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Keepanasseril A, Pande SN, Suriya Y, Baghel J, Mondal N, Pillai AA, Satheesh S, Siu SC. Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis. Am Heart J 2024; 273:140-147. [PMID: 38614235 DOI: 10.1016/j.ahj.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. METHODS The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. RESULTS Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. CONCLUSIONS Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.
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Affiliation(s)
- Anish Keepanasseril
- Departments of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Swaraj Nandini Pande
- Departments of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Yavana Suriya
- Departments of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jyoti Baghel
- Departments of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedita Mondal
- Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Ajith A Pillai
- Cardiology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Santhosh Satheesh
- Cardiology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Canada; Division of Cardiology, University of Western Ontario, London, Canada
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2
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Cabrera Fernandez DL, Lopez KN, Bravo-Jaimes K, Mackie AS. The Impact of Social Determinants of Health on Transition From Pediatric to Adult Cardiology Care. Can J Cardiol 2024; 40:1043-1055. [PMID: 38583706 DOI: 10.1016/j.cjca.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024] Open
Abstract
Social determinants of health (SDoH) are the economic, social, environmental, and psychosocial factors that influence health. Adolescents and young adults with congenital heart disease (CHD) require lifelong cardiology follow-up and therefore coordinated transition from pediatric to adult healthcare systems. However, gaps in care are common during transition, and they are driven in part by pervasive disparities in SDoH, including race, ethnicity, socioeconomic status, access to insurance, and remote location of residence. These disparities often coexist and compound the challenges faced by patients and families. For example, Black and Indigenous individuals are more likely to be subject to systemic racism and implicit bias within healthcare and other settings, to be unemployed and poor, to have limited access to insurance, and to have a lower likelihood of transfer of care to adult CHD specialists. SDoH also are associated with acquired cardiovascular disease, a comorbidity that adults with CHD face. This review summarizes existing evidence regarding the impact of SDoH on the transition to adult care and proposes strategies at the individual, institutional, and population and/or system levels. to reduce inequities faced by transition-age youth. These strategies include routinely screening for SDoH in clinical settings with referral to appropriate services, providing formal transition education for all transition-age youth, including training on navigating complex medical systems, creating satellite cardiology clinics to facilitate access to care for those who live remote from tertiary centres, advocating for lifelong insurance coverage where applicable, mandating cultural-sensitivity training for providers, and increasing the diversity of healthcare providers in pediatric and adult CHD care.
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Affiliation(s)
- Diana L Cabrera Fernandez
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Keila N Lopez
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital and Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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3
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Rizi SS, Wiens E, Hunt J, Ducas R. Cardiac physiology and pathophysiology in pregnancy. Can J Physiol Pharmacol 2024. [PMID: 38815593 DOI: 10.1139/cjpp-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.
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Affiliation(s)
- Shekoofeh Saboktakin Rizi
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evan Wiens
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Hunt
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
| | - Robin Ducas
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
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4
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Rakisheva A, Sliwa K, Bauersachs J, Van Linthout S, Chopra VK, Bayes-Genis A, Fruzzetti F, Cannatà A, Deniau B, Mebazaa A, Savarese G, Ray R, Vitale C, Metra M, Rosano GMC. Multidisciplinary care of peripartum heart failure: A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:742-753. [PMID: 38679896 DOI: 10.1002/ejhf.3246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/22/2024] [Accepted: 04/04/2024] [Indexed: 05/01/2024] Open
Abstract
Heart failure is the most common cardiovascular complication during pregnancy and the postpartum period. It is associated with increased risk of maternal morbidity and mortality as well as potentially life-threatening foetal pathology. Management of heart failure in pregnancy requires expert knowledge of cardiovascular disease as well as obstetrics which underscores the importance of multidisciplinary cardio-obstetrics teams in order to optimize diagnosis, treatment and outcome. This includes counselling of women at risk before and during the course of pregnancy in order to strengthen the relationship between medical specialists and patients, as well as to allow patient-centred delivery of care and improve quality of life.
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Affiliation(s)
- Amina Rakisheva
- Department of Cardiology, City Cardiology Center, Almaty, Kazakhstan
- Qonaev City Hospital, Almaty, Kazakhstan
| | - Karen Sliwa
- Cape Heart Institute, Department of Cardiology and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité - Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | | | - Antoni Bayes-Genis
- CIBERCV, Carlos III Institute of Health, Madrid, Spain
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Franca Fruzzetti
- Department of Obstetrics and Gynecology, Pisa University Hospital, Pisa, Italy
| | - Antonio Cannatà
- King's College London, British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine & Sciences, London, UK
| | - Benjamin Deniau
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis - Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, DMU Parabol, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis - Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, DMU Parabol, Paris, France
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Robin Ray
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, St George's Hospital, London, UK
| | - Cristiana Vitale
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, St George's Hospital, London, UK
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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5
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Wiens EJ, Kawa K, Kass M, Shah AH. Impact of biological sex on valvular heart disease, interventions, and outcomes. Can J Physiol Pharmacol 2024. [PMID: 38427984 DOI: 10.1139/cjpp-2023-0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Valvular heart disease (VHD) is common, affecting >14% of individuals aged >75, and is associated with morbidity, including heart failure and arrhythmia, and risk of early mortality. Increasingly, important sex differences are being found between males and females with VHD. These sex differences can involve the epidemiology, pathophysiology, presentation, diagnosis, and outcomes of the disease. Females are often disadvantaged, and female sex has been shown to be associated with delayed diagnosis and inferior outcomes in various forms of VHD. In addition, the unique pathophysiologic state of pregnancy is associated with increased risk for maternal and fetal morbidity and mortality in many forms of VHD. Therefore, understanding and recognizing these sex differences, and familiarity with the attendant risks of pregnancy and management of pregnant females with VHD, is of great importance for any primary care or cardiovascular medicine practitioner caring for the female patient. This review will outline sex differences in aortic, mitral, pulmonic, and tricuspid VHD, with particular focus on differences in pathophysiology, clinical presentation, and outcomes. In addition, the pathophysiology and management implications of pregnancy will be discussed.
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Affiliation(s)
- Evan J Wiens
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kristal Kawa
- College of Nursing, University of Manitoba, Winnipeg, MB, Canada
| | - Malek Kass
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ashish H Shah
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Norris CM, Mullen KA, Foulds HJ, Jaffer S, Nerenberg K, Gulati M, Parast N, Tegg N, Gonsalves CA, Grewal J, Hart D, Levinsson AL, Mulvagh SL. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health. CJC Open 2024; 6:205-219. [PMID: 38487069 PMCID: PMC10935698 DOI: 10.1016/j.cjco.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/31/2023] [Indexed: 03/17/2024] Open
Abstract
Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.
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Affiliation(s)
- Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kerri-Anne Mullen
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shahin Jaffer
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kara Nerenberg
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martha Gulati
- Barbra Streisand Women’s Heart Centre, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nazli Parast
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nicole Tegg
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jasmine Grewal
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donna Hart
- Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | | | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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7
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Clavel MA, Van Spall HG, Mantella LE, Foulds H, Randhawa V, Parry M, Liblik K, Kirkham AA, Cotie L, Jaffer S, Bruneau J, Colella TJ, Ahmed S, Dhukai A, Gomes Z, Adreak N, Keeping-Burke L, Limbachia J, Liu S, Jacques KE, Mullen KA, Mulvagh SL, Norris CM. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada. CJC Open 2024; 6:220-257. [PMID: 38487042 PMCID: PMC10935691 DOI: 10.1016/j.cjco.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/14/2023] [Indexed: 03/17/2024] Open
Abstract
Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.
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Affiliation(s)
- Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Harriette G.C. Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, McMaster University, Toronto, Ontario, Canada
| | - Laura E. Mantella
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Heather Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Varinder Randhawa
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Kingston, Ontario, Canada
| | - Amy A. Kirkham
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Lisa Cotie
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Shahin Jaffer
- General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jill Bruneau
- Faculty of Nursing, Memorial University of Newfoundland and Labrador, St John, Newfoundland and Labrador, Canada
| | - Tracey J.F. Colella
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Sofia Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Zoya Gomes
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Najah Adreak
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Keeping-Burke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Jayneel Limbachia
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Shuangbo Liu
- Section of Cardiology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Karen E. Jacques
- Person with lived experience, Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | - Kerri A. Mullen
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Blissett S, Alphonsus L, Eastabrook G, Banner H, Siu SC. Designing a Multidisciplinary Cardio-obstetrics Curriculum for General Cardiology and Obstetrics Residents: A National Survey of Educational Needs. CJC Open 2024; 6:174-181. [PMID: 38487046 PMCID: PMC10935673 DOI: 10.1016/j.cjco.2023.12.014] [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: 03/16/2023] [Accepted: 12/10/2023] [Indexed: 03/17/2024] Open
Abstract
Background The increasing and potentially preventable cardiac events in pregnant patients have led to calls to enhance multidisciplinary cardio-obstetrics education. To design a multidisciplinary cardio-obstetrics curriculum for general cardiology and obstetrics and gynecology (OBGYN) residents, we need to define educational needs from the perspectives of both cardiology and OBGYN residents. Our study characterizes the educational needs of Canadian cardiology and OBGYN residents. Methods Canadian cardiology and OBGYN residents were surveyed on clinical exposures, perceived needs for topics, unperceived needs for topics (multiple-choice questions) and preferences for educational formats. High priorities were defined as ≥ 50% of responses indicating a perceived need or ≥ 50% indicating an unperceived need. Results A total of 154 residents participated (cardiology n = 44, OBGYN n = 110). Residents reported insufficient clinical exposure to nearly all cardiac disorders, with 33% of exposures occurring in multidisciplinary contexts. All topics aside from gestational hypertension were rated as high priority on perceived needs by both specialties. High-priority unperceived needs were congenital heart disease (both specialties), pre-existing acquired heart disease (both specialties), medication safety (OBGYN), peripartum management (OBGYN), and pregnancy-related heart disease (OBGYN). Cardiology and OBGYN residents shared preferences for in-person simulation, virtual simulation, and online modules. Conclusions Residents in both specialties reported low clinical exposure to most cardiac disorders during pregnancy, identified high-priority perceived needs in multiple topics, and shared 2 high-priority unperceived needs. OBGYN residents identified 3 additional high-priority unperceived needs. These data can inform design of multidisciplinary cardio-obstetrics curricula for general cardiology and OBGYN residents.
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Affiliation(s)
- Sarah Blissett
- Department of Medicine, Division of Cardiology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Centre for Education Research & Innovation (CERI), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Lotus Alphonsus
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Genevieve Eastabrook
- Department of Obstetrics and Gynecology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Harrison Banner
- Department of Obstetrics and Gynecology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Samuel C. Siu
- Department of Medicine, Division of Cardiology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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9
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Mulvagh SL, Colella TJ, Gulati M, Crosier R, Allana S, Randhawa VK, Bruneau J, Pacheco C, Jaffer S, Cotie L, Mensour E, Clavel MA, Hill B, Kirkham AA, Foulds H, Liblik K, Van Damme A, Grace SL, Bouchard K, Tulloch H, Robert H, Pike A, Benham JL, Tegg N, Parast N, Adreak N, Boivin-Proulx LA, Parry M, Gomes Z, Sarfi H, Iwegim C, Van Spall HG, Nerenberg KA, Wright SP, Limbachia JA, Mullen KA, Norris CM. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations. CJC Open 2024; 6:258-278. [PMID: 38487064 PMCID: PMC10935707 DOI: 10.1016/j.cjco.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/03/2023] [Indexed: 03/17/2024] Open
Abstract
This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.
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Affiliation(s)
- Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tracey J.F. Colella
- KITE-UHN-Toronto Rehabilitation, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Martha Gulati
- Barbra Streisand Women’s Heart Center, Cedars Sinai Heart Institute, Los Angeles, California, USA
| | - Rebecca Crosier
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Jill Bruneau
- Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Christine Pacheco
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Shahin Jaffer
- Department of Medicine, Division of Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Cotie
- KITE-UHN-Toronto Rehabilitation, Toronto, Ontario, Canada
| | - Emma Mensour
- University of Western Ontario, London, Ontario, Canada
| | | | - Braeden Hill
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Amy A. Kirkham
- KITE-UHN-Toronto Rehabilitation, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Heather Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kiera Liblik
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Andrea Van Damme
- University of Alberta Faculty of Graduate & Postdoctoral Studies, Edmonton, Alberta, Canada
| | - Sherry L. Grace
- York University and University Health Network, Toronto, Ontario, Canada
| | - Karen Bouchard
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather Tulloch
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Helen Robert
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - April Pike
- Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jamie L. Benham
- Departments of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Tegg
- Faculties of Nursing, Medicine, and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nazli Parast
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Najah Adreak
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Zoya Gomes
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hope Sarfi
- Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | - Chinelo Iwegim
- Fraser Health Authority, Surrey, British Columbia, Canada
| | - Harriette G.C. Van Spall
- Departments of Medicine and Health Research Methods, Evidence, and Impact, Research Institute of St Joe’s, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kara A. Nerenberg
- Departments of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Colleen M. Norris
- Faculties of Nursing, Medicine, and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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10
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Bassett AS, Reuter MS, Malecki S, Silversides C, Oechslin E. Clinically Relevant Genetic Considerations for Patients With Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:426-439. [PMID: 38161665 PMCID: PMC10755827 DOI: 10.1016/j.cjcpc.2023.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/05/2023] [Indexed: 01/03/2024]
Abstract
Genetic changes affect embryogenesis, cardiac and extracardiac phenotype, development, later onset conditions, and both short- and long-term outcomes and comorbidities in the increasing population of individuals with tetralogy of Fallot (TOF). In this review, we focus on current knowledge about clinically relevant genetics for patients with TOF across the lifespan. The latest findings for TOF genetics that are pertinent to day-to-day practice and lifelong management are highlighted: morbidity/mortality, cardiac/extracardiac features, including neurodevelopmental expression, and recent changes to prenatal screening and diagnostics. Genome-wide microarray is the first-line clinical genetic test for TOF across the lifespan, detecting relevant structural changes including the most common for TOF, the 22q11.2 microdeletion. Accumulating evidence illustrates opportunities for advances in understanding and care that may arise from genetic diagnosis at any age. We also glimpse into the near future when the multigenic nature of TOF will be more fully revealed, further enhancing possibilities for preventive care. Precision medicine is nigh.
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Affiliation(s)
- Anne S. Bassett
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, and Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada
| | - Miriam S. Reuter
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sarah Malecki
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Candice Silversides
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Erwin Oechslin
- The Dalglish Family 22q Clinic, University Health Network, Toronto, Ontario, Canada
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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11
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Mackie AS, Bravo-Jaimes K, Keir M, Sillman C, Kovacs AH. Access to Specialized Care Across the Lifespan in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:267-282. [PMID: 38161668 PMCID: PMC10755796 DOI: 10.1016/j.cjcpc.2023.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/05/2023] [Indexed: 01/03/2024]
Abstract
Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.
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Affiliation(s)
- Andrew S. Mackie
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Sillman
- Adult Congenital Heart Disease Program, Sutter Heart and Vascular Institute, Sacramento, California, USA
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12
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Shan D, Ji Y, Hu Y, Li T. Treasure to the mother and threat to the fetus: case report of warfarin-associated fetal intracranial hemorrhage and review of literature. J Int Med Res 2023; 51:3000605231192773. [PMID: 37572075 PMCID: PMC10423455 DOI: 10.1177/03000605231192773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/20/2023] [Indexed: 08/14/2023] Open
Abstract
In patients with mechanical heart valve protheses, warfarin is usually recommended because of its exceptional anticoagulation effects. However, warfarin can cross the placenta, leading to teratogenicity and even catastrophic hemorrhage in the fetus. The present article describes a case of warfarin-associated fetal intracranial hemorrhage. The patient was a woman in her early 30s. At the age of 11 years, she had undergone aortic valve replacement (mechanical) for aortic regurgitation. Since then, she had been taking oral warfarin. During her pregnancy, her prothrombin time-international normalized ratio was maintained between 1.5 and 2.5. At 35 weeks of gestation, fetal ultrasonography revealed an intracranial mass in the left hemisphere. An emergency cesarean section was performed because fetal intracranial hemorrhage was suspected. A male infant was delivered with a 1- 5-, and 10-minute Apgar score of 1, 5, and 7, respectively. Cranial computed tomography revealed multiple hemorrhage sites with newly emerged bleeding spots. In patients with mechanical heart valve protheses, obstetricians face the dilemma of individual-patient differences and the difficulty of intensive monitoring of the coagulation parameters in the fetus. Tailor-made anticoagulation therapy and a more intensive ultrasonic monitoring strategy, even that involving regular magnetic resonance imaging, are necessary in these patients.
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Affiliation(s)
- Dan Shan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan
| | - Yurou Ji
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan
| | - Yayi Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan
| | - Tao Li
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan
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13
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Zhang R, Peng L, Xu Y, Liu Y. Mechanical thrombectomy for acute ischemic stroke with large vessel occlusion in pregnancy with mechanical heart valves: A case report. Heliyon 2023; 9:e18616. [PMID: 37560712 PMCID: PMC10407143 DOI: 10.1016/j.heliyon.2023.e18616] [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: 02/07/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The management of anticoagulation for mechanical heart valves (MHVs) during pregnancy posed a special challenge. Mechanical thrombectomy (MT) was the standard treatment for acute ischemic stroke (AIS) in anterior circulation with large vessel occlusion. However, the efficacy and safety of MT in the treatment of acute ischemic stroke in pregnancy were unknown. CASE PRESENTATION A 29-year-old woman with MHVs in her first pregnancy at 7 weeks' gestation underwent MT because of a large occlusive thrombus in the end of the internal carotid artery despite therapeutic anticoagulation with low-molecular-weight heparin. This pregnant woman recovered well after MT with a modified rank score (mRS) of 0 at 90 days. CONCLUSION At present, there was no standard protocol of anticoagulation therapy for pregnant women with MHVs. Acute ischemic stroke with large vessel occlusion in pregnancy was rare, but could bring devastating consequences for both mother and infant. Our case report demonstrated that MT could be safe and effective in pregnancy.
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Affiliation(s)
- Renwei Zhang
- Department of Neurology, Zhongnan Hospital of Wuhan Universtiy, Wuhan, China
| | - Li Peng
- Department of Cardiology, Zhongnan Hospital of Wuhan Universtiy, Wuhan, China
| | - Yao Xu
- Department of Neurology, Zhongnan Hospital of Wuhan Universtiy, Wuhan, China
| | - Yumin Liu
- Department of Neurology, Zhongnan Hospital of Wuhan Universtiy, Wuhan, China
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14
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Siu SC, Lee DS, Fang J, Austin PC, Silversides CK. New Hypertension After Pregnancy in Patients With Heart Disease. J Am Heart Assoc 2023; 12:e029260. [PMID: 37158089 DOI: 10.1161/jaha.122.029260] [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] [Indexed: 05/10/2023]
Abstract
Background After pregnancy, patients with preexisting heart disease are at high risk for cardiovascular complications. The primary objective was to compare the incidence of new hypertension after pregnancy in patients with and without heart disease. Methods and Results This was a retrospective matched-cohort study comparing the incidence of new hypertension after pregnancy in 832 patients who are pregnant with congenital or acquired heart disease to a comparison group of 1664 patients who are pregnant without heart disease; matching was by demographics and baseline risk for hypertension at the time of the index pregnancy. We also examined whether new hypertension was associated with subsequent death or cardiovascular events. The 20-year cumulative incidence of hypertension was 24% in patients with heart disease, compared with 14% in patients without heart disease (hazard ratio [HR], 1.81 [95% CI, 1.44-2.27]). The median follow-up time at hypertension diagnosis in the heart disease group was 8.1 years (interquartile range, 4.2-11.9 years). The elevated rate of new hypertension was observed not only in patients with ischemic heart disease, but also in those with left-sided valve disease, cardiomyopathy, and congenital heart disease. Pregnancy risk prediction methods can further stratify risk of new hypertension. New hypertension was associated with an increased rate of subsequent death or cardiovascular events (HR, 1.54 [95% CI, 1.05-2.25]). Conclusions Patients with heart disease are at higher risk for developing hypertension in the decades after pregnancy when compared with those without heart disease. New hypertension in this young cohort is associated with adverse cardiovascular events highlighting the importance of systematic and lifelong surveillance.
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Affiliation(s)
- Samuel C Siu
- Division of Cardiology University of Toronto Pregnancy and Heart Disease Program Toronto Canada
- Maternal Cardiology Program, Division of Cardiology Department of Medicine Schulich School of Medicine and Dentistry London Ontario Canada
- ICES Toronto Ontario Canada
- Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health Network University of Toronto Ontario Canada
| | - Douglas S Lee
- ICES Toronto Ontario Canada
- Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health Network University of Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada
| | | | - Peter C Austin
- ICES Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada
| | - Candice K Silversides
- Division of Cardiology University of Toronto Pregnancy and Heart Disease Program Toronto Canada
- Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health Network University of Toronto Ontario Canada
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15
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Boot E, Óskarsdóttir S, Loo JCY, Crowley TB, Orchanian-Cheff A, Andrade DM, Arganbright JM, Castelein RM, Cserti-Gazdewich C, de Reuver S, Fiksinski AM, Klingberg G, Lang AE, Mascarenhas MR, Moss EM, Nowakowska BA, Oechslin E, Palmer L, Repetto GM, Reyes NGD, Schneider M, Silversides C, Sullivan KE, Swillen A, van Amelsvoort TAMJ, Van Batavia JP, Vingerhoets C, McDonald-McGinn DM, Bassett AS. Updated clinical practice recommendations for managing adults with 22q11.2 deletion syndrome. Genet Med 2023; 25:100344. [PMID: 36729052 DOI: 10.1016/j.gim.2022.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 02/03/2023] Open
Abstract
This review aimed to update the clinical practice guidelines for managing adults with 22q11.2 deletion syndrome (22q11.2DS). The 22q11.2 Society recruited expert clinicians worldwide to revise the original clinical practice guidelines for adults in a stepwise process according to best practices: (1) a systematic literature search (1992-2021), (2) study selection and synthesis by clinical experts from 8 countries, covering 24 subspecialties, and (3) formulation of consensus recommendations based on the literature and further shaped by patient advocate survey results. Of 2441 22q11.2DS-relevant publications initially identified, 2344 received full-text review, with 2318 meeting inclusion criteria (clinical care relevance to 22q11.2DS) including 894 with potential relevance to adults. The evidence base remains limited. Thus multidisciplinary recommendations represent statements of current best practice for this evolving field, informed by the available literature. These recommendations provide guidance for the recognition, evaluation, surveillance, and management of the many emerging and chronic 22q11.2DS-associated multisystem morbidities relevant to adults. The recommendations also address key genetic counseling and psychosocial considerations for the increasing numbers of adults with this complex condition.
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Affiliation(s)
- Erik Boot
- Advisium, 's Heeren Loo Zorggroep, Amersfoort, The Netherlands; The Dalglish Family 22q Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.
| | - Sólveig Óskarsdóttir
- Department of Pediatric Rheumatology and Immunology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Joanne C Y Loo
- The Dalglish Family 22q Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Terrence Blaine Crowley
- 22q and You Center, Clinical Genetics Center, and Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ani Orchanian-Cheff
- Library and Information Services, and The Institute of Education Research (TIER), University Health Network, Toronto, Ontario, Canada
| | - Danielle M Andrade
- Adult Genetic Epilepsy Program, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Jill M Arganbright
- Division of Otolaryngology, Children's Mercy Hospital and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - René M Castelein
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Steven de Reuver
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ania M Fiksinski
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands; Department of Pediatric Psychology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Anthony E Lang
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Maria R Mascarenhas
- Division of Gastroenterology and 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Erwin Oechslin
- Toronto Adult Congenital Heart Disease Program, Peter Munk Cardiac Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lisa Palmer
- The Dalglish Family 22q Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Gabriela M Repetto
- Rare Diseases Program, Institute for Sciences and Innovation in Medicine, Facultad de Medicina Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Nikolai Gil D Reyes
- The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Maude Schneider
- Clinical Psychology Unit for Intellectual and Developmental Disabilities, Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Candice Silversides
- Toronto ACHD Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen E Sullivan
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA; Division of Allergy and Immunology and 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ann Swillen
- Center for Human Genetics, University Hospital UZ Leuven, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | | | - Jason P Van Batavia
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA; Division of Urology and 22q and You Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Claudia Vingerhoets
- Advisium, 's Heeren Loo Zorggroep, Amersfoort, The Netherlands; Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Donna M McDonald-McGinn
- 22q and You Center, Clinical Genetics Center, and Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA; Department of Human Biology and Medical Genetics, Sapienza University, Rome, Italy.
| | - Anne S Bassett
- The Dalglish Family 22q Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Clinical Genetics Research Program and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Mental Health and Division of Cardiology, Department of Medicine, and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.
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16
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Keir M, Borman M, Clegg R, Colbert J, Guron N, Harper L, Helmerson D, Patzer J, Reynolds S, Alvarez N. Caring for the Aging Patient With Adult Congenital Heart Disease: A Review of Cardiac and Noncardiac Comorbidities. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:274-281. [PMID: 37969485 PMCID: PMC10642149 DOI: 10.1016/j.cjcpc.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2023]
Abstract
As the demographics of congenital heart disease (CHD) have shifted, there are now more adults living with CHD than children in North America. This presents unprecedented challenges as patients with CHD acquire noncardiac comorbidities and seek care for a variety of reasons, including noncardiac surgery and emergency department (ED) visits. CHD shifts from a one organ problem to a multisystem disease and requires a team of specialists to maintain high-quality longitudinal care. In this review, we summarize the challenges patients with CHD and their providers face as they age. We review the demographics of CHD and health care utilization. We examine the rates of noncardiac comorbidities and the current quality of care received by adult patients with CHD.
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Affiliation(s)
- Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meredith Borman
- Section of Gastroenterology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robin Clegg
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Colbert
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nita Guron
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lea Harper
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Helmerson
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Patzer
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Reynolds
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nanette Alvarez
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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17
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Wright JM, Bottega N, Therrien J, Hatzakorzian R, Buithieu J, Shum-Tim D, Wou K, Ghandour A, Pelletier P, Li Pi Shan W, Kaufman I, Brown R, Malhamé I. The multidisciplinary management of a mechanical mitral valve thrombosis in pregnancy: a case report and review of the literature. Eur Heart J Case Rep 2022; 6:ytac424. [PMID: 36405542 PMCID: PMC9668069 DOI: 10.1093/ehjcr/ytac424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/14/2022] [Accepted: 10/26/2022] [Indexed: 08/14/2023]
Abstract
Background The management of anticoagulation for mechanical heart valves during pregnancy poses a unique challenge. Mechanical valve thrombosis is a devastating complication for which surgery is often the treatment of choice. However, cardiac surgery for prosthetic valve dysfunction in pregnant patients confers a high risk of maternofetal morbidity and mortality. Case summary A 39-year-old woman in her first pregnancy at 30 weeks gestation presented to hospital with a mechanical mitral valve thrombosis despite therapeutic anticoagulation with low-molecular-weight heparin. She underwent an emergent caesarean section followed immediately by a bioprosthetic mitral valve replacement. This occurred after careful planning and organization on the part of a large multidisciplinary team. Discussion A proactive, rather than reactive, approach to the surgical management of a mechanical valve thrombosis in pregnancy will maximize the chances of successful maternal and fetal outcomes.
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Affiliation(s)
- Jennifer M Wright
- Department of Medicine, McGill University, McGill University Health Centre, Montréal, Quebec, Canada
| | - Natalie Bottega
- Department of Medicine, McGill University, McGill University Health Centre, Montréal, Quebec, Canada
| | - Judith Therrien
- Department of Medicine, Jewish General Hospital, Montréal, Quebec, Canada
| | - Roupen Hatzakorzian
- Department of Anaesthesia, McGill University Health Centre, Montréal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montréal, Quebec, Canada
| | - Jean Buithieu
- Department of Medicine, McGill University, McGill University Health Centre, Montréal, Quebec, Canada
| | - Dominique Shum-Tim
- Department of Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Karen Wou
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montréal, Quebec, Canada
| | - Amale Ghandour
- Department of Surgery, McGill University Health Centre, Montréal, Quebec, Canada
| | - Patricia Pelletier
- Department of Medicine, McGill University, McGill University Health Centre, Montréal, Quebec, Canada
| | - William Li Pi Shan
- Department of Anaesthesia, McGill University Health Centre, Montréal, Quebec, Canada
| | - Ian Kaufman
- Department of Anaesthesia, McGill University Health Centre, Montréal, Quebec, Canada
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montréal, Quebec, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University, McGill University Health Centre, Montréal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research institute of the McGill University Health Centre, Montréal, Quebec, Canada
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18
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Gédéon T, Akl E, D'Souza R, Altit G, Rowe H, Flannery A, Siriki P, Bhatia K, Thorne S, Malhamé I. Acute Myocardial Infarction in Pregnancy. Curr Probl Cardiol 2022; 47:101327. [PMID: 35901856 DOI: 10.1016/j.cpcardiol.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.
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Affiliation(s)
- Tara Gédéon
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Elie Akl
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gabriel Altit
- Department of Paediatrics, McGill University Health Centre, Montreal, Canada
| | - Hilary Rowe
- Department of Pharmacy, Nanaimo Regional General Hospital, Island Health, Nanaimo, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alexandria Flannery
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Kailash Bhatia
- Department of Anaesthesia, Manchester University Hospitals and St Mary's Hospital, University of Manchester, Manchester, United Kingdom
| | - Sara Thorne
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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19
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Fernandez Campos BA, Silversides CK. Marfan syndrome and pregnancy-related aortic complications: contemporary outcomes from two Spanish Marfan units. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:542-544. [PMID: 35339410 DOI: 10.1016/j.rec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Beatriz Aldara Fernandez Campos
- University of Toronto, Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Candice K Silversides
- University of Toronto, Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Canada.
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Malhamé I, Raker CA, Hardy EJ, Spalding H, Bouvier BA, Hurlburt H, Vrees R, Daskalopoulou SS, Nerenberg K, Savitz DA, Mehta N, Danilack VA. Development and Internal Validation of a Risk Prediction Model for Acute Cardiovascular Morbidity in Preeclampsia. Can J Cardiol 2022; 38:1591-1599. [PMID: 35709932 DOI: 10.1016/j.cjca.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/05/2022] [Accepted: 05/08/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Persons with preeclampsia are at increased short-term risk of adverse cardiovascular outcomes during pregnancy and the early postpartum period. We aimed to develop and internally validate a risk assessment tool to predict acute cardiovascular morbidity in preeclampsia. METHODS The study was conducted at an academic obstetric hospital. Participants with preeclampsia at delivery between 2007 and 2017 were included. A model to predict acute cardiovascular morbidity at delivery and within 6 weeks postpartum was developed and evaluated. The primary composite outcome included pulmonary edema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm, and difficult-to-control severe hypertension. We assessed model discrimination and calibration. We used bootstrapping for internal validation. RESULTS 4,171 participants with preeclampsia were included. The final model comprised 8 variables. Predictors positively associated with acute cardiovascular morbidity (presented as odds ratio [OR] with 95% confidence interval [CI]) were: gestational age at delivery (20-36 weeks 5.36 [3.67, 7.82]; 37-38 weeks 1.75 [1.16, 2.64]), maternal age (≥40 years 1.65 [1.00, 2.72]; 35-39 years 1.49 [1.07, 2.09]), and prior cesarean delivery (1.47, [1.01, 2.13]). The model had an area under the receiver operating characteristic curve of 0.72 (95% CI [0.69, 0.74]). Moreover, it was adequately calibrated and performed well on internal validation. CONCLUSIONS This risk prediction tool identified women with preeclampsia at highest risk of acute cardiovascular morbidity. If externally validated, this tool may facilitate early interventions aimed at preventing adverse cardiovascular outcomes in pregnancy and postpartum.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; Research institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - Christina A Raker
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Erica J Hardy
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA; Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Hannah Spalding
- Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Benjamin A Bouvier
- Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Heather Hurlburt
- Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Roxanne Vrees
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Stella S Daskalopoulou
- Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; Research institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kara Nerenberg
- Departments of Medicine, Obstetrics & Gynecology, and Community Health Sciences Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David A Savitz
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Niharika Mehta
- Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Valery A Danilack
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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Fernandez Campos BA, Silversides CK. Síndrome de Marfan y complicaciones aórticas en el embarazo. Resultados contemporáneos de dos unidades de Marfan españolas. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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22
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Keepanasseril A, Pfaller B, Metcalfe A, Siu SC, Davis MB, Silversides CK. Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies. Can J Cardiol 2021; 37:1969-1978. [PMID: 34600086 DOI: 10.1016/j.cjca.2021.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/16/2022] Open
Abstract
There has been an increase in maternal deaths from cardiovascular disease in many countries. In high-income countries, cardiovascular deaths secondary to cardiomyopathies, ischemic heart disease, sudden arrhythmic deaths, aortic dissection, and valve disease are responsible for up to one-third of all pregnancy-related maternal deaths. In low- and middle-income countries, rheumatic heart disease is a much more common cause of cardiac death during pregnancy. Although deaths occur in women with known heart conditions or cardiovascular risk factors such as hypertension, many women present for the first time in pregnancy with unrecognised heart disease or with de novo cardiovascular conditions such as preeclampsia, peripartum cardiomyopathy, spontaneous coronary artery dissection. Not only has maternal cardiovascular mortality increased, but serious cardiac morbidity, or "near misses," during pregnancy also have increased in frequency. Although maternal morbidity and mortality are often preventable, many health professionals remain unaware of the impact of cardiovascular disease in this population, and the lack of awareness contributes to inappropriate care and preventable deaths. In this review, we discuss the maternal mortality from cardiovascular causes in both high- and low- and middle-income countries and strategies to improve outcomes.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Birgit Pfaller
- Department of Internal Medicine 1, University Hospital of St Pölten, Karl Landsteiner University of Health Sciences, Karl Landsteiner Institute for Nephrology, St Pölten, Austria
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, Department of Community Health Sciences and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada.
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Smith J, Velez MP, Dayan N. Infertility, Infertility Treatment and Cardiovascular Disease: An Overview. Can J Cardiol 2021; 37:1959-1968. [PMID: 34534621 DOI: 10.1016/j.cjca.2021.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022] Open
Abstract
The prevalence of maternal cardiovascular disease (CVD) has risen throughout the developed world, reflecting an increase in acquired cardiovascular risk factors, such as hypertension and diabetes, and the improved life expectancy of those living with congenital CVD due to advances in care. Because many cardiovascular risk factors or cardiovascular conditions are associated with infertility, reproductive-aged women with CVD may increasingly seek reproductive assistance. The worldwide use of assisted reproductive technologies (ART), such as in-vitro fertilization (IVF) with or without intracytoplasmic sperm injection, or intrauterine insemination following pharmacological ovulation induction have increased steadily over the last several decades. It is incumbent among providers who care for reproductive-aged women with pre-existing CVD or CVD risk factors to understand and appreciate the types of treatments offered and inherent risks related to infertility treatments, in order to guide their patients to making safe reproductive choices in line with their values and preferences. While infertility treatments increase the risk of complicated pregnancy, whether these risks are compounded among individuals with pre-existing CVD is less well known. In this review, we summarize current available evidence regarding short-term and long-term cardiovascular implications of ART among individuals with and without CVD, as well as treatment considerations for these women. Existing knowledge gaps and priority areas for further study are presented.
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Affiliation(s)
- Julia Smith
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Maria P Velez
- Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
| | - Natalie Dayan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Research Institute, McGill University Health Centre, Montreal, Quebec, Canada; Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada.
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