in women is ever urgent. Public health surveillance and health care delivery systems now continuously generate massive amounts of data that could be leveraged to enable both screening of cardiovascular risk and implementation of tailored preventive interventions across a woman's life span. However, health care providers, clinical guidelines committees, and health policy experts are not yet sufficiently equipped to optimize the collection of data on women, use or interpret these data, or develop approaches to targeting interventions. Therefore, we provide a broad overview of the key opportunities for cardiovascular screening in women while highlighting the potential applications of artificial intelligence along with digital technologies and tools.
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Affiliation(s)
- Demilade A. Adedinsewo
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Amy W. Pollak
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Sabrina D. Phillips
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Taryn L. Smith
- Division of General Internal Medicine (T.L.S.), Mayo Clinic, Jacksonville, FL
| | - Anna Svatikova
- Department of Cardiovascular Diseases (A.S.), Mayo Clinic, Phoenix, AZ
| | - Sharonne N. Hayes
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
| | - Sharon L. Mulvagh
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada (S.L.M.)
| | - Colleen Norris
- Cardiovascular Health and Stroke Strategic Clinical Network, Edmonton, Canada (C.N.)
| | - Veronique L. Roger
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
- Department of Quantitative Health Sciences (V.L.R.), Mayo Clinic, Rochester, MN
- Epidemiology and Community Health Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (V.L.R.)
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y.), Mayo Clinic, Rochester, MN
| | - Rickey E. Carter
- Department of Quantitative Health Sciences (R.E.C.), Mayo Clinic, Jacksonville, FL
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126
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Tanne JH. Six in 10 US women have poor cardiovascular health before pregnancy, study finds. BMJ 2022; 376:o402. [PMID: 35172960 DOI: 10.1136/bmj.o402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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127
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Lindley KJ. Call for Action to Address Increasing Maternal Cardiovascular Mortality in the United States: Strategies for Improving Maternal Cardiovascular Care. Circulation 2022; 145:502-504. [PMID: 35157515 DOI: 10.1161/circulationaha.122.058772] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
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128
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HYPERLIPIDEMIA AND RISK FOR PRECLAMPSIA. J Clin Lipidol 2022; 16:253-260. [DOI: 10.1016/j.jacl.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/27/2022] [Accepted: 02/14/2022] [Indexed: 11/22/2022]
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129
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DeFilippis EM, Walsh MN. Cardiovascular Outcomes of Severe Maternal Morbidity: Decades in the Making. Circ Cardiovasc Qual Outcomes 2022; 15:e008727. [PMID: 35098731 DOI: 10.1161/circoutcomes.121.008727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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130
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Wong MJ, Bharadwaj S, Galey JL, Lankford AS, Galvagno S, Kodali BS. Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients. Anesth Analg 2022; 135:277-289. [PMID: 35122684 DOI: 10.1213/ane.0000000000005861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.
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Affiliation(s)
- Michael J Wong
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shobana Bharadwaj
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jessica L Galey
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allison S Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine and Program in Trauma and Anesthesia Critical Care, Shock Trauma Center, Baltimore, Maryland
| | - Samuel Galvagno
- Department of Anesthesiology, Multi Trauma Critical Care Unit, Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhavani Shankar Kodali
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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131
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Zhang X, Liang X, Cao W. Evaluation of Cardiac Function of Pregnant Women with High Blood Pressure during Gestation Period and Coupling of Hearts with Peripheral Vessels by Ultrasonic Cardiogram under Artificial Intelligence Algorithm. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5019153. [PMID: 35126627 PMCID: PMC8813232 DOI: 10.1155/2022/5019153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/11/2021] [Accepted: 12/22/2021] [Indexed: 11/18/2022]
Abstract
The research was aimed at analyzing the value of the optimized eXtreme Gradient Boosting (XGBoost) algorithm-based ultrasound cardiogram images in the diagnosis of pregnant hypertension patients. A total of 145 pregnant women (85 cases suffered from hypertension disease during pregnancy and 60 other normal women were healthy) were selected as the reference to the comparison and analysis of ultrasound cardiac function parameter, common carotid artery parameter, and the coupling relationship between hearts and cervical vessels of pregnant hypertension patients. The results demonstrated ultrasound cardiac function parameter of pregnant hypertension patients as follows. The maximum volume of the left atrium (LAVmax) was 35.65 mm, left ventricular end-systolic volume (LVESV) was 31.07 mm, and left ventricular end-diastolic volume (LVEDV) was 88.73 mm. All the above indexes were obviously higher than those of the normal control group (P < 0.05). Besides, intima-media thickness (IMT) of common carotid artery (465.84 μm), pulse wave velocity (PWV) (8.09 m/s), pressure of turning point 1 from isovolumic contraction phase to ejection phase (PT1) (126.5 mmHg), arterial enhancement pressure (AP) (6.14 mmHg), and arterial pressure enhancement index (8.58%) were all significantly higher than those of the normal control group (P < 0.05). In addition, the correlation between the coupling (E/A) of hearts and carotid artery of pregnant hypertension patients and PWV was not obvious (r = -0.08432, P > 0.05). The results of the research indicated that intima-media inside carotid artery of pregnant hypertension patients thickened obviously, and it became less elastic compared with that of normal healthy pregnant women. What is more, cardiac morphological changes were manifested mainly as the enlargement of the left atrial chamber and the thickening of the interventricular septum. Volume load and blood flow velocity both increased, and left ventricular diastolic function was damaged. XGBoost algorithm-based ultrasound cardiogram images could improve the diagnostic effects of hypertension during pregnancy effectively.
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Affiliation(s)
- Xia Zhang
- Department of Function, The Affiliated Wuxi Maternal and Child Health Care Hospital of Nanjing Medical University, Wuxi, 214002 Jiangsu, China
| | - Xi Liang
- Department of Function, The Affiliated Wuxi Maternal and Child Health Care Hospital of Nanjing Medical University, Wuxi, 214002 Jiangsu, China
| | - Wen Cao
- Department of Function, The Affiliated Wuxi Maternal and Child Health Care Hospital of Nanjing Medical University, Wuxi, 214002 Jiangsu, China
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132
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Churchwell K, Lloyd-Jones DM, Rochat Harris S, Mehta LS. Policy Change Needed to Improve Maternal Cardiovascular Health. Circulation 2022; 145:e1-e3. [PMID: 34965163 DOI: 10.1161/circulationaha.121.058054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University, Chicago, IL (D.M.L-J.)
| | | | - Laxmi S Mehta
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, OH (L.S.M.)
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133
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Kasargod Prabhakar CR, Pamment D, Thompson PJ, Chong H, Thorne SA, Fox C, Morris K, Hudsmith LH. Pre-conceptual counselling in cardiology patients: still work to do and still missed opportunities. A comparison between 2015 and 2019 in women with cardiac disease attending combined obstetric cardiology clinics. Should the European Guidelines change anything? Cardiol Young 2022; 32:64-70. [PMID: 34030760 DOI: 10.1017/s1047951121001530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Women with underlying cardiac conditions have an increased risk of adverse pregnancy outcomes. Counselling reproductive age women with heart disease is important to assist them in deciding whether to pursue pregnancy, to ensure their best cardiovascular status prior to pregnancy, and that they understand the risks of pregnancy for them and baby. This also provides an opportunity to explore management strategies to reduce risks. For this growing cohort of women, there is a great need for pre-conceptual counselling.This retrospective comparative audit assessed new referrals and pre-conceptual counselling of women attending a joint obstetric-cardiology clinic at a tertiary maternity centre in a 12-month period of 2015-2016 compared with 2018-2019. This reflected the timing of the introduction of a multidisciplinary meeting prior to clinics and assessed the impact on referrals with the introduction of the European Society of Cardiology guidelines.Data were reviewed from 56 and 67 patients in respective audit periods. Patient's risk was stratified using modified World Health Organization classification.Less than 50% of women with pre-existing cardiac conditions had received pre-conceptual counselling, although half of them had risks clearly documented. The majority of patients had a recent electrocardiograph and echocardiogram performed prior to counselling, and there was a modest improvement in the number of appropriate functional tests performed between time points. One-third of patients in both cohorts were taking cardiac medications during pregnancy.There was a significant increase in the number of pregnant women with cardiac disease and in complexity according to modified World Health Organization risk classification. While there have been improvements, it is clear that further work to improve availability and documentation of pre-pregnancy counselling is needed.
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Affiliation(s)
| | - Daisy Pamment
- University of Birmingham Medical School, Birmingham, UK
| | | | - Hsu Chong
- The Rosie Maternity Hospital, Cambridge, UK
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134
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Leo I, Nakou E, de Marvao A, Wong J, Bucciarelli-Ducci C. Imaging in Women with Heart Failure: Sex-specific Characteristics and Current Challenges. Card Fail Rev 2022; 8:e29. [PMID: 36303591 PMCID: PMC9585642 DOI: 10.15420/cfr.2022.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022] Open
Abstract
Cardiovascular disease (CVD) represents a significant threat to women's health. Heart failure (HF) is one CVD that still has an increasing incidence and about half of all cases involve women. HF is characterised by strong sex-specific features in aetiology, clinical manifestation and outcomes. Women are more likely to have hypertensive heart disease and HF with preserved ejection fraction, they experience worse quality of life but have a better overall survival rate. Women's hearts also have unique morphological characteristics that should be considered during cardiovascular assessment. It is important to understand and highlight these sex-specific features to be able to provide a tailored diagnostic approach and therapeutic management. The aim of this article is to review these aspects together with the challenges and the unique characteristics of different imaging modalities used for the diagnosis and follow-up of women with HF.
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Affiliation(s)
- Isabella Leo
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London, UK.,Department of Medical and Surgical Sciences, Magna Graecia University Catanzaro, Italy
| | - Eleni Nakou
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London, UK
| | - Antonio de Marvao
- Medical Research Council, London Institute of Medical Sciences, Imperial College London London, UK
| | - Joyce Wong
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London, UK
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London, UK.,School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London London, UK
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135
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Steiner JM, Lokken E, Bayley E, Pechan J, Curtin A, Buber J, Albright C. Cardiac and Pregnancy Outcomes of Pregnant Patients With Congenital Heart Disease According to Risk Classification System. Am J Cardiol 2021; 161:95-101. [PMID: 34635313 PMCID: PMC10686784 DOI: 10.1016/j.amjcard.2021.08.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
Pregnancy risk assessment for patients with adult congenital heart disease (ACHD) must include physiologic and anatomic impacts. We aimed to determine whether maternal cardiac and pregnancy outcomes vary by disease severity defined according to the following 3 different classifications: ACHD anatomic severity, ACHD physiologic class, and modified World Health Organization (mWHO) class. Cardiac outcomes included a composite of arrhythmia, heart failure, stroke, and thromboembolism. Pregnancy outcomes included a composite of intrauterine growth restriction, preterm birth, preeclampsia, or postpartum hemorrhage. We employed generalized estimating equations to account for multiple pregnancies. Of the 245 pregnancies, 17.1% were preterm and 45.7% were cesarean deliveries. Cardiac hospitalizations occurred in 22.0% and arrhythmias in 12.7%. Cardiac outcomes tended to be more prevalent in people with more severe heart disease. Pregnancy outcomes were U-shaped or less prevalent in people with more severe disease. There was a 2.9-fold increased risk for the composite cardiac outcome for complex anatomy (adjusted incidence rate ratio 2.90, 95% confidence interval 1.08 to 7.81, p = 0.04), a 9.4-fold increased risk for physiologic class C or D (9.37, 1.28 to 68.79, p = 0.03), and a fourfold increased risk for mWHO class III or IV (3.99, 1.53 to 10.40, p = 0.005). There was a lower risk for the composite pregnancy outcome for mWHO class II or II to III (0.54, 0.36 to 0.79, p = 0.002) but no association with anatomy or physiology. In conclusion, physiologic class may be most accurately associated with adverse outcomes and therefore efforts to optimize hemodynamics before pregnancy may help to mitigate the risk.
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Affiliation(s)
| | - Erica Lokken
- Department of Obstetrics and Gynecology; Department of Global Health, University of Washington, Seattle, Washington
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136
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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137
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 521] [Impact Index Per Article: 173.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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138
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Marill MC. Getting To The Heart Of America's Maternal Mortality Crisis. Health Aff (Millwood) 2021; 40:1824-1829. [PMID: 34871087 DOI: 10.1377/hlthaff.2021.01702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A Missouri cardio-obstetrics program and a national registry target the leading cause of maternal death.
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Affiliation(s)
- Michele Cohen Marill
- This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. Michele Cohen Marill is a freelance reporter based in Atlanta, Georgia. The patient referred to as Megan requested the use of only her first name to protect her privacy
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139
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Adedinsewo DA, Johnson PW, Douglass EJ, Attia IZ, Phillips SD, Goswami RM, Yamani MH, Connolly HM, Rose CH, Sharpe EE, Blauwet L, Lopez-Jimenez F, Friedman PA, Carter RE, Noseworthy PA. Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 2:586-596. [PMID: 34993486 PMCID: PMC8715757 DOI: 10.1093/ehjdh/ztab078] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/12/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022]
Abstract
Aims Cardiovascular disease is a major threat to maternal health, with cardiomyopathy being among the most common acquired cardiovascular diseases during pregnancy and the postpartum period. The aim of our study was to evaluate the effectiveness of an electrocardiogram (ECG)-based deep learning model in identifying cardiomyopathy during pregnancy and the postpartum period. Methods and results We used an ECG-based deep learning model to detect cardiomyopathy in a cohort of women who were pregnant or in the postpartum period seen at Mayo Clinic. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. The study cohort included 1807 women; 7%, 10%, and 13% had left ventricular ejection fraction (LVEF) of 35% or less, <45%, and <50%, respectively. The ECG-based deep learning model identified cardiomyopathy with AUCs of 0.92 (LVEF ≤ 35%), 0.89 (LVEF < 45%), and 0.87 (LVEF < 50%). For LVEF of 35% or less, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to White (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 to 0.86 and 0.72, respectively. Conclusions An ECG-based deep learning model effectively identifies cardiomyopathy during pregnancy and the postpartum period and outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting.
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Affiliation(s)
- Demilade A Adedinsewo
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Patrick W Johnson
- Department of Quantitative Health Sciences, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Erika J Douglass
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Itzhak Zachi Attia
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sabrina D Phillips
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Rohan M Goswami
- Department of Transplant Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Mohamad H Yamani
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Carl H Rose
- Department of Maternal and Fetal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Lori Blauwet
- Department of Cardiovascular Diseases, Olmsted Medical Center, 210 Ninth Street SE Rochester, MN 55904, USA
| | - Francisco Lopez-Jimenez
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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140
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Shah LM, Wand A, Ying W, Hays AG, Blumenthal RS, Barouch LA, Zakaria S, Sharma G. Prevention Starts in the Womb: Opportunities for Addressing Cardiovascular Risk Factors During Pregnancy and Beyond. Methodist Debakey Cardiovasc J 2021; 17:48-59. [PMID: 34824681 PMCID: PMC8588699 DOI: 10.14797/mdcvj.696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022] Open
Abstract
Early identification and mitigation of sex-specific cardiovascular disease risk factors is a potential trajectory-changing strategy to improve lifelong cardiovascular health in women. These sex-specific risk factors include adverse pregnancy outcomes, polycystic ovarian syndrome, and premature menopause. We start by discussing the impact and management of risk factors for adverse pregnancy outcomes as an upstream intervention for cardiovascular disease risk reduction and then address the long-term effect and mitigation of sex-specific risk factors for cardiovascular disease.
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Affiliation(s)
- Lochan M Shah
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Alison Wand
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Wendy Ying
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Allison G Hays
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | | | - Lili A Barouch
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Sammy Zakaria
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Garima Sharma
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
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141
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Management of Maternal Complex Congenital Heart Disease During Pregnancy. Curr Heart Fail Rep 2021; 18:353-361. [PMID: 34783997 DOI: 10.1007/s11897-021-00534-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF THE REVIEW The purpose of this review is to discuss the risk stratification and management of pregnancy in women with complex congenital heart disease. RECENT FINDINGS Classifying congenital heart defects (CHD) including both anatomy and physiology is important for maternal risk stratification. Although most women with CHD can tolerate the physiological challenge of pregnancy, some may experience serious risks both to their health and that of their foetus. The WHO maternal risk classification model remains the best-validated risk measure. Ideally, women with CHD should have pre-conception assessment with a CHD cardiologist. General principles of management, such as need for expert centre delivery, a multidisciplinary team, epidural and mode of delivery are based on WHO risk in combination with expert assessment of status. CHD is increasingly prevalent in women of child-bearing age. Assessment by an adult CHD cardiologist, ideally pre-conception, is key in assessing and minimising risk to mother and foetus.
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142
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Mulrenin IR, Garcia JE, Fashe MM, Loop MS, Daubert MA, Urrutia RP, Lee CR. The impact of pregnancy on antihypertensive drug metabolism and pharmacokinetics: current status and future directions. Expert Opin Drug Metab Toxicol 2021; 17:1261-1279. [PMID: 34739303 DOI: 10.1080/17425255.2021.2002845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are rising in prevalence, and increase risk of adverse maternal and fetal outcomes. Physiologic changes occur during pregnancy that alter drug pharmacokinetics. However, antihypertensive drugs lack pregnancy-specific dosing recommendations due to critical knowledge gaps surrounding the extent of gestational changes in antihypertensive drug pharmacokinetics and underlying mechanisms. AREAS COVERED This review (1) summarizes currently recommended medications and dosing strategies for non-emergent HDP treatment, (2) reviews and synthesizes existing literature identified via a comprehensive Pubmed search evaluating gestational changes in the maternal pharmacokinetics of commonly prescribed HDP drugs (notably labetalol and nifedipine), and (3) offers insight into the metabolism and clearance mechanisms underlying altered HDP drug pharmacokinetics during pregnancy. Remaining knowledge gaps and future research directions are summarized. EXPERT OPINION A series of small pharmacokinetic studies illustrate higher oral clearance of labetalol and nifedipine during pregnancy. Pharmacokinetic modeling and preclinical studies suggest these effects are likely due to pregnancy-associated increases in hepatic UGT1A1- and CYP3A4-mediated first-pass metabolism and lower bioavailability. Accordingly, higher and/or more frequent doses may be needed to lower blood pressure during pregnancy. Future research is needed to address various evidence gaps and inform the development of more precise antihypertensive drug dosing strategies.
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Affiliation(s)
- Ian R Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julian E Garcia
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Muluneh M Fashe
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Shane Loop
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Rachel Peragallo Urrutia
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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143
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Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg MJ, Valente AM, Roos-Hesselink J. Management of acute cardiovascular complications in pregnancy. Eur Heart J 2021; 42:4224-4240. [PMID: 34405872 DOI: 10.1093/eurheartj/ehab546] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/30/2021] [Accepted: 07/27/2021] [Indexed: 11/14/2022] Open
Abstract
The growing population of women with heart disease of reproductive age has been associated with an increasing number of high-risk pregnancies. Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications. Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review summarizes best practice for the treatment of common cardiovascular complications during pregnancy, based on expert opinion, current guidelines, and available evidence. Topics covered include heart failure (HF), arrhythmias, coronary artery disease, aortic and thromboembolic events, and the management of mechanical heart valves during pregnancy. Cardiovascular pathology is the leading cause of non-obstetric morbidity and mortality during pregnancy in developed countries. For women with pre-existing cardiac conditions, preconception counselling and structured follow-up during pregnancy are important measures for reducing the risk of acute cardiovascular complications during gestation and at the time of delivery. However, many women do not receive pre-pregnancy counselling often due to gaps in what should be lifelong care, and physicians are increasingly encountering pregnant women who present acutely with cardiac complications, including HF, arrhythmias, aortic events, coronary syndromes, and bleeding or thrombotic events. This review provides a summary of recommendations on the management of acute cardiovascular complication during pregnancy, based on available literature and expert opinion. This article covers the diagnosis, risk stratification, and therapy and is organized according to the clinical presentation and the type of complication, providing a reference for the practicing cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research.
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Affiliation(s)
- Gabriele Egidy Assenza
- Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, 40138 Bologna, Italy
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Werner Budts
- Congenital and Structural Cardiology University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Andrea Donti
- Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, 40138 Bologna, Italy
| | - Katherine E Economy
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gaetano Domenico Gargiulo
- Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via G. Massarenti, 9, 40138 Bologna, Italy
| | - Michael Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Michael Job Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW People with childbearing capacity who are diagnosed with systemic lupus erythematosus (SLE) and Sjogren's syndrome (SS) have specific and important reproductive health considerations. RECENT FINDINGS Recommendations from the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) provide rheumatologists and other clinicians with guidance for reproductive health management of patients with rheumatic diseases. Patient-centered reproductive health counseling can help clinicians to operationalize the EULAR and ACR guidelines and enhance patient care. SUMMARY Disease activity monitoring, risk factor stratification, and prescription of pregnancy-compatible medications during pregnancy help to anticipate complications and enhance pregnancy outcomes in SLE and SS. Assisted reproductive technologies are also safe among people with well-controlled disease. Safe and effective contraceptive methods are available for patients with SLE and SS, and pregnancy termination appears to be safe among these patients.
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145
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Kris-Etherton PM, Petersen KS, Després JP, Braun L, de Ferranti SD, Furie KL, Lear SA, Lobelo F, Morris PB, Sacks FM. Special Considerations for Healthy Lifestyle Promotion Across the Life Span in Clinical Settings: A Science Advisory From the American Heart Association. Circulation 2021; 144:e515-e532. [PMID: 34689570 DOI: 10.1161/cir.0000000000001014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
At a population level, engagement in healthy lifestyle behaviors is suboptimal in the United States. Moreover, marked disparities exist in healthy lifestyle behaviors and cardiovascular risk factors as a result of social determinants of health. In addition, there are specific challenges to engaging in healthy lifestyle behaviors related to age, developmental stage, or major life circumstances. Key components of a healthy lifestyle are consuming a healthy dietary pattern, engaging in regular physical activity, avoiding use of tobacco products, habitually attaining adequate sleep, and managing stress. For these health behaviors, there are guidelines and recommendations; however, promotion in clinical settings can be challenging, particularly in certain population groups. These challenges must be overcome to facilitate greater promotion of healthy lifestyle practices in clinical settings. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with consideration for the demands of clinical settings. In this science advisory, we summarize specific considerations for lifestyle-related behavior change counseling using the 5A Model for patients across the life span. In all life stages, social determinants of health and unmet social-related health needs, as well as overweight and obesity, are associated with increased risk of cardiovascular disease, and there is the potential to modify this risk with lifestyle-related behavior changes. In addition, specific considerations for lifestyle-related behavior change counseling in life stages in which lifestyle behaviors significantly affect cardiovascular disease risk are outlined. Greater attention to healthy lifestyle behaviors during every clinician visit will contribute to improved cardiovascular health.
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146
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L'Écuyer É, Codsi E, Mongeon FP, Dore A, Morin F, Leduc L. Perinatal and cardiac outcomes of women with hypertrophic cardiomyopathy. J Matern Fetal Neonatal Med 2021; 35:8625-8630. [PMID: 34651531 DOI: 10.1080/14767058.2021.1990883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
RATIONALE Pregnancy causes important physiologic stress for women with hypertrophic cardiomyopathy. Data regarding the impact of this condition on obstetrical outcomes is missing. OBJECTIVES Our objective was to report obstetrical and cardiac outcomes in pregnant women with hypertrophic cardiomyopathy and to assess the possible adverse effects of left ventricular outflow tract obstruction in pregnancy. STUDY DESIGN This was a retrospective cohort study of pregnant women diagnosed with HCM and followed at single tertiary center between 1995 and 2019. Demographic, medical and surgical data, echocardiographic parameters, and pregnancy outcomes were abstracted through extensive chart review. Patients were divided into 2 groups: obstructive (maximal left ventricular outflow tract gradient over 30 mmHg) versus non-obstructive hypertrophic cardiomyopathy. Outcomes between groups were compared with t-test, Mann-Whitney and Fisher's exact tests when appropriate. RESULTS Eighteen women with 27 pregnancies were included. The study population was formed of 18 women with a total of 27 pregnancies that reached at least 20 weeks of gestation: 12 pregnancies in women with obstructive hypertrophic cardiomyopathy and 15 pregnancies in women with non-obstructive hypertrophic cardiomyopathy. Among the non-obstructive hypertrophic cardiomyopathy, 5 of them had been treated for their obstruction. One patient with obstructive hypertrophic cardiomyopathy had a medical termination of pregnancy for uncontrolled arrhythmia at 21 weeks. There were no maternal deaths. Left ventricular outflow tract obstruction was associated with increased cardiac events including arrhythmias and heart failure (5/12 versus 0/15; p = .006). Preterm birth occurred in more than 50% of cases, resulting from induced delivery for a maternal (40%) or fetal reason (60%). Most deliveries were late preterm between 34 and 36 6/7 weeks. In both groups, birthweight was mainly distributed below the 50th percentile (89%) and 35% of neonates were born small for gestational age defined as a birthweight below the 10th percentile. Most severe cases of small for gestational age (birthweight under the 5th percentile) were found in patients with treated obstructive hypertrophic cardiomyopathy. CONCLUSION Hypertrophic cardiomyopathy is associated with prematurity and small for gestational age. Left ventricular outflow tract obstruction is associated with adverse cardiac events including arrythmias or heart failure. Treated obstructive cardiomyopathy constitutes a sub-group of patients at high risk of severe small for gestational age and deserves a close surveillance. Therefore, fetal growth surveillance with ultrasound, early in the third trimester and doppler studies to assess the utero-placental perfusion in the second and third trimesters are warranted in all patients with hypertrophic cardiomyopathy regardless of the severity of their condition.
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Affiliation(s)
- Émilie L'Écuyer
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Division, University Hospital Centre Sainte-Justine, Montreal, Canada.,University of Montreal, Montreal, Canada
| | - Elisabeth Codsi
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Division, University Hospital Centre Sainte-Justine, Montreal, Canada.,University of Montreal, Montreal, Canada
| | - François-Pierre Mongeon
- University of Montreal, Montreal, Canada.,Adult Congenital Heart Disease Center, Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Annie Dore
- University of Montreal, Montreal, Canada.,Adult Congenital Heart Disease Center, Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Francine Morin
- University of Montreal, Montreal, Canada.,Department of Obstetrical Medicine, University Hospital Centre Sainte-Justine, Montreal, Canada
| | - Line Leduc
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Division, University Hospital Centre Sainte-Justine, Montreal, Canada.,University of Montreal, Montreal, Canada
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147
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Mehta LS, Sharma G, Creanga AA, Hameed AB, Hollier LM, Johnson JC, Leffert L, McCullough LD, Mujahid MS, Watson K, White CJ. Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association. Circulation 2021; 144:e251-e269. [PMID: 34493059 DOI: 10.1161/cir.0000000000001000] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.
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148
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Warner LL, Arendt KW, Theiler RN, Sharpe EE. Analgesic considerations for induction of labor. Best Pract Res Clin Obstet Gynaecol 2021; 77:76-89. [PMID: 34627722 DOI: 10.1016/j.bpobgyn.2021.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.
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Affiliation(s)
- Lindsay L Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States.
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States
| | - Regan N Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States
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149
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Anticoagulation of women with congenital heart disease during pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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150
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Ogunwole SM, Chen X, Mitta S, Minhas A, Sharma G, Zakaria S, Vaught AJ, Toth-Manikowski SM, Smith G. Interconception Care for Primary Care Providers: Consensus Recommendations on Preconception and Postpartum Management of Reproductive-Age Patients With Medical Comorbidities. Mayo Clin Proc Innov Qual Outcomes 2021; 5:872-890. [PMID: 34585084 PMCID: PMC8452893 DOI: 10.1016/j.mayocpiqo.2021.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Severe maternal morbidity and mortality continue to increase in the United States, largely owing to chronic and newly diagnosed medical comorbidities. Interconception care, or care and management of medical conditions between pregnancies, can improve chronic disease control before, during, and after pregnancy. It is a crucial and time-sensitive intervention that can decrease maternal morbidity and mortality and improve overall health. Despite these potential benefits, interconception care has not been well implemented by the primary care community. Furthermore, there is a lack of guidelines for optimizing preconception chronic disease, risk stratifying postpartum chronic diseases, and recommending general collaborative management principles for reproductive-age patients in the period between pregnancies. As a result, many primary care providers, especially those without obstetric training, are unclear about their specific role in interconception care and may be unsure of effective methods for collaborating with obstetric care providers. In particular, internal medicine physicians, the largest group of primary care physicians, may lack sufficient clinical exposure to medical conditions in the obstetric population during their residency training and may feel uncomfortable in caring for these patients in their subsequent practice. The objective of this article is to review concepts around interconception care, focusing specifically on preconception care for patients with chronic medical conditions (eg, chronic hypertension, chronic diabetes mellitus, chronic kidney disease, venous thromboembolism, and obesity) and postpartum care for those with medically complicated pregnancies (eg, hypertensive disorders of pregnancy, gestational diabetes mellitus, excessive gestational weight gain, peripartum cardiomyopathy, and peripartum mood disorders). We also provide a pragmatic checklist for preconception and postpartum management.
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Key Words
- ACE, angiotensin-converting enzyme
- ACOG, American College of Obstetricians and Gynecologists
- ARB, angiotensin receptor blocker
- BMI, body mass index
- CKD, chronic kidney disease
- CVD, cardiovascular disease
- DM, diabetes mellitus
- GDM, gestational diabetes mellitus
- HDP, hypertensive disorder of pregnancy
- HbA1c, hemoglobin A1c
- MFM, maternal-fetal medicine
- NTD, neural tube defect
- OB/GYN, obstetrician/gynecologist
- PCP, primary care provider
- PPCM, peripartum cardiomyopathy
- SMFM, Society for Maternal-Fetal Medicine
- VTE, venous thromboembolism
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Affiliation(s)
- S Michelle Ogunwole
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiaolei Chen
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Srilakshmi Mitta
- Division of Obstetric and Consultative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Anum Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arthur Jason Vaught
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie M Toth-Manikowski
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago
| | - Graeme Smith
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Queens University School of Medicine, Kingston, Ontario, Canada
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