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Gomez SE, Fazal M, Nunes JC, Shah S, Perino AC, Narayan SM, Tamirisa KP, Han JK, Rodriguez F, Baykaner T. Racial, ethnic, and sex disparities in atrial fibrillation management: rate and rhythm control. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01383-x. [PMID: 36224481 PMCID: PMC10097842 DOI: 10.1007/s10840-022-01383-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] [Received: 07/18/2022] [Accepted: 09/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) affects around 6 million Americans. AF management involves pharmacologic therapy and/or interventional procedures to control rate and rhythm, as well as anticoagulation for stroke prevention. Different populations may respond differently to distinct management strategies. This review will describe disparities in rate and rhythm control and their impact on outcomes among women and historically underrepresented racial and/or ethnic groups. METHODS This is a narrative review exploring the topic of sex and racial and/or ethnic disparities in rate and rhythm management of AF. We describe basic terminology, summarize AF epidemiology, discuss diversity in clinical research, and review landmark clinical trials. RESULTS Despite having higher rates of traditional AF risk factors, Black and Hispanic adults have lower risk of AF than non-Hispanic White (NHW) patients, although those with AF experience more severe symptoms and report lower quality-of-life scores than NHW patients with AF. NHW patients receive antiarrhythmic drugs, cardioversions, and invasive therapies more frequently than Black and Hispanic patients. Women have lower rates of AF than men, but experience more severe symptoms, heart failure, stroke, and death after AF diagnosis. Women and people from diverse racial and ethnic backgrounds are inadequately represented in AF trials; prevalence findings may be a result of underdetection. CONCLUSION Race, ethnicity, and gender are social determinants of health that may impact the prevalence, evolution, and management of AF. This impact reflects differences in biology as well as disparities in treatment and representation in clinical trials.
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Affiliation(s)
- Sofia E Gomez
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Muhammad Fazal
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Julio C Nunes
- Stanford Center for Clinical Research, Stanford University, Stanford, CA, USA.,Department of Psychiatry, Yale University, New Haven, CT, USA.,Cardiac Arrhythmia Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Shayena Shah
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Sanjiv M Narayan
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | | | - Janet K Han
- Cardiac Arrhythmia Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine, UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Fatima Rodriguez
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA
| | - Tina Baykaner
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H2146, Stanford, CA, 94305, USA.
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2
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Zeitler EP, Poole JE, Albert CM, Al-Khatib SM, Ali-Ahmed F, Birgersdotter-Green U, Cha YM, Chung MK, Curtis AB, Hurwitz JL, Lampert R, Sandhu RK, Shaik F, Sullivan E, Tamirisa KP, Santos Volgman A, Wright JM, Russo AM. Arrhythmias in Female Patients: Incidence, Presentation and Management. Circ Res 2022; 130:474-495. [PMID: 35175839 DOI: 10.1161/circresaha.121.319893] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.
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Affiliation(s)
- Emily P Zeitler
- The Geisel School of Medicine at Dartmouth, Hanover, NH (E.P.Z.).,Division of Cardiology, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, Lebanon, NH (E.P.Z.)
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle (J.E.P.)
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA (C.M.A., R.K.S.)
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.M.A.-K.)
| | | | | | - Yong-Mei Cha
- Mayo Clinic, St Mary's Campus, Rochester, MN (F.A.-A., Y.-M.C.)
| | | | - Anne B Curtis
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo General Medical Center, NY (A.B.C.)
| | | | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (R.L.)
| | - Roopinder K Sandhu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA (C.M.A., R.K.S.)
| | - Fatima Shaik
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ (F.S., A.M.R.)
| | | | | | | | - Jennifer M Wright
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI (J.M.W.)
| | - Andrea M Russo
- Division of Cardiology, Cooper Medical School of Rowan University, Camden, NJ (F.S., A.M.R.)
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Williams DS, Mikhova K, Sodhi S. Arrhythmias and Pregnancy: Management of Preexisting and New-Onset Maternal Arrhythmias. Cardiol Clin 2021; 39:67-75. [PMID: 33222815 DOI: 10.1016/j.ccl.2020.09.013] [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: 10/23/2022]
Abstract
Arrhythmias are the most common cardiovascular complication of pregnancy in women with and without structural heart disease. Appropriate maternal diagnosis and management is of utmost importance to optimize maternal and fetal outcomes. A multidisciplinary care approach with cardiology, maternal fetal medicine, anesthesia, and pediatrics is important for preconceptional, pregnancy, and delivery planning.
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Affiliation(s)
- Dominique S Williams
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA.
| | - Krasimira Mikhova
- Cardiovascular Division, Electrophysiology, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Sandeep Sodhi
- Department of Medicine, Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
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4
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Park K, Bairey Merz CN, Bello NA, Davis M, Duvernoy C, Elgendy IY, Ferdinand KC, Hameed A, Itchhaporia D, Minissian MB, Reynolds H, Mehta P, Russo AM, Shah RU, Volgman AS, Wei J, Wenger NK, Pepine CJ, Lindley KJ. Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol 2021; 77:1799-1812. [PMID: 33832606 PMCID: PMC8061780 DOI: 10.1016/j.jacc.2021.01.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 01/28/2021] [Indexed: 01/08/2023]
Abstract
Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.
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Affiliation(s)
- Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Melinda Davis
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Claire Duvernoy
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Keith C Ferdinand
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Afshan Hameed
- Department of Obstetrics, University of California Irvine, Irvine, California, USA
| | - Dipti Itchhaporia
- Jeffrey M. Carlton Heart & Vascular Institute, Hoag Memorial Hospital Presbyterian, Newport Beach, California, USA
| | - Margo B Minissian
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Harmony Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H Charney Division of Cardiology Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Puja Mehta
- Emory University School of Medicine, Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, Georgia, USA
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nanette K Wenger
- Emory University School of Medicine, Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, Georgia, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Volgman AS, Benjamin EJ, Curtis AB, Fang MC, Lindley KJ, Naccarelli GV, Pepine CJ, Quesada O, Vaseghi M, Waldo AL, Wenger NK, Russo AM. Women and atrial fibrillation. J Cardiovasc Electrophysiol 2020; 32:2793-2807. [PMID: 33332669 DOI: 10.1111/jce.14838] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation (AF) remains a growing problem in the United States and worldwide, imposing a high individual and health system burden, including increased resource consumption due to repeated hospitalizations, stroke, dementia, heart failure, and death. This comprehensive review summarizes the most recent data on sex-related differences in risks associated with AF. Women with AF have increased risk of stroke and death compared to men, and possible reasons for this disparity are explored. Women also continue to have worse symptoms and quality of life, and poorer outcomes with stroke prevention, as well as with rate and rhythm control management strategies. Many current rhythm control treatment strategies for AF, including cardioversion and ablation, are used less frequently in women as compared to men, whereas women are more likely to be treated with rate control strategies or antiarrhythmic drugs. Sex differences should be considered in treating women with AF to improve outcomes and women and men should be offered the same interventions for AF. We need to improve the evidence base to understand if variation in utilization of rate and rhythm control management between men and women represents health inequities or appropriate clinical judgement.
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Affiliation(s)
| | - Emelia J Benjamin
- Boston University School of Medicine and School of Public Health, Boston, Massachusetts, USA
| | - Anne B Curtis
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, California, USA
| | | | | | - Carl J Pepine
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Odayme Quesada
- The Christ Hospital Women's Heart Center, Cincinnati, Ohio, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA
| | - Albert L Waldo
- Division of Cardiovascular Medicine, Case Western Reserve University Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nanette K Wenger
- Department of Medicine, Section of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Janjua NB, Birmani SA, McDonagh T, Hameed A, McKernan M. New-onset lone maternal atrial fibrillation: A case report. Medicine (Baltimore) 2020; 99:e19156. [PMID: 32049843 PMCID: PMC7035010 DOI: 10.1097/md.0000000000019156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/14/2019] [Accepted: 10/30/2019] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Atrial fibrillation (AF) is encountered rarely in pregnancy. Management of maternal AF is challenging as it poses a threat to both maternal and fetal well-being. PATIENT CONCERNS We report a case of a 35 weeks pregnant woman who presented in emergency with sudden-onset palpitations and mild shortness of breath with no personal/family history of cardiac diseases. DIAGNOSES Patient's pulse was irregularly irregular with an average rate of 179 beats per minute. The obstetric examination was normal. DIAGNOSIS High-sensitive cardiac troponin T (hs-cTnT) was elevated. The 12 lead electrocardiogram (ECG) confirmed AF. The obstetric ultrasound, electronic fetal heart rate (EFHR) trace, and maternal echocardiography were normal. INTERVENTIONS The patient was admitted under joint cardiology and obstetric care and monitored with continuous telemetry. She was commenced on a therapeutic dose of low-molecular weight heparin (LMWH) and intravenous fluid. She received a single 200 Joule synchronized direct current (DC) shock under general anesthesia in operation theater, which reverted the rhythm back to normal. EFHR monitoring was normal pre- and post-DC cardioversion. We acknowledge the unwise use of therapeutic dose of LMWH before DC cardioversion (DCCV) because of a potential need for emergency cesarean delivery for maternal and/or fetal compromise. OUTCOME The patient remained well and in sinus rhythm after cardioversion. She was discharged home the following day on Flecainide (anti-arrhythmic) and therapeutic dose of low molecular weight heparin (LMWH) and followed up in outpatient clinics frequently. She had a baby at term and received prophylactic LMWH for 10 days post-cesarean. She was discharged from cardiology clinic when she was 10 weeks postnatal, and Flecainide was discontinued. LESSONS We are reporting this case because of the rarity of the condition and successful use of DCCV for treating maternal AF. High-sensitive cardiac troponin T (hs-cTnT) level is a useful laboratory indicator to gauge the severity of AF in pregnancy. We emphasize to make the arrangements for EFHR monitoring and potential cesarean delivery and advocate cautious use of thromboprophylaxis while planning for electrical cardioversion (ECV) for maternal AF.
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, O’Corragain OA, Sharma K, Prechawat S, Ungprasert P, Watthanasuntorn K, Pachariyanon P, Cheungpasitporn W. Incidence of atrial fibrillation in pregnancy and clinical significance: A meta-analysis. Adv Med Sci 2019; 64:415-422. [PMID: 31521944 DOI: 10.1016/j.advms.2019.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/06/2019] [Accepted: 07/29/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, and is associated with increased morbidity and mortality. However, the incidence and maternal/fetal outcomes of AF in pregnancy remain unclear. This study's aims were to investigate the pooled incidence of AF in pregnant women and to assess maternal/fetal outcomes of AF in pregnancy. MATERIAL AND METHODS A literature search for studies that reported incidence of AF in pregnancy, was conducted using MEDLINE, EMBASE and Cochrane Database from inception through May 2018. Pooled incidence with 95%CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018095955). RESULTS We identified 7 cohort studies including 301,638 pregnancies. The pooled estimated incidence of AF in pregnancy among women with no known heart disease, and those with structural heart disease was 0.3% (95%CI: 0.01%-40.6%) and 2.2% (95%CI: 0.96%-5.01%), respectively. Among women with known AF, the pooled estimated incidence of recurrent AF in pregnancy was 39.2% (95%CI: 16.9%-67.2%). The pooled estimated incidence of pre-eclampsia and congestive heart failure among pregnant patients with AF was 4.1% (95%CI: 2.1%-7.8%) and 9.6% (95%CI: 5.7%-15.9%), respectively. The pooled estimated incidence of fetal events including premature birth, small for gestational age, respiratory distress syndrome, intraventricular hemorrhage, death was 26.6% (95%CI: 20.4%-34.0%). CONCLUSION The overall estimated incidence of AF and recurrent AF during pregnancy is as high as 2.2% and 39.2%, respectively. AF during pregnancy may result in poor maternal and fetal outcomes.
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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