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Saxena R, Benson G, Sidebottom AC, Okeson B, Hayes J, Shaw K, Jordan-Baechler C, Wagner W. Reach and effectiveness of a non-university cardio-obstetrics program. J Matern Fetal Neonatal Med 2024; 37:2367090. [PMID: 38910113 DOI: 10.1080/14767058.2024.2367090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Current guidelines recommend multidisciplinary cardiovascular obstetric programs (CVOB) to manage complex pregnant patients with cardiovascular disease. Minimal evaluation of these programs exists, with most of these programs offered at university-based centers. METHODS A cohort of 113 patients managed by a CVOB team at a non-university health system (2018-2019) were compared to 338 patients seen by cardiology prior to the program (2016-2017). CVOB patients were matched with comparison patients (controls) on modified World Health Organization (mWHO) category classification, yielding a cohort of 102 CVOB and 102 controls. RESULTS CVOB patients were more ethnically diverse and cardiovascular risk was higher compared to controls based on mWHO ≥ II-III (57% vs 17%) and. After matching, CVOB patients had more cardiology tests during pregnancy (median of 8 tests vs 5, p < .001) and were more likely to receive telemetry care (32% vs 19%, p = .025). The median number of perinatology visits was significantly higher in the CVOB group (8 vs 2, p < .001). Length of stay was a half day longer for vaginal delivery patients in the CVOB group (median 2.66 vs 2.13, p = .006). CONCLUSION Implementation of a CVOB program resulted in a more diverse patient population than previously referred to cardiology. The CVOB program participants also experienced a higher level of care in terms of increased cardiovascular testing, monitoring, care from specialists, and appropriate use of medications during pregnancy.
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Affiliation(s)
- Retu Saxena
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
- Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Gretchen Benson
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | | | - Brynn Okeson
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Joy Hayes
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Kirsten Shaw
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | | | - William Wagner
- Minnesota Perinatal Physicians, Allina Health, Minneapolis, MN, USA
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2
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Root AL, Crossley NP, Heck JL, McCage S, Proulx J, Jones EJ. Effects of Mindfulness-Based Interventions on Cardiometabolic-Related Adverse Pregnancy Outcomes: A Systematic Review. J Cardiovasc Nurs 2024; 39:335-346. [PMID: 37878581 DOI: 10.1097/jcn.0000000000001054] [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] [Indexed: 10/27/2023]
Abstract
BACKGROUND Growing evidence suggests maternal stress contributes to the development of adverse pregnancy outcomes that are associated with cardiovascular and cardiometabolic risk in birthing persons. Mindfulness-based interventions may positively affect psychological stress in pregnancy and, in turn, reduce stress. However, few study authors have examined the effects of mindfulness-based interventions on adverse pregnancy outcomes that heighten cardiovascular risk. OBJECTIVE The aim of this study was to appraise available literature examining the effects of mindfulness-based interventions delivered during pregnancy on adverse pregnancy outcomes associated with future cardiovascular and cardiometabolic disease risk. METHODS In this systematic review, multiple electronic databases were searched using major keywords, including "mindfulness-based intervention," "pregnancy," "preterm delivery," "gestational diabetes," "small for gestational age," "preeclampsia," and "hypertension in pregnancy" during February 2023. RESULTS Six studies using mindfulness-based interventions during pregnancy were included. The review indicated that these interventions were largely effective at reducing prenatal stress; however, the overall effects of interventions were mixed concerning their impact on pregnancy complications. Study authors examining the effects on gestational diabetes-related outcomes reported significant improvements in blood glucose levels, hemoglobin A 1c , and oral glucose tolerance. Outcomes were mixed or inconclusive related to the effects of interventions on the incidence of preterm birth, birth of a small-for-gestational-age newborn, and preeclampsia. CONCLUSIONS Mitigating cardiovascular and cardiometabolic risk-associated adverse pregnancy outcomes through mindfulness-based approaches may represent an emerging field of study. The few studies and limited, mixed findings synthesized in this review indicate that high-validity studies are warranted to examine the effects of mindfulness-based interventions on pregnancy complications that contribute to cardiovascular-related maternal morbidity and suboptimal life course health for diverse birthing persons.
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Cao Zhang AM, Ziogos E, Harb T, Gerstenblith G, Leucker TM. Emerging clinical role of proprotein convertase subtilisin/kexin type 9 inhibition-Part two: Current and emerging concepts in the clinical use of PCSK9 inhibition. Eur J Clin Invest 2024:e14272. [PMID: 38924090 DOI: 10.1111/eci.14272] [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: 04/03/2024] [Revised: 05/20/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have emerged as a novel class of drugs with cardioprotective effects through their lipid-lowering effects. OBJECTIVE This review aims to discuss existing and novel strategies of PCSK9 inhibition, providing an overview of established randomized controlled trials and ongoing outcome trials that assess the efficacy and long-term safety of PCSK9 inhibitors. It also explores the evolving role of PCSK9 beyond lipid metabolism and outlines the pleiotropic actions of PCSK9 inhibition in various disorders and future directions including novel strategies to target PCSK9. CONCLUSION PCSK9 inhibition shows promise not only in lipid metabolism but also in other disease processes, including atherosclerotic plaque remodeling, acute coronary syndrome, stroke, inflammation, and immune response.
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Affiliation(s)
- Alexander M Cao Zhang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Efthymios Ziogos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tarek Harb
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gerstenblith
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thorsten M Leucker
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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Sebastian SA, Sethi Y, Mathews AM, Santhosh T, Lorraine Co E, Padda I, Johal G. Cardiovascular complications during pregnancy: Advancing cardio-obstetrics. Dis Mon 2024:101780. [PMID: 38910052 DOI: 10.1016/j.disamonth.2024.101780] [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: 06/25/2024]
Abstract
As the incidence of cardiovascular diseases (CVDs) continues to rise among women of childbearing age, the pregnant population with pre-existing heart conditions presents a complex and heterogeneous profile. These women face varying degrees of risk concerning maternal cardiovascular, obstetric, and fetal complications. Effectively managing adverse cardiovascular events during pregnancy presents substantial clinical challenges. The uncertainties surrounding diagnostic and therapeutic approaches create a dynamic landscape with potential implications for maternal and fetal health. Cardio-obstetrics has become increasingly recognized as a vital multidisciplinary field necessitating a collaborative approach to managing cardiovascular conditions during pregnancy. In this review, we aim to provide a thorough and up-to-date examination of the existing evidence, offering a comprehensive overview of strategies and considerations in the management of cardiovascular complications during pregnancy. Special emphasis is placed on the safety assessment of diagnostic procedures and the exploration of treatment options designed to prioritize the well-being of the mother and fetus. We also explore the significance of a multidisciplinary cardio-obstetrics team in providing comprehensive care for women of childbearing age with or at risk for CVD.
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Affiliation(s)
- Sneha Annie Sebastian
- Department of Internal Medicine, Azeezia Medical College, Kollam, Kerala, India; Research Nexus, Philadelphia, United States.
| | - Yashendra Sethi
- Department of Internal Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun, India
| | | | - Tony Santhosh
- Department of Internal Medicine, Dr. Somervell Memorial CSI Medical College, KUHS, Kerala, India
| | - Edzel Lorraine Co
- Research Nexus, Philadelphia, United States; Department of Internal Medicine, University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines
| | - Inderbir Padda
- Department of Internal Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, NY, USA
| | - Gurpreet Johal
- Department of Cardiology, University of Washington, Valley Medical Center, Seattle, USA
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5
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Mehta A, Spitz J, Sharma S, Bonomo J, Brewer LC, Mehta LS, Sharma G. Addressing Social Determinants of Health in Maternal Cardiovascular Health. Can J Cardiol 2024; 40:1031-1042. [PMID: 38387722 DOI: 10.1016/j.cjca.2024.02.010] [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: 11/09/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024] Open
Abstract
Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.
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Affiliation(s)
- Adhya Mehta
- Department of Internal Medicine, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, New York, USA
| | - Jared Spitz
- Department of Cardiovascular Medicine, Inova Health System, Falls Church, Virginia, USA
| | - Sneha Sharma
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jason Bonomo
- Department of Cardiovascular Medicine, Inova Health System, Falls Church, Virginia, USA
| | - LaPrincess C Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Laxmi S Mehta
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Garima Sharma
- Department of Cardiovascular Medicine, Inova Health System, Falls Church, Virginia, USA.
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6
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Oren D, Moeller CM, Haythe JH, Rubinstein G, Fernandez Valledor A, Lotan D, Rosenblum H, Colombo PC, Yuzefpolskaya M, Topkara VK, Clerkin KJ, Raikhelkar JK, Fried JA, Naka Y, Takeda K, Latif F, Sayer G, Uriel N. Pumping for Two: Pregnancy in Patients Supported With a Left Ventricular Assist Device. ASAIO J 2024; 70:461-468. [PMID: 37934714 DOI: 10.1097/mat.0000000000002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
This review discusses the challenges and outcomes associated with pregnancy during left ventricular assist device (LVAD) support. Women account for a third of the heart failure population in the United States. Left ventricular assist devices have emerged as a safe and effective treatment option for patients with advanced heart failure. Pregnancy during LVAD support can occur, and it presents significant risks to both mother and fetus, including hemodynamic stress, thrombotic events, medication-associated teratogenicity, and uterine impingement. This literature review identified 10 cases of confirmed pregnancy during LVAD support, of which eight resulted in successful births. Maternal and fetal mortality occurred in one case, and there was a spontaneous abortion in one case. The review highlights the importance of a multidisciplinary approach, promotion of shared decision-making, thoughtful anticoagulation, adjustment of LVAD speed, and medication optimization to maintain hemodynamic support during pregnancy. Hemodynamic changes during pregnancy include increased cardiac output, heart rate, and plasma volume, as well as decreased systemic vascular resistance, which can impact LVAD support. Despite reduced pulsatility in LVAD-supported patients, ovulation and reproductive capacity might be preserved, and viable pregnancies may be achieved with appropriate management. The review provides insights into the risks and considerations for a viable pregnancy during LVAD support, including the need for ongoing research to inform joined decision-making.
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Affiliation(s)
- Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Haythe
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Andrea Fernandez Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hannah Rosenblum
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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7
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Agarwala A, Dixon DL, Gianos E, Kirkpatrick CF, Michos ED, Satish P, Birtcher KK, Braun LT, Pillai P, Watson K, Wild R, Mehta LS. Dyslipidemia management in women of reproductive potential: An expert clinical consensus from the national lipid association. J Clin Lipidol 2024:S1933-2874(24)00188-0. [PMID: 38824114 DOI: 10.1016/j.jacl.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among women and its incidence has been increasing recently, particularly among younger women. Across major professional society guidelines, dyslipidemia management remains a central tenet for atherosclerotic CVD prevention for both women and men. Despite this, women, particularly young women, who are candidates for statin therapy are less likely to be treated and less likely to achieve their recommended therapeutic objectives for low-density lipoprotein cholesterol (LDL-C) levels. Elevated LDL-C and triglycerides are the two most common dyslipidemias that should be addressed during pregnancy due to the increased risk for adverse pregnancy outcomes, such as preeclampsia, gestational diabetes mellitus, and pre-term delivery, as well as pancreatitis in the presence of severe hypertriglyceridemia. In this National Lipid Association Expert Clinical Consensus, we review the roles of nutrition, physical activity, and pharmacotherapy as strategies to address elevated levels of LDL-C and/or triglycerides among women of reproductive age. We include a special focus on points to consider during the shared decision-making discussion regarding pharmacotherapy for dyslipidemia during preconception planning, pregnancy, and lactation.
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Affiliation(s)
- Anandita Agarwala
- Center for Cardiovascular Disease Prevention Cardiovascular Division, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA (Dr Agarwala).
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA (Dr Dixon); Center for Pharmacy Practice Innovation, Virginia Commonwealth University, Richmond, Virginia, USA (Dr Dixon)
| | - Eugenia Gianos
- Department of Cardiology, Northwell Health, New Hyde Park, Cardiovascular Institute, Lenox Hill Hospital Northwell, New York, NY, USA (Dr Gianos)
| | - Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA (Dr Kirkpatrick); Kasiska Division of Health Sciences, Idaho State University, Pocatello, ID, USA (Dr Kirkpatrick)
| | - Erin D Michos
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore, MD, USA (Dr Michos)
| | - Priyanka Satish
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, TX, USA (Dr Satish)
| | - Kim K Birtcher
- University of Houston College of Pharmacy, Houston, TX, USA (Dr Birtcher)
| | - Lynne T Braun
- Rush University College of Nursing, Rush Heart Center for Women, Chicago, IL, USA (Dr Braun)
| | - Priyamvada Pillai
- Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA (Dr Pillai)
| | - Karol Watson
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (Dr Watson)
| | - Robert Wild
- Oklahoma University Health Sciences Center, Oklahoma City, OK, USA (Dr Wild)
| | - Laxmi S Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (Dr Mehta)
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8
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Bandyopadhyay A, Puri S, Samra T, Ashok V. Preeclamptic heart failure - perioperative concerns and management: a narrative review. Perioper Med (Lond) 2024; 13:37. [PMID: 38730290 PMCID: PMC11083801 DOI: 10.1186/s13741-024-00391-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.
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Affiliation(s)
- Anjishnujit Bandyopadhyay
- Department of Anaesthesiology, Pain Medicine and Critical Care, JPNATC, All India Institute of Medical Science, New Delhi, India
| | - Sunaakshi Puri
- Department of Paediatric Anaesthesia, Post Graduate Institute of Child Health, Noida, India
| | - Tanvir Samra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vighnesh Ashok
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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9
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Lewek J, Bielecka-Dąbrowa A, Toth PP, Banach M. Dyslipidaemia management in pregnant patients: a 2024 update. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae032. [PMID: 38784103 PMCID: PMC11114474 DOI: 10.1093/ehjopen/oeae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/14/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
Over several decades, the approach to treating dyslipidaemias during pregnancy remains essentially unchanged. The lack of advancement in this field is mostly related to the fact that we lack clinical trials of pregnant patients both with available as well as new therapies. While there are numerous novel therapies developed for non-pregnant patients, there are still many limitations in dyslipidaemia treatment during pregnancy. Besides pharmacotherapy and careful clinical assessment, the initiation of behavioural modifications as well as pre-conception management is very important. Among the various lipid-lowering medications, bile acid sequestrants are the only ones officially approved for treating dyslipidaemia in pregnancy. Ezetimibe and fenofibrate can be considered if their benefits outweigh potential risks. Statins are still considered contraindicated, primarily due to animal studies and human case reports. However, recent systematic reviews and meta-analyses as well as data on familial hypercholesterolaemia (FH) in pregnant patients have indicated that their use may not be harmful and could even be beneficial in certain selected cases. This is especially relevant for pregnant patients at very high cardiovascular risk, such as those who have already experienced an acute cardiovascular event or have homozygous or severe forms of heterozygous FH. In these cases, the decision to continue therapy during pregnancy should weigh the potential risks of discontinuation. Bempedoic acid, olezarsen, evinacumab, evolocumab and alirocumab, and inclisiran are options to consider just before and after pregnancy is completed. In conclusion, decisions regarding lipid-lowering therapy for pregnant patients should be personalized. Despite the challenges in designing and conducting studies in pregnant women, there is a strong need to establish the safety and efficacy of dyslipidaemia treatment during pregnancy.
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Affiliation(s)
- Joanna Lewek
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Rzgowska 281/289, 93-338 Lodz, Poland
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Rzgowska 281/289, 93-338 Lodz, Poland
| | - Agata Bielecka-Dąbrowa
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Rzgowska 281/289, 93-338 Lodz, Poland
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Rzgowska 281/289, 93-338 Lodz, Poland
| | - Peter P Toth
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Carnegie 591, Baltimore, MD 21287, USA
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Rzgowska 281/289, 93-338 Lodz, Poland
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Rzgowska 281/289, 93-338 Lodz, Poland
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Carnegie 591, Baltimore, MD 21287, USA
- Cardiovascular Research Centre, Zyty 28, 65-417 Zielona Góra, Poland
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10
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Richardson M, Bonnet JP, Coulon C, Domanski O, Constans B, Estevez MG, Gautier S, Marsili L, Hamoud YO, Coisne A, Ridon H, Polge AS, Mouton S, Haddad Y, Juthier F, Moussa M, Vehier CM, Lemesle G, Schurtz G, Garabedian C, Jourdain M, Ninni S, Brigadeau F, Montaigne D, Lamblin N, Ghesquiere L. Management and outcomes of pregnant women with cardiovascular diseases in a cardio-obstetric team. Arch Cardiovasc Dis 2024; 117:343-350. [PMID: 38644069 DOI: 10.1016/j.acvd.2024.02.009] [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: 12/12/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are currently the leading cause of maternal death in Western countries. Although multidisciplinary cardio-obstetric teams are recommended to improve the management of pregnant women with CVD, data supporting this approach are scarce. AIMS To describe the characteristics and outcomes of pregnant patients with CVD managed within the cardio-obstetric programme of a tertiary centre. METHODS We included every pregnant patient with history of CVD managed by our cardio-obstetric team between June 2017 and December 2019, and collected all major cardiovascular events (death, heart failure, acute coronary syndromes, stroke, endocarditis and aortic dissection) that occurred during pregnancy, peripartum and the following year. RESULTS We included 209 consecutive pregnancies in 202 patients. CVDs were predominantly valvular heart diseases (37.8%), rhythm disorders (26.8%), and adult congenital heart diseases (22.5%). Altogether, 47.4% were classified modified World Health Organization (mWHO)>II, 66.5% had CARdiac disease in PREGnancy score (CARPREG II)≥2 and 80 pregnancies (38.3%) were delivered by caesarean section. Major cardiovascular events occurred in 16 pregnancies (7.7%, 95% confidence interval [CI] 4.5-12.2) during pregnancy and in three others (1.5%, 95% CI 0.3-4.1) during 1-year follow-up. Most events (63.1%) occurred in the 16.3% of patients with unknown CVD before pregnancy. CONCLUSIONS The management of pregnant patients with CVD within a cardio-obstetric team seems encouraging as we found a relatively low rate of cardiovascular events compared to the high-risk profile of our population. However, most of the remaining events occurred in patients without cardiac monitoring before pregnancy.
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Affiliation(s)
- Marjorie Richardson
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France.
| | - Jean Philippe Bonnet
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Capucine Coulon
- Department of Obstetrics, Jeanne-de-Flandre Maternity, Lille University Hospital, Lille, France
| | - Olivia Domanski
- Department of Paediatrics and Congenital Heart Diseases, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Benjamin Constans
- Department of Anaesthesia, Jeanne-de-Flandre Maternity, Lille University Hospital, Lille, France
| | - Max Gonzalez Estevez
- Department of Anaesthesia, Jeanne-de-Flandre Maternity, Lille University Hospital, Lille, France
| | - Sophie Gautier
- Department of Pharmacology, Lille University Hospital, Lille, France
| | - Luisa Marsili
- Department of Clinical Genetic, Lille University Hospital, Lille, France
| | - Yasmine Ould Hamoud
- Department of Obstetrics, Jeanne-de-Flandre Maternity, Lille University Hospital, Lille, France
| | - Augustin Coisne
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France; Cardiovascular Research Foundation, New York, NY, USA; Inserm, U1011-EGID, Institut Pasteur de Lille, University of Lille, CHU de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, Lille, France; European Genomic Institute for Diabetes (E.G.I.D.), FR 3508, Lille, France
| | - Hélène Ridon
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Anne-Sophie Polge
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Stéphanie Mouton
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Yasmine Haddad
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Francis Juthier
- Faculté de médecine de Lille, université de Lille, Lille, France; Department of Surgery, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France; Inserm U1011, Institut Pasteur de Lille, Lille, France
| | - Mouhamed Moussa
- Department of Anaesthesia, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Claire Mounier Vehier
- Department of Vascular Medicine and Hypertension, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - Gilles Lemesle
- Faculté de médecine de Lille, université de Lille, Lille, France; Cardiac Intensive Care Unit, Heart and Lung Institute, CHU de Lille, Lille, France; FACT (French Alliance for Cardiovascular Trial), Paris, France
| | - Guillaume Schurtz
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU de Lille, Lille, France
| | - Charles Garabedian
- Department of Obstetrics, Jeanne-de-Flandre Maternity, Lille University Hospital, Lille, France; Faculté de médecine de Lille, université de Lille, Lille, France; METRICS, ULR 2694, Assessment of Health Technologies and Medical Practices, Lille, France
| | - Mercedes Jourdain
- Faculté de médecine de Lille, université de Lille, Lille, France; Intensive Care Unit, CHU de Lille, Lille, France; Inserm U1190, Lille, France
| | - Sandro Ninni
- Faculté de médecine de Lille, université de Lille, Lille, France; European Genomic Institute for Diabetes (E.G.I.D.), FR 3508, Lille, France; Department of Cardiology, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - François Brigadeau
- Department of Cardiology, Heart and Lung Institute, Lille University Hospital, Lille, France
| | - David Montaigne
- Department of Clinical Physiology and Echocardiography, Heart Valve Clinic, Heart and Lung Institute, Lille University Hospital, Lille, France; Inserm, U1011-EGID, Institut Pasteur de Lille, University of Lille, CHU de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, Lille, France; European Genomic Institute for Diabetes (E.G.I.D.), FR 3508, Lille, France
| | - Nicolas Lamblin
- Faculté de médecine de Lille, université de Lille, Lille, France; Cardiac Intensive Care Unit, Heart and Lung Institute, CHU de Lille, Lille, France; Inserm U1167, Institut Pasteur de Lille, Lille, France
| | - Louise Ghesquiere
- Department of Obstetrics, Jeanne-de-Flandre Maternity, Lille University Hospital, Lille, France; Faculté de médecine de Lille, université de Lille, Lille, France; METRICS, ULR 2694, Assessment of Health Technologies and Medical Practices, Lille, France
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11
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Bikdeli B, Krishnathasan D, Khairani CD, Bejjani A, Davies J, Porio N, Tristani A, Armero A, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Ortiz-Rios MD, Zuluaga-Sánchez V, Achanta A, Jesudasen SJ, Tiu B, Merli GJ, Leiva O, Fanikos J, Grandone E, Sharma A, Rizzo S, Pfeferman MB, Morrison RB, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll B, Goldhaber SZ, Lan Z, Piazza G. Low absolute risk of thrombotic and cardiovascular events in outpatient pregnant women with COVID-19. Thromb Res 2024; 237:209-215. [PMID: 38677791 DOI: 10.1016/j.thromres.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Pregnancy may contribute to an excess risk of thrombotic or cardiovascular events. COVID-19 increases the risk of these events, although the risk is relatively limited among outpatients. We sought to determine whether outpatient pregnant women with COVID-19 are at a high risk for cardiovascular or thrombotic events. MATERIALS & METHODS We analyzed pregnant outpatients with COVID-19 from the multicenter CORONA-VTE-Network registry. The main study outcomes were a composite of adjudicated venous or arterial thrombotic events, and a composite of adjudicated cardiovascular events. Events were assessed 90 days after the COVID-19 diagnosis and reported for non-pregnant women ≤45 years, and for men ≤45 years, as points of reference. RESULTS Among 6585 outpatients, 169 were pregnant at diagnosis. By 90-day follow-up, two pregnant women during the third trimester had lower extremity venous thrombosis, one deep and one superficial vein thrombosis. The cumulative incidence of thrombotic events was 1.20 % (95 % confidence interval [CI]: 0.0 to 2.84 %). Respective rates were 0.47 % (95 % CI: 0.14 % to 0.79 %) among non-pregnant women, and 0.49 % (95 % CI: 0.06 % to 0.91 %) among men ≤45 years. No non-thrombotic cardiovascular events occurred in pregnant women. The rates of cardiovascular events were 0.53 % (95 % CI: 0.18 to 0.87) among non-pregnant women, and 0.68 % (95 % CI: 0.18 to 1.18) in men aged ≤45 years. CONCLUSIONS Thrombotic and cardiovascular events are rare among outpatients with COVID-19. Although a higher event rate among outpatient pregnant women cannot be excluded, the absolute event rates are low and do not warrant population-wide cardiovascular interventions to optimize outcomes.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ali A Assi
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Marcos D Ortiz-Rios
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo (Foggia), Italy; Department of Obstetrics and Gynecology, First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Samantha Rizzo
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Mariana B Pfeferman
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ruth B Morrison
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett Carroll
- Smith Center for Cardiovascular Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA.
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12
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Shara N, Mirabal-Beltran R, Talmadge B, Falah N, Ahmad M, Dempers R, Crovatt S, Eisenberg S, Anderson K. Use of Machine Learning for Early Detection of Maternal Cardiovascular Conditions: Retrospective Study Using Electronic Health Record Data. JMIR Cardio 2024; 8:e53091. [PMID: 38648629 DOI: 10.2196/53091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Cardiovascular conditions (eg, cardiac and coronary conditions, hypertensive disorders of pregnancy, and cardiomyopathies) were the leading cause of maternal mortality between 2017 and 2019. The United States has the highest maternal mortality rate of any high-income nation, disproportionately impacting those who identify as non-Hispanic Black or Hispanic. Novel clinical approaches to the detection and diagnosis of cardiovascular conditions are therefore imperative. Emerging research is demonstrating that machine learning (ML) is a promising tool for detecting patients at increased risk for hypertensive disorders during pregnancy. However, additional studies are required to determine how integrating ML and big data, such as electronic health records (EHRs), can improve the identification of obstetric patients at higher risk of cardiovascular conditions. OBJECTIVE This study aimed to evaluate the capability and timing of a proprietary ML algorithm, Healthy Outcomes for all Pregnancy Experiences-Cardiovascular-Risk Assessment Technology (HOPE-CAT), to detect maternal-related cardiovascular conditions and outcomes. METHODS Retrospective data from the EHRs of a large health care system were investigated by HOPE-CAT in a virtual server environment. Deidentification of EHR data and standardization enabled HOPE-CAT to analyze data without pre-existing biases. The ML algorithm assessed risk factors selected by clinical experts in cardio-obstetrics, and the algorithm was iteratively trained using relevant literature and current standards of risk identification. After refinement of the algorithm's learned risk factors, risk profiles were generated for every patient including a designation of standard versus high risk. The profiles were individually paired with clinical outcomes pertaining to cardiovascular pregnancy conditions and complications, wherein a delta was calculated between the date of the risk profile and the actual diagnosis or intervention in the EHR. RESULTS In total, 604 pregnancies resulting in birth had records or diagnoses that could be compared against the risk profile; the majority of patients identified as Black (n=482, 79.8%) and aged between 21 and 34 years (n=509, 84.4%). Preeclampsia (n=547, 90.6%) was the most common condition, followed by thromboembolism (n=16, 2.7%) and acute kidney disease or failure (n=13, 2.2%). The average delta was 56.8 (SD 69.7) days between the identification of risk factors by HOPE-CAT and the first date of diagnosis or intervention of a related condition reported in the EHR. HOPE-CAT showed the strongest performance in early risk detection of myocardial infarction at a delta of 65.7 (SD 81.4) days. CONCLUSIONS This study provides additional evidence to support ML in obstetrical patients to enhance the early detection of cardiovascular conditions during pregnancy. ML can synthesize multiday patient presentations to enhance provider decision-making and potentially reduce maternal health disparities.
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Affiliation(s)
- Nawar Shara
- MedStar Health Research Institute, Hyattesville, MD, United States
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC, DC, United States
| | | | | | - Noor Falah
- MedStar Health Research Institute, Hyattesville, MD, United States
| | - Maryam Ahmad
- MedStar Health Research Institute, Hyattesville, MD, United States
| | | | | | | | - Kelley Anderson
- School of Nursing, Georgetown University, Washington, DC, United States
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13
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Roh JD, Castro C, Yu A, Rana S, Shahul S, Gray KJ, Honigberg MC, Ricke-Hoch M, Iwamoto Y, Yeri A, Kitchen R, Guerra JB, Hobson R, Chaudhari V, Chang B, Sarma A, Lerchenmüller C, Al Sayed ZR, Diaz Verdugo C, Xia P, Skarbianskis N, Zeisel A, Bauersachs J, Kirkland JL, Karumanchi SA, Gorcsan J, Sugahara M, Damp J, Hanley-Yanez K, Ellinor PT, Arany Z, McNamara DM, Hilfiker-Kleiner D, Rosenzweig A. Placental senescence pathophysiology is shared between peripartum cardiomyopathy and preeclampsia in mouse and human. Sci Transl Med 2024; 16:eadi0077. [PMID: 38630848 DOI: 10.1126/scitranslmed.adi0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
Peripartum cardiomyopathy (PPCM) is an idiopathic form of pregnancy-induced heart failure associated with preeclampsia. Circulating factors in late pregnancy are thought to contribute to both diseases, suggesting a common underlying pathophysiological process. However, what drives this process remains unclear. Using serum proteomics, we identified the senescence-associated secretory phenotype (SASP), a marker of cellular senescence associated with biological aging, as the most highly up-regulated pathway in young women with PPCM or preeclampsia. Placentas from women with preeclampsia displayed multiple markers of amplified senescence and tissue aging, as well as overall increased gene expression of 28 circulating proteins that contributed to SASP pathway enrichment in serum samples from patients with preeclampsia or PPCM. The most highly expressed placental SASP factor, activin A, was associated with cardiac dysfunction or heart failure severity in women with preeclampsia or PPCM. In a murine model of PPCM induced by cardiomyocyte-specific deletion of the gene encoding peroxisome proliferator-activated receptor γ coactivator-1α, inhibiting activin A signaling in the early postpartum period with a monoclonal antibody to the activin type II receptor improved heart function. In addition, attenuating placental senescence with the senolytic compound fisetin in late pregnancy improved cardiac function in these animals. These findings link senescence biology to cardiac dysfunction in pregnancy and help to elucidate the pathogenesis underlying cardiovascular diseases of pregnancy.
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Affiliation(s)
- Jason D Roh
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Claire Castro
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Andy Yu
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Sarosh Rana
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago School of Medicine, Chicago, IL 60637, USA
| | - Sajid Shahul
- Department of Anesthesia and Critical Care, University of Chicago School of Medicine, Chicago, IL 60637, USA
| | - Kathryn J Gray
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Michael C Honigberg
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Melanie Ricke-Hoch
- Department of Cardiology and Angiology, Hannover Medical School, Hannover 30625, Germany
| | - Yoshiko Iwamoto
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Ashish Yeri
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert Kitchen
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Justin Baldovino Guerra
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Stanley and Judith Frankel Institute for Heart and Brain Health, University of Michigan Medical Center, Ann Arbor, MI 48109, USA
| | - Ryan Hobson
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Vinita Chaudhari
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Bliss Chang
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Amy Sarma
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Carolin Lerchenmüller
- Department of Cardiology, Angiology, and Pneumology, University of Heidelberg, Heidelberg 69120, Germany
- German Center for Heart and Cardiovascular Research (DZHK), Partner Site, Heidelberg/Mannheim, Heidelberg 69120, Germany
| | - Zeina R Al Sayed
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Carmen Diaz Verdugo
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Peng Xia
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Niv Skarbianskis
- Faculty of Biotechnology and Food Engineering, Technion Israel Institute of Technology, Haifa, Israel
| | - Amit Zeisel
- Faculty of Biotechnology and Food Engineering, Technion Israel Institute of Technology, Haifa, Israel
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover 30625, Germany
| | - James L Kirkland
- Departments of Medicine and Physiology and Bioengineering, Mayo Clinic, Rochester, MN 55905, USA
| | - S Ananth Karumanchi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - John Gorcsan
- Penn State College of Medicine, Hershey, PA 17033, USA
| | - Masataka Sugahara
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan
| | - Julie Damp
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Karen Hanley-Yanez
- Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Patrick T Ellinor
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Zoltan Arany
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dennis M McNamara
- Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Hannover Medical School, Hannover 30625, Germany
- Department of Cardiovascular Complications of Oncologic Therapies, Medical Faculty of the Philipps University Marburg, Marburg 35037, Germany
| | - Anthony Rosenzweig
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Stanley and Judith Frankel Institute for Heart and Brain Health, University of Michigan Medical Center, Ann Arbor, MI 48109, USA
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14
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Bekiaridou A, Coleman KM, Sharma N, George D, Liu Y, Gianos E, Rosen S, Mieres J, Mountantonakis SE. Clinical Significance of Supraventricular Tachycardia During Pregnancy in Healthy Women. JACC Clin Electrophysiol 2024:S2405-500X(24)00195-6. [PMID: 38661600 DOI: 10.1016/j.jacep.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Supraventricular tachycardias (SVT) are the most frequently encountered arrhythmias in pregnancy with unclear clinical significance. OBJECTIVES This study sought to report the prevalence, describe the management, and explore the association between SVT and adverse obstetric outcomes. METHODS Cohort study of primiparous and multiparous women without history of Cesarean section (CS), and with structurally normal hearts admitted in labor. The study group consisted of women with at least 1 SVT episode during pregnancy, and the control group was randomly selected in a 4:1 ratio. RESULTS Of 141,769 women meeting the inclusion criteria, SVT diagnosis was confirmed in 122. A total of 76 (age 33.2 ± 4.8 years) had at least 1 symptomatic and documented episode during pregnancy. In women with a known SVT diagnosis before pregnancy, medical therapy was not associated with a lower risk of SVT recurrence (OR: 1.07; 95% CI: 0.41-2.80). However, catheter ablation before pregnancy was associated with significantly lower risk of SVT recurrence (OR: 0.09; 95% CI: 0.04-0.23). Women with SVT during pregnancy had higher incidence of CS (39.5% vs 27.0%; P = 0.03), and preterm labor (PTL) (30.3% vs 8.6%; P < 0.001). Adjusting for age and parity, SVT during pregnancy was an independent predictor of CS (OR: 1.80; 95% CI: 1.03-3.10), particularly planned CS (OR: 2.89; 95% CI: 1.06-7.89) and PTL (OR: 4.37; 95% CI: 2.30-8.31). CONCLUSIONS SVT during pregnancy is associated with increased risk for CS and PTL in healthy women. History of SVT should be sought as early as preconception counseling, and a multidisciplinary approach is warranted for both prevention and management of SVT occurrence.
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Affiliation(s)
- Alexandra Bekiaridou
- Northwell Health, New Hyde Park, New York, USA; Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Kristie M Coleman
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA. https://twitter.com/keepinrhythm
| | - Nikhil Sharma
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Deepika George
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Yan Liu
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Eugenia Gianos
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA
| | - Stacey Rosen
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Jennifer Mieres
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Stavros E Mountantonakis
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA.
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15
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Bigeh A, Mehta L, Lastinger L. Diagnostic and Management Considerations in a High-Risk Pregnant Patient With Ischemic Cardiomyopathy. JACC Case Rep 2024; 29:102268. [PMID: 38645282 PMCID: PMC11031657 DOI: 10.1016/j.jaccas.2024.102268] [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: 06/11/2023] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 04/23/2024]
Abstract
Ischemic heart disease is an important cause of heart failure in pregnancy. Involvement of a cardio-obstetrics team is crucial for managing high-risk pregnant patients with cardiovascular disease. We present a case of cardiogenic shock in a pregnant woman unmasking underlying multivessel obstructive coronary artery disease.
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Affiliation(s)
- Allison Bigeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
| | - Laxmi Mehta
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
| | - Lauren Lastinger
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
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16
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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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17
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Bruyère M, Morau E, Verspyck E. [Maternal mortality due to cardiovascular diseases in France 2016-2018]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:221-230. [PMID: 38373486 DOI: 10.1016/j.gofs.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/21/2024]
Abstract
Between 2016 and 2018, cardiovascular diseases were responsible for 41 deaths, making it the leading cause of maternal death within 42 days postpartum in France. The maternal mortality ratio (MMR) for cardiovascular disease is 1.8 per 100,000 NV, a non-significant increase compared with the 2013-2015 triennium (MMR of 1.5 per 100,000 NV). Deaths from cardiac causes accounted for the majority (n=28), with 26 deaths secondary to cardiac disease aggravated by pregnancy (indirect deaths) and 2 deaths related to peripartum cardiomyopathy (direct deaths). Deaths from vascular causes (n=13) corresponded to 9 aortic dissections and 4 ruptures of large vessels, including 3 ruptures of the splenic artery. Preventability of death (possible or probable) was found in 56% of cases compared with 66% in the previous triennium. Care was considered sub-optimal in 57% of cases, down from 72% in the 2013-2015 triennium. In women with known cardiovascular disease, the areas for improvement concern multidisciplinary follow-up, repeated assessment of the cardiovascular risk (WHO grade) and early referral to an expert centre (expert cardiologists, obstetricians, anaesthetists and intensive care). In all pregnant women or women who have recently given birth, a cardiovascular etiology should be considered in the presence of suggestive symptoms (dyspnea, chest or abdominal pain). Ultrasound "point of care" examination (fluid effusions, cardiac dysfunction) and cardiac enzymes assay can help in the diagnosis. Finally, the woman must be involved in her own care.
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Affiliation(s)
- Marie Bruyère
- Service d'anesthésie-réanimation et médecine périopératoire, hôpital Bicêtre, université Paris-Saclay, AP-HP, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
| | - Estelle Morau
- Département d'anesthésie-réanimation, hôpital universitaire Carémeau, place du Pr.-Robert-Debré, 30029 Nîmes cedex 9, France.
| | - Eric Verspyck
- Clinique gynécologique et obstétricale, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France.
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18
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Schenone CV, Ashley Cain M, Schenone AL, Smith T, Tsalatsanis A, Louis JM, Crousillat DR. Changes in rate-pressure product associated with pregnancy. Am J Obstet Gynecol MFM 2024; 6:101338. [PMID: 38453019 DOI: 10.1016/j.ajogmf.2024.101338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited. OBJECTIVE This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies. STUDY DESIGN This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates. RESULTS Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter. CONCLUSION This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.
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Affiliation(s)
- Claudio V Schenone
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat).
| | - M Ashley Cain
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat)
| | - Aldo L Schenone
- Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY (Dr A Schenone)
| | - Teagen Smith
- Department of Research Methodology and Biostatistics Core, University of South Florida Morsani College of Medicine, Tampa, FL (Ms Smith)
| | - Athanasios Tsalatsanis
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL (Dr Tsalatsanis)
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat)
| | - Daniela R Crousillat
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat); Division of Cardiovascular Sciences, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL (Dr Crousillat)
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19
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Hart WM, Cobb B, Quist-Nelson J, Tully KP. Development and implementation of a pregnancy heart team at a Southeastern United States tertiary hospital: a qualitative study. Am J Obstet Gynecol MFM 2024; 6:101336. [PMID: 38453018 DOI: 10.1016/j.ajogmf.2024.101336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The United States has seen a significant rise in maternal mortality and morbidity associated with cardiovascular disease over the past 4 decades. Contributing factors may include an increasing number of parturients with comorbid conditions, a higher rate of pregnancy among women of advanced maternal age, and more patients with congenital heart disease who survive into childbearing age and experiencing pregnancy. In response, national medical organizations have recommended the creation of multidisciplinary obstetric-cardiac teams, also known as pregnancy heart teams, to provide comprehensive preconception counseling and coordinated pregnancy management that extend through the postpartum period. OBJECTIVE We sought to describe the development and implementation of a pregnancy heart team for parturients with cardiac disease at a southeastern United States tertiary hospital. STUDY DESIGN This was a qualitative study that was conducted among healthcare team members involved during the pregnancy heart team formation. Semi-structured interviews were conducted between April and May 2022, professionally transcribed, and the responses were thematically coded for categories and themes using constructs from The Consolidated Framework for Implementation Research. RESULTS Themes identified included intentional collaboration to improve outpatient and inpatient coordination through earlier awareness of patients who meet the criteria and via documented care planning. The pregnancy heart team united clinicians around best practices and coordination to promote the success and safety of pregnancies and not only to minimize maternal health risks. Developing longitudinal care plans was critical among the pathway team to build on collective expertise and to provide clarity for those on shift to reduce hesitancy and achieve timely, vetted practices without additional consults. Establishing a proactive approach of specialists offering their perspectives was viewed as positively contributing to a culture of speaking up. Barriers to the successful development and sustainability of the pregnancy heart team included unmet administrative needs and clinician turnover within a context of shortages in staffing and high workload. CONCLUSION This study described the process of developing and implementing a pregnancy heart team at 1 institution, thereby offering insights for future multidisciplinary care for maternal cardiac patients. Establishing pregnancy heart teams can enhance quality care for high-risk patients, foster learning and collaboration among physician and nursing specialties, and improve coordination to manage complex maternal cardiac cases.
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Affiliation(s)
- William Michael Hart
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Hart and Cobb).
| | - Ben Cobb
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Hart and Cobb)
| | - Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Quist-Nelson and Tully)
| | - Kristin P Tully
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Quist-Nelson and Tully)
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20
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Narvaez-Guerra OD, Sorour N, Aurigemma GP, Parker MW, Kanter DJ, Kovell LC. A Multimodality Imaging and Multidisciplinary Approach to Manage Anomalous Right Coronary Artery from the Pulmonary Artery in Pregnancy. CASE (PHILADELPHIA, PA.) 2024; 8:122-126. [PMID: 38524969 PMCID: PMC10954573 DOI: 10.1016/j.case.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
•ARCAPA can present with minimal symptoms. •A dilated RCA and intramyocardial collateralization are suspicious for ARCAPA. •CCT is the noninvasive diagnostic modality of choice to confirm ARCAPA. •Risk stratification of pregnant patients is key to preventing delivery complications.
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Affiliation(s)
- Offdan D. Narvaez-Guerra
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
| | - Nouran Sorour
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
| | - Gerard P. Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
| | - Matthew W. Parker
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
| | - David J. Kanter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
| | - Lara C. Kovell
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan School of Medicine, Worcester, Massachusetts
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21
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Fixler JS, Byrne JJ, Mcintire DD, Nelson DB, Gary Cunningham F. Intrapartum trends of NT-proBNP and hs-cTnT in patients with severe features of preeclampsia. Pregnancy Hypertens 2024; 35:1-5. [PMID: 38029452 DOI: 10.1016/j.preghy.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Preeclampsia with severe features (SPE) is a multisystem syndrome associated with long-term cardiovascular morbidity. Serum concentrations of N-terminal B-type natriuretic peptide (NT-proBNP) and high sensitivity cardiac troponin-T (hs-cTnT) are sensitive markers of cardiac stretch and ischemia, respectively. OBJECTIVE Our aim was to examine NT-proBNP and hs-cTnT in patients with SPE during labor. We hypothesized that patients with severe preeclampsia would have increased serum concentrations of these analytes as compared with normotensive laboring patients. STUDY DESIGN This was a prospective cohort study of intrapartum patients with SPE and normotensive controls. Patients were recruited at the time of SPE diagnosis or admission to the labor unit, and those with medical conditions that could predispose to baseline cardiac dysfunction were excluded. Serum from venous blood was collected for NT-proBNP and hs-cTnT measurement at three time points: 0-2 h, 4 h, and 12 h after admission. A mixed random effects regression model was used to compare analyte levels at each time point and to compare trends over time. The primary outcome was NT-proBNP concentration at each collection time point in patients with severe preeclampsia as compared to normotensive controls. Power analysis yielded a goal sample of 25 patients with a 12 h and at least 1 other sample in each arm. Two-tailed P values less than 0.05 were considered statistically significant. P value adjustment for multiple comparisons was performed. RESULTS Of 78 patients analyzed, 36 had severe preeclampsia and 42 were normotensive controls with 25 in each cohort having a 12 h and at least 1 other sample. The NT-proBNP trend was significantly different in the two cohorts (P < 0.001). After adjustment for multiple comparisons, the mean serum concentration of NT-proBNP was elevated in the severe preeclampsia group at 0-2 and 4 h, but not at 12 h. After similar adjustment, detectable serum concentrations of hs-cTnT were more frequent in patients with severe preeclampsia at all three timepoints. CONCLUSION Intrapartum serum concentrations of NT-proBNP were elevated nearly twofold in patients with SPE when compared with normotensive controls, with the most pronounced differences found during early labor. Detectable but low serum concentrations of hs-cTnT were more common in women with severe preeclampsia as compared with normotensive controls. These findings suggest cardiac dysfunction with SPE may be present at the time of admission and contribute to features of maternal cardiovascular morbidity and mortality.
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Affiliation(s)
- Joseph S Fixler
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - John J Byrne
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Donald D Mcintire
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - David B Nelson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - F Gary Cunningham
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern, Dallas, TX, USA
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22
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Afari H, Sheehan M, Reza N. Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy. Cardiol Ther 2024; 13:17-37. [PMID: 38340291 PMCID: PMC10899150 DOI: 10.1007/s40119-024-00351-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024] Open
Abstract
Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.
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Affiliation(s)
- Henrietta Afari
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 11Th Floor South Pavilion, Philadelphia, PA, 19104, USA
| | - Megan Sheehan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 11Th Floor South Pavilion, Philadelphia, PA, 19104, USA.
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23
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Nguyen AH, Murrin E, Moyo A, Sharma G, Sullivan SA, Maxwell GL, Kennedy JLW, Saad AF. Ischemic heart disease in pregnancy: a practical approach to management. Am J Obstet Gynecol MFM 2024; 6:101295. [PMID: 38278176 DOI: 10.1016/j.ajogmf.2024.101295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/03/2024] [Indexed: 01/28/2024]
Abstract
Ischemic heart disease is a crucial issue during pregnancy. The term is composed of both preexisting conditions and acute coronary syndrome in pregnancy, including pregnancy-associated myocardial infarction, which can have a significant effect on maternal and fetal outcomes. This review provides a complete guide to managing ischemic heart disease in pregnant women, emphasizing the importance of multidisciplinary care and individualized treatment strategies. Cardiovascular disease, particularly ischemic heart disease, is now the leading cause of maternal mortality worldwide. Pregnancy introduces unique physiological changes that increase the risk of acute myocardial infarction, with pregnancy-associated myocardial infarction cases often associated with factors, such as advanced maternal age, chronic hypertension, and preexisting cardiovascular conditions. This review distinguishes between preexisting ischemic heart disease and pregnancy-associated myocardial infarction. It will emphasize the various etiologies of pregnancy-associated myocardial infarction, including coronary atherosclerosis and plaque rupture presenting as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and other nonatherosclerotic causes, including spontaneous coronary artery dissection, vasospasm, and embolism. Our study discusses the practical management of ischemic heart disease in pregnancy, with a focus on preconception counseling, risk assessment, and tailored antenatal planning for women with preexisting ischemic heart disease. Moreover, this document focuses on the challenges of diagnosing cardiovascular disease, especially when presented with nonclassical risk factors and presentation. It provides insight into the appropriate diagnostic testing methods, such as electrocardiogram, cardiac biomarkers, and echocardiography. In addition, the review covers various treatment strategies, from medical management to more invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft. Special attention is given to medication safety during pregnancy, including anticoagulation, beta-blockers, and antiplatelet agents. The complexities of delivery planning in women with ischemic heart disease are discussed, advocating for a multidisciplinary team-based approach and careful consideration of the timing and mode of delivery. Furthermore, the roles of breastfeeding and postpartum care are explored, emphasizing the long-term benefits and the suitability of various medications during lactation. Lastly, this review provides crucial insights into the management of ischemic heart disease in pregnancy, stressing the need for heightened awareness, prompt diagnosis, and tailored management to optimize maternal and fetal health outcomes.
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Affiliation(s)
- Andrew H Nguyen
- Department of Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia (Drs Nguyen and Moyo)
| | - Ellen Murrin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad)
| | - Axucillia Moyo
- Department of Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia (Drs Nguyen and Moyo)
| | - Garima Sharma
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, Virginia (Drs Sharma and Kennedy)
| | - Scott A Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad)
| | - George L Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Dr Maxwell)
| | - Jamie L W Kennedy
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, Virginia (Drs Sharma and Kennedy)
| | - Antonio F Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad).
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24
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Petersen J, Abusnina W, Beesabathina S, Desu SS, Walters RW, Alla VM. Racial Disparities in Outcomes of Delivery and Cardiac Complications Among Pregnant Women with Congenital Heart Disease. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-01950-0. [PMID: 38416292 DOI: 10.1007/s40615-024-01950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/29/2024]
Abstract
Advances in cardiology have led to improved survival among patients with congenital heart disease (CHD). Racial disparities in cardiovascular and maternal outcomes are well known and are likely to be more profound among pregnant women with CHD. Using the 2001 to 2018 National Inpatient Sample, we identified all hospitalizations for delivery among women ≥ 18 years of age with CHD. Unadjusted and adjusted between-race differences in adverse maternal cardiovascular, obstetric, and fetal events were assessed using logistic regression models. During the study period, we identified 52,711 hospitalizations for delivery among women with concomitant CHD. Of these, 66%, 11%, and 16% were White, Black, and Hispanic, respectively. Obstetric complications and fetal adverse events were higher among Blacks compared to Whites and Hispanics (44% vs. 33% vs. 37%, p < .001; 36% vs. 28% vs. 30%, p < .001), respectively. No between-race differences were observed in overall cardiovascular adverse events (27% vs. 24% vs. 23%, p < .21). However, heart failure was significantly higher among Black women (3.6% vs. 1.7% vs. 2.2%, p = 0.001). While a lower income quartile was associated with higher rates of adverse outcomes, adjustment for income did not attenuate the adverse impact of race. Black females with CHD diagnoses were more likely to experience adverse obstetric, fetal events, and heart failure compared to White and Hispanic women irrespective of their income status. Further research is needed to identify causes and devise interventions to mitigate racial disparities in the care of pregnant women with CHD.
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Affiliation(s)
- John Petersen
- Creighton University School of Medicine, Omaha, NE, USA
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | | | | | - Ryan W Walters
- Department of Clinical Research and Public Health, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata Mahesh Alla
- Division of Cardiology, Creighton University School of Medicine, 7710 Mercy Rd., Suite #401, Omaha, NE, 68123, USA.
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25
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Kim JA, Kim SY, Virk HUH, Alam M, Sharma S, Johnson MR, Krittanawong C. Acute Myocardial Infarction in Pregnancy. Cardiol Rev 2024:00045415-990000000-00222. [PMID: 38411170 DOI: 10.1097/crd.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Pregnancy-associated myocardial infarction is an overall uncommon event, but can be associated with significant maternal and fetal morbidity and mortality. In contrast to myocardial infarction in the general nonpregnant population, the mechanism of pregnancy-associated myocardial infarction is most commonly due to nonatherosclerotic mechanisms such as coronary dissection, vasospasm, or thromboembolism. The diagnosis of pregnancy-associated myocardial infarction can be challenging, requiring a high index of suspicion for prompt recognition and management. Furthermore, the management of pregnancy-associated myocardial infarction can be complex due to maternal and fetal considerations and may vary based on the specific underlying mechanism of the myocardial infarction. This review aims to review the recent literature on pregnancy-associated myocardial infarction and summarize the epidemiology, mechanisms, diagnosis, and treatment strategies for this uncommon entity.
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Affiliation(s)
- Jitae A Kim
- From the Department of Cardiology, University of Buffalo, New York, NY
| | - Sophie Y Kim
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, El Paso, TX
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mahboob Alam
- Division of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Mark R Johnson
- Academic Department of Obstetrics and Gynaecology, Institute of Reproductive and Developmental Biology, Chelsea and Westminster Hospital, Imperial College London, London, UK; and
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26
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Lewey J, Beckie TM, Brown HL, Brown SD, Garovic VD, Khan SS, Miller EC, Sharma G, Mehta LS. Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e330-e346. [PMID: 38346104 PMCID: PMC11185178 DOI: 10.1161/cir.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.
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27
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Bigelow C, Campbell A, Poulose A, Sannes H, Longtin C, Lynch-Salamon D, Saxena R. Cardio-Obstetrics Team-Based Management of a Pregnant Patient With Severe Bioprosthetic Aortic Valve Disease. JACC Case Rep 2024; 29:102197. [PMID: 38361555 PMCID: PMC10865213 DOI: 10.1016/j.jaccas.2023.102197] [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: 07/05/2023] [Revised: 11/14/2023] [Accepted: 12/07/2023] [Indexed: 02/17/2024]
Abstract
A 38-year-old pregnant patient was managed by the cardio-obstetrics multidisciplinary team for severe degenerative bioprosthetic aortic valve failure. She was medically managed utilizing echocardiogram and brain natriuretic peptide until she demonstrated worsening heart failure. A valve and cardio-obstetrics team evaluation led to valve-in-valve transcatheter aortic valve replacement at 30 weeks' gestation.
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Affiliation(s)
| | - Alex Campbell
- Allina Health Minneapolis Heart Institute, Minneapolis Minnesota, USA
| | - Anil Poulose
- Allina Health Minneapolis Heart Institute, Minneapolis Minnesota, USA
| | - Heidi Sannes
- Minnesota Perinatal Physicians, Minneapolis Minnesota, USA
| | - Cassie Longtin
- Minnesota Perinatal Physicians, Minneapolis Minnesota, USA
| | | | - Retu Saxena
- Allina Health Minneapolis Heart Institute, Minneapolis Minnesota, USA
- Minneapolis Heart Institute Foundation, Minneapolis Minnesota, USA
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Sarma AA, Lau ES, Sharma G, King LP, Economy KE, Wood R, Wood MJ, Feinberg L, Isselbacher EM, Hameed AB, DeFaria Yeh D, Scott NS. Maternal Cardiovascular Health Post-Dobbs. NEJM EVIDENCE 2024; 3:EVIDra2300273. [PMID: 38320493 DOI: 10.1056/evidra2300273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Maternal Cardiovascular Health Post-DobbsPregnancy is associated with increasing morbidity and mortality in the United States. In the post-Dobbs era, many pregnant patients at highest risk no longer have access to abortion, which has been a crucial component of standard medical care.
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Affiliation(s)
- Amy A Sarma
- Division of Cardiology, Massachusetts General Hospital, Boston
| | - Emily S Lau
- Division of Cardiology, Massachusetts General Hospital, Boston
| | - Garima Sharma
- Inova Schar Heart and Vascular, Inova Health System, Falls Church, VA
| | - Louise P King
- Division of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston
| | | | - Rachel Wood
- Division of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston
| | | | - Loryn Feinberg
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston
| | | | | | | | - Nandita S Scott
- Division of Cardiology, Massachusetts General Hospital, Boston
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Taube N, Kabir R, Ebenebe OV, Garbus H, Alam El Din SM, Illingworth E, Fitch M, Wang N, Kohr MJ. Prenatal arsenite exposure alters maternal cardiac remodeling during late pregnancy. Toxicol Appl Pharmacol 2024; 483:116833. [PMID: 38266874 PMCID: PMC10922692 DOI: 10.1016/j.taap.2024.116833] [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: 08/01/2023] [Revised: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 01/26/2024]
Abstract
Exposure to inorganic arsenic through drinking water is widespread and has been linked to many chronic diseases, including cardiovascular disease. Arsenic exposure has been shown to alter hypertrophic signaling in the adult heart, as well as in utero offspring development. However, the effect of arsenic on maternal cardiac remodeling during pregnancy has not been studied. As such, there is a need to understand how environmental exposure contributes to adverse pregnancy-related cardiovascular events. This study seeks to understand the impact of trivalent inorganic arsenic exposure during gestation on maternal cardiac remodeling in late pregnancy, as well as offspring outcomes. C57BL/6 J mice were exposed to 0 (control), 100 or 1000 μg/L sodium arsenite (NaAsO2) beginning at embryonic day (E) 2.5 and continuing through E17.5. Maternal heart function and size were assessed via transthoracic echocardiography, gravimetric measurement, and histology. Transcript levels of hypertrophic markers were probed via qRT-PCR and confirmed by western blot. Offspring outcomes were assessed through echocardiography and gravimetric measurement. We found that maternal heart size was smaller and transcript levels of Esr1 (estrogen receptor alpha), Pgrmc1 (progesterone receptor membrane component 1) and Pgrmc2 (progesterone receptor membrane component 2) reduced during late pregnancy with exposure to 1000 μg/L iAs vs. non-exposed pregnant controls. Both 100 and 1000 μg/L iAs also reduced transcription of Nppa (atrial natriuretic peptide). Akt protein expression was also significantly reduced after 1000 μg/L iAs exposure in the maternal heart with no change in activating phosphorylation. This significant abrogation of maternal cardiac hypertrophy suggests that arsenic exposure during pregnancy can potentially contribute to cardiovascular disease. Taken together, our findings further underscore the importance of reducing arsenic exposure during pregnancy and indicate that more research is needed to assess the impact of arsenic and other environmental exposures on the maternal heart and adverse pregnancy events.
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Affiliation(s)
- Nicole Taube
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Raihan Kabir
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Obialunanma V Ebenebe
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Haley Garbus
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Sarah-Marie Alam El Din
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Emily Illingworth
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Michael Fitch
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Nadan Wang
- Cardiology Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mark J Kohr
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
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Stuenkel CA. Reproductive milestones across the lifespan and cardiovascular disease risk in women. Climacteric 2024; 27:5-15. [PMID: 37769699 DOI: 10.1080/13697137.2023.2259793] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/12/2023] [Indexed: 10/03/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of death for women across the developed and developing world. Beyond traditional cardiovascular risk factors, a number of reproductive milestones have been recognized. The goal of this White Paper, issued by the International Menopause Society in conjunction with World Menopause Day 2023, is to highlight female reproductive milestones in terms of potential cardiovascular risk and to review recommendations for minimizing that risk. The primary milestones discussed relate to menstrual cyclicity, adverse pregnancy outcomes, breast cancer treatments and menopause. Each of these categories has a number of permutations that have been shown in observational studies to be associated with increased cardiovascular risks. In current clinical care, recognition of these reproductive milestones has been encouraged so patients can be informed and motivated to engage in primary prevention of CVD early in their life course rather than retrospectively later in life. Options for specifically targeted care with specialist teams are designed to enhance success with risk identification, screening and possible detection of CVD and, optimally, primary or secondary prevention of CVD. Promoting cardiovascular health of women has far-reaching effects for themselves, their families and their progeny. It is time to make women's cardiovascular health a priority.
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Affiliation(s)
- C A Stuenkel
- Department of Medicine, Division of Endocrinology and Metabolism, UC San Diego School of Medicine, La Jolla, CA, USA
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Yurista S, Wadhera P, Eder RA, Elkayam U, Siddiqi OK. Peripartum HFpEF: Identification of a Novel Phenotype and the Need for Cardio-Obstetrics Management. JACC. ADVANCES 2024; 3:100799. [PMID: 38939402 PMCID: PMC11198047 DOI: 10.1016/j.jacadv.2023.100799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Salva Yurista
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Priya Wadhera
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Robert A. Eder
- New York Institute of Technology College of Osteopathic Medicine, New York, New York, USA
| | - Uri Elkayam
- Division of Cardiovascular Medicine and Department of Obstetrics and Gynecology, Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Omar K. Siddiqi
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Peterson AN, Hickerson LC, Pschirrer ER, Friend LB, Taub CC. Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature. Am J Cardiol 2024; 210:118-129. [PMID: 37838071 DOI: 10.1016/j.amjcard.2023.10.019] [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: 08/23/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.
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Affiliation(s)
- Ashleigh N Peterson
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Leigh C Hickerson
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - E Rebecca Pschirrer
- Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lynsy B Friend
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Cynthia C Taub
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York.
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Vinsard PA, Arendt KW, Sharpe EE. Care for the Obstetric Patient with Complex Cardiac Disease. Adv Anesth 2023; 41:53-69. [PMID: 38251622 DOI: 10.1016/j.aan.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.
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Affiliation(s)
- Patrice A Vinsard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Rosenfeld EB, Brandt JS, Fields JC, Lee R, Graham HL, Sharma R, Ananth CV. Chronic Hypertension and the Risk of Readmission for Postpartum Cardiovascular Complications. Obstet Gynecol 2023; 142:1431-1439. [PMID: 37917949 PMCID: PMC10662390 DOI: 10.1097/aog.0000000000005424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Preeclampsia is an important risk factor for cardiovascular disease (CVD, including heart disease and stroke) along the life course. However, whether exposure to chronic hypertension in pregnancy, in the absence of preeclampsia, is implicated in CVD risk during the immediate postpartum period remains poorly understood. Our objective was to estimate the risk of readmission for CVD complications within the calendar year after delivery for people with chronic hypertension. METHODS The Healthcare Cost and Utilization Project's Nationwide Readmission Database (2010-2018) was used to conduct a retrospective cohort study of patients aged 15-54 years. International Classification of Diseases codes were used to identify patients with chronic hypertension and postpartum readmission for CVD complications within 1 year of delivery. People with CVD diagnosed during pregnancy or delivery admission, multiple births, or preeclampsia or eclampsia were excluded. Excess rates of CVD readmission among patients with and without chronic hypertension were estimated. Associations between chronic hypertension and CVD complications were determined from Cox proportional hazards regression models. RESULTS Of 27,395,346 delivery hospitalizations that resulted in singleton births, 2.0% of individuals had chronic hypertension (n=544,639). The CVD hospitalization rate among patients with chronic hypertension and normotensive patients was 645 (n=3,791) per 100,000 delivery hospitalizations and 136 (n=37,664) per 100,000 delivery hospitalizations, respectively (rate difference 508, 95% CI 467-549; adjusted hazard ratio 4.11, 95% CI 3.64-4.66). The risk of CVD readmission, in relation to chronic hypertension, persisted for 1 year after delivery. CONCLUSION The heightened CVD risk as early as 1 month postpartum in relation to chronic hypertension underscores the need for close monitoring and timely care after delivery to reduce blood pressure and related complications.
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Affiliation(s)
- Emily B. Rosenfeld
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Justin S. Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New York University Langone, New York, NY
| | - Jessica C. Fields
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Rachel Lee
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Hillary L. Graham
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Clinical Epidemiology Division, Faculty of Medicine at Solna, Karolinska Institute, Stockholm, Sweden
| | - Ruchira Sharma
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Cande V. Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Rice B, Mbatidde L, Oluleye O, Onwuanyi A, Adedinsewo D. Managing hypertension in African Americans with heart failure: A guide for the primary care clinician. J Natl Med Assoc 2023:S0027-9684(23)00144-X. [PMID: 38135590 DOI: 10.1016/j.jnma.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Hypertension is the predominant risk factor for cardiovascular disease related morbidity and mortality among Black adults in the United States. It contributes significantly to the development of heart failure and increases the risk of death following heart failure diagnosis. It is also a leading predisposing factor for hypertensive disorders of pregnancy and peripartum cardiomyopathy in Black women. As such, all stakeholders including health care providers, particularly primary care clinicians (including physicians and advanced practice providers), patients, and communities must be aware of the consequences of uncontrolled hypertension among Black adults. Appropriate treatment strategies should be identified and implemented to ensure timely and effective blood pressure management among Black individuals, particularly those with, and at risk for heart failure.
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Affiliation(s)
- Bria Rice
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Lydia Mbatidde
- Department of Family Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Anekwe Onwuanyi
- Department of Cardiovascular Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Demilade Adedinsewo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States.
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36
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Behrooz L, Lenneman CG, Hamburg NM. Emerging Medical Therapies for the Treatment of Obesity in Women with Cardiovascular Diseases. Curr Cardiol Rep 2023; 25:1475-1488. [PMID: 37874468 PMCID: PMC10682277 DOI: 10.1007/s11886-023-01961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW In this review, the impact of obesity on cardiovascular disease in women and emerging anti-obesity pharmacologic treatments are discussed. RECENT FINDINGS Robust evidence demonstrates the burden of obesity across the lifespan in women and links obesity to a diverse set of cardiovascular diseases. Female-specific risk factors including sex hormones and pregnancy factors intersect with obesity and cardiovascular risk. Sustained weight loss has potential for cardiovascular benefits. Recent trials demonstrate cardiovascular benefits of emerging agents with weight loss effects including GLP-1 RA and SGLT2 inhibitors in women. Treatment and prevention strategies for cardiovascular disease in obese women should include integration of weight management strategies including the targeted use of emerging pharmacologic therapies.
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Affiliation(s)
- Leili Behrooz
- Whitaker Cardiovascular Institute and Section of Vascular Biology, Boston University Chobanian and Avedisian School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Carrie G Lenneman
- University of Alabama at Birmingham, UAB Heersink School of Medicine, Birmingham, AL, USA
| | - Naomi M Hamburg
- Whitaker Cardiovascular Institute and Section of Vascular Biology, Boston University Chobanian and Avedisian School of Medicine, 72 East Concord St, Boston, MA, 02118, USA.
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Warner ED, Farhan S, Bierowski M, Sahawneh F, Oliveros E, Pirlamarla P, Marek-Iannucci S, Ramu B, Ullah W, Brailovsky Y, Rajapreyar IN. Trends in cardiovascular complications of pregnancy: A nationwide inpatient sample analysis. Am J Med Sci 2023; 366:337-346. [PMID: 37678669 DOI: 10.1016/j.amjms.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/15/2023] [Accepted: 09/01/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. Physiologic stress of pregnancy can induce several hemodynamic changes that contribute to an increased risk of cardiac complications in the peripartum period. There are ongoing efforts to improve cardiovascular mortality in pregnant patients. Understanding trends in cardiovascular complications during pregnancy may provide insight into improving care for high-risk pregnancies. METHODS We retrospectively analyzed data from the National Inpatient Sample (NIS) Database and identified all inpatient hospitalizations for pregnancy and delivery. We then analyzed trends in the rates of cardiac complications in the pregnant patient. RESULTS There are concerning increases in trends of cardiac complications and comorbidities in pregnant people including: acute coronary syndrome, spontaneous coronary artery dissection, cardiogenic shock, pulmonary hypertension, chronic congestive heart failure, heart transplant, aortic syndromes, stroke, and pulmonary embolism. While the rates of STEMI have decreased, the incidence of peripartum cardiomyopathy has remained stable. CONCLUSION There are concerning increases in certain cardiac complications during pregnancy. This is likely due to increasing age at the time of pregnancy and associated comorbidities.
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Affiliation(s)
- Eric D Warner
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Saaniya Farhan
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Bierowski
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Farhan Sahawneh
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Estefania Oliveros
- Division of Cardiology, Temple University Hospital, Philadelphia, PA, USA
| | | | | | - Bhavadharini Ramu
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Waqas Ullah
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA, USA
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Ali Al-Allak HM, Noaman Al-Aboodi AH. A Four-Dimensional Volumetric Quantification of the Left Ventricle in Healthy Pregnant Women in the Third Trimester. Cureus 2023; 15:e46342. [PMID: 37920612 PMCID: PMC10618626 DOI: 10.7759/cureus.46342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Hemodynamic load and heart structural remodeling rise during pregnancy because these changes are physiologically necessary. Adaptations in the mother's circulatory system may either initiate or aggravate the development of cardiovascular disease in the offspring. If the body is unable to adjust to these changes, it may develop heart conditions like cardiomyopathy. There is a lack of third-trimester echocardiographic data on left ventricular (LV) volume and function in healthy Iraqi women. To understand the cardiac alterations that occur during normal pregnancy, a precise tool that evaluates cardiac function is needed. In that regard, the four-dimensional echocardiography (4DE) technique has markedly improved the quality and accuracy of assessing the size and function of the left ventricle. AIM The present study aimed to assess LV volume and function in the third trimester of a healthy pregnancy using 4DE and to compare the results of LV assessment using 4DE with those of LV assessment using conventional two-dimensional (2D) echocardiography. METHODS The study was conducted on 75 healthy pregnant women (the case group) and 75 non-pregnant women (the control group). The participants attended Al-Fortat Teaching Hospital from April 1, 2022, to May 30, 2023, and had 2D and 4D echocardiographic studies performed on them. RESULTS The LV end-diastolic volume (EDV), end-systolic volume (ESV), and cardiac output (CO) were significantly increased in the case group compared to the control group (90.87 ± 18.03 ml vs. 62.64 ± 14.11 ml, P<0.001; 35.59 ± 6.52 ml vs. 22.42 ± 5.82 ml, P<0.001; and 4.87 ± 1.27 vs. 3.35 ± 0.87 L/m, P<0.001, respectively). In contrast, the LV ejection fraction (LVEF) was significantly decreased in the pregnant group compared to the control group (60.37 ± 5.42 % vs. 64.04 ± 4.99 %, P<0.01). Additionally, the study showed significant differences in EDV, ESV, ejection fraction (EF%), and CO (P<0.001) between 2D and 4D echocardiography, according to the Bland Altman test. CONCLUSION In healthy pregnant women in their third trimester, there is an increase in the indicators of preload (ventricular volume and CO) and a decrease in EF%. The 4DE provides detailed images and information about cardiac volumes and function, allowing for the early detection of any potential problems that may arise during pregnancy and thus improving the health outcomes of both the mother and the developing fetus.
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Albertini L, Spears DA. Management of arrhythmias during pregnancy. Heart Rhythm O2 2023; 4:597-598. [PMID: 37936664 PMCID: PMC10626184 DOI: 10.1016/j.hroo.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Affiliation(s)
- Lisa Albertini
- Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Danna A. Spears
- Toronto General Hospital, University Health Network Toronto, Ontario, Canada
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40
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Shah A, Kapcin K, Deicke M, Pappan N, Holden K, Routray SK, Schmetzer A, DuMont T, Nashar K, Bajwa O, Ivanova V. Hypertension in Women and Pregnancy. Crit Care Nurs Q 2023; 46:377-390. [PMID: 37684733 DOI: 10.1097/cnq.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Hypertension has been shown to have long-term cardiovascular effects if left untreated. Hypertension also has been shown to affect women during pregnancy, which can be detrimental not only to the patient but also to the fetus. Early identification and treatment are paramount to prevent adverse outcomes. This article details the epidemiology, clinical presentation, diagnosis, and treatment of essential hypertension in women, gestational hypertension, preeclampsia, and eclampsia.
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Affiliation(s)
- Aaisha Shah
- Divisions of Internal Medicine (Drs Shah, Kapcin, and Deicke), Pulmonary and Critical Care (Drs Holden, Schmetzer, and DuMont), Nephrology and Critical Care Medicine (Dr Routray), Nephrology (Dr Nashar), and Pulmonary and Critical Care Medicine (Dr Bajwa), Allegheny Health Network Medicine Institute, Pittsburgh, Pennsylvania; and Division of Cardiovascular Disease, Allegheny Health Network Cardiovascular Institute (Drs Pappan and Ivanova)
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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Evans K, Wu P, Mamas MA, Irwin C, Kang P, Perlow JH, Foley M, Gulati M. Substance Use in Pregnancy and its Association With Cardiovascular Events. JACC. ADVANCES 2023; 2:100619. [PMID: 38938361 PMCID: PMC11198094 DOI: 10.1016/j.jacadv.2023.100619] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 06/29/2024]
Abstract
Background Substance use and cardiovascular (CV) events are increasing among pregnant women in the United States, but association between substance use in pregnancy and CV events remains unknown. Objectives The purpose of this study was to examine the association between substance use and acute CV events in pregnancy. Methods We identified all women with a delivery hospitalization between 2004 and 2018 in the Nationwide Inpatient Sample, stratified on the presence or absence of substance use. The primary outcome was any acute CV event, defined as the presence of: acute myocardial infarction, stroke, arrhythmia, endocarditis, acute cardiomyopathy or heart failure, or cardiac arrest. Secondary outcomes were individual acute CV events, major adverse cardiac events, and maternal mortality. The association between substance use and outcomes were examined using multivariable logistical regression. Results A total of 60,014,368 delivery hospitalizations occurred from 2004 to 2018, with substance use complicating 955,531 (1.6%) deliveries. Substance use was independently associated with CV events (adjusted odds ratio [aOR]: 1.61; 95% CI: 1.53-1.70; P < 0.001), major adverse cardiac events (aOR: 1.53; 95% CI: 1.46-1.61; P < 0.001), and maternal mortality (aOR: 2.65; 95% CI: 2.15-3.25; P < 0.001) during delivery hospitalization. All individual substances had an increased association with CV events; however, amphetamine/methamphetamine had the strongest association (aOR: 2.71; 95% CI: 2.35-3.12; P < 0.001). All substances other than cocaine and cannabis had a significant association with maternal death. Conclusions Substance use has a strong association with acute CV events and maternal mortality during hospitalization for delivery and women with substance use warrant increased surveillance for CV events during this time.
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Affiliation(s)
- Kari Evans
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arizona, Phoenix, Arizona, USA
| | - Pensée Wu
- Department of Cardiology, Keele University, Keele, United Kingdom
| | - Mamas A. Mamas
- Department of Cardiology, Keele University, Keele, United Kingdom
| | - Chase Irwin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arizona, Phoenix, Arizona, USA
| | - Paul Kang
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arizona, Phoenix, Arizona, USA
| | - Jordan H. Perlow
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arizona, Phoenix, Arizona, USA
| | - Michael Foley
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arizona, Phoenix, Arizona, USA
| | - Martha Gulati
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Birla S, Angural A, Madathumchalil A, Shende RV, Shastry SV, Mahadevappa M, Shambhu SK, Vishwanath P, Prashant A. Redefining the polypill: pros and cons in cardiovascular precision medicine. Front Pharmacol 2023; 14:1268119. [PMID: 37799963 PMCID: PMC10549989 DOI: 10.3389/fphar.2023.1268119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
Polypill is a multi-drug formulation in a single pill intended to simplify the drug regimen and reduce medication-induced adverse effects. The most common multidrug combinations in a polypill are used to treat cardiovascular diseases and are targeted against key modifiable risk factors such as hypertension and hyperlipidemia. These contain blood-pressure lowering agents, statins, and anti-platelet agents usually in a fixed dose. Polypills can be an affordable therapeutic intervention for treating high-risk patients, as these are proven to increase patients' adherence to medication and improve clinical outcomes. Over the previous years, randomized clinical trials of several polypills have yielded contradictory findings, raising skepticism regarding their widespread use in primary disease prevention. Here, we have reviewed the concept of polypills, the evidence-based strengths, the limitations of this polypharmacy intervention strategy, and discussed future directions for their use in the primary and secondary preventive management of cardiovascular diseases and associated risk factors.
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Affiliation(s)
- Siddharth Birla
- Department of Biochemistry, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Arshia Angural
- Department of Medical Genetics, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Arya Madathumchalil
- Department of Medical Genetics, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Ritika V. Shende
- Department of Medical Genetics, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Sharvani V. Shastry
- Department of Medical Genetics, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Manjappa Mahadevappa
- Department of Cardiology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Sunil Kumar Shambhu
- Department of Cardiology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Prashant Vishwanath
- Department of Biochemistry, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
| | - Akila Prashant
- Department of Biochemistry, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
- Department of Medical Genetics, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
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Coroyannakis C, Tome M, Watt-Coote I, Cauldwell M. Pregnancy following personalised aortic root support in Marfan syndrome. Obstet Med 2023; 16:200-202. [PMID: 37719992 PMCID: PMC10504882 DOI: 10.1177/1753495x221078447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 01/03/2022] [Accepted: 01/18/2022] [Indexed: 09/19/2023] Open
Abstract
Marfan syndrome (MFS) is linked with adverse pregnancy events, one of the most significant being aortic dissection. We present a case of a woman with MFS with prior aortic root dilatation who opted for a Personalised External Aortic Root Support (PEARS). To date, she is only the fifth woman to have had this valve-sparing procedure prior to pregnancy. We outline her care in a tertiary centre with multidisciplinary expertise, from preconception through to the postpartum period.
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Affiliation(s)
- Christina Coroyannakis
- Christina Coroyannakis, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Maite Tome
- St George’s University Hospitals NHS Foundation Trust, London, UK
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45
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Misra A, Porras MP, Rajendran A, Contreras J, Scott NS. Cardio-Obstetrics: A Focused Review. Curr Cardiol Rep 2023; 25:1065-1073. [PMID: 37540401 DOI: 10.1007/s11886-023-01928-0] [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] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease is the leading cause of maternal mortality in the USA. All cardiovascular care providers should have a foundational knowledge on the management of pregnant individuals with heart disease. This focused review touches on several key cardio-obstetric themes. RECENT FINDINGS Many individuals with cardiovascular disease can safely undergo pregnancy, but should have counseling preconception to optimize cardiac status. There are several cardiovascular conditions that are high risk for maternal mortality and morbidity. These individuals should be adequately counseled preconception and offered reliable birth control. The approach to a high-risk pregnant patient with cardiac disease is best managed by a multidisciplinary team to address potential maternal and fetal complications. Identification of at risk individuals can be estimated preconception with several risk scores. The development of risk scores to stratify and identify those at elevated risk during pregnancy is an area of continued research and development.
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Affiliation(s)
- Amrit Misra
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Aardra Rajendran
- Department of Internal Medicine, John Hopkins University, Baltimore, MD, USA
| | - Johanna Contreras
- Department of Cardiology, Division of Advanced Heart Failure and Transplant, Icahn School of Medicine, Mount Sinai, New York City, NY, USA
| | - Nandita S Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA.
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46
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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47
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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48
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Li JJ, Zhao SP, Zhao D, Lu GP, Peng DQ, Liu J, Chen ZY, Guo YL, Wu NQ, Yan SK, Wang ZW, Gao RL. 2023 Chinese guideline for lipid management. Front Pharmacol 2023; 14:1190934. [PMID: 37711173 PMCID: PMC10498001 DOI: 10.3389/fphar.2023.1190934] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/26/2023] [Indexed: 09/16/2023] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death among urban and rural residents in China, and elevated low-density lipoprotein cholesterol (LDL-C) is a risk factor for ASCVD. Considering the increasing burden of ASCVD, lipid management is of the utmost importance. In recent years, research on blood lipids has made breakthroughs around the world, hence a revision of Chinese guideline for lipid management is imperative, especially since the target lipid levels in the general population vary in respect to the risk of ASCVD. The level of LDL-C, which can be regarded as appropriate in a population without frisk factors, can be considered abnormal in people at high risk of developing ASCVD. As a result, the "Guidelines for the prevention and treatment of dyslipidemia" were adapted into the "Chinese guideline for Lipid Management" (henceforth referred to as the new guidelines) by an Experts' committee after careful deliberation. The new guidelines still recommend LDL-C as the primary target for lipid control, with cardiovascular disease (CVD) risk stratification to determine its target value. These guidelines recommend that moderate intensity statin therapy in adjunct with a heart-healthy lifestyle, be used as an initial line of treatment, followed by cholesterol absorption inhibitors or/and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, as necessary. The new guidelines provide guidance for lipid management across various age groups, from children to the elderly. The aim of these guidelines is to comprehensively improve the management of lipids and promote the prevention and treatment of ASCVD by guiding clinical practice.
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Affiliation(s)
- Jian-Jun Li
- National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shui-Ping Zhao
- The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Dong Zhao
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guo-Ping Lu
- Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dao-Quan Peng
- The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jing Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhen-Yue Chen
- Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuan-Lin Guo
- National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Na-Qiong Wu
- National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Sheng-Kai Yan
- Affiliated Hospital of Zunyi Medical University, School of Laboratory Medicine of Zunyi Medical University, Zunyi, Guizhou, China
| | - Zeng-Wu Wang
- National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Run-Lin Gao
- National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Martino F, Bassareo PP, Martino E, Romeo F, Calcaterra G, Perrone Filardi P, Indolfi C, Nodari S, Montemurro V, Guccione P, Salvo GD, Chessa M, Pedrinelli R, Mercuro G, Barillà F. Cardiovascular prevention in childhood: a consensus document of the Italian Society of Cardiology Working Group on Congenital Heart Disease and Cardiovascular Prevention in Paediatric Age. J Cardiovasc Med (Hagerstown) 2023; 24:492-505. [PMID: 37409595 DOI: 10.2459/jcm.0000000000001488] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Cardiovascular diseases (CVD) may be manifested from a very early age. Genetic and environmental (epigenetic) factors interact to affect development and give rise to an abnormal phenotypical expression of genetic information, although not eliciting changes in the nucleotide sequence of DNA. It has been scientifically proven that increased oxidative stress (OS) caused by disease (overweight, obesity, diabetes), nutritional imbalances, unhealthy lifestyles (smoking, alcohol, substance abuse) in the mother during pregnancy may induce placental dysfunction, intrauterine growth restriction, prematurity, low birth weight, postnatal adiposity rebound, metabolic alterations and consequent onset of traditional cardiovascular risk factors. OS represents the cornerstone in the onset of atherosclerosis and manifestation of CVD following an extended asymptomatic period. OS activates platelets and monocytes eliciting the release of pro-inflammatory, pro-atherogenic and pro-oxidising substances resulting in endothelial dysfunction, decrease in flow-mediated arterial dilatation and increase in carotid intima-media thickness. The prevention of CVD is defined as primordial (aimed at preventing risk factors development), primary (aimed at early identification and treatment of risk factors), secondary (aimed at reducing risk of future events in patients who have already manifested a cardiovascular event), and tertiary (aimed at limiting the complex outcome of disease). Atherosclerosis prevention should be implemented as early as possible. Appropriate screening should be carried out to identify children at high risk who are apparently healthy and implement measures including dietary and lifestyle changes, addition of nutritional supplements and, lastly, pharmacological treatment if risk profiles fail to normalise. Reinstating endothelial function during the reversible stage of atherosclerosis is crucial.
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Affiliation(s)
- Francesco Martino
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, La Sapienza University, Rome, Italy
| | - Pier Paolo Bassareo
- University College of Dublin, School of Medicine, Mater Misericordiae University Hospital and Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Eliana Martino
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, La Sapienza University, Rome, Italy
| | | | | | | | - Ciro Indolfi
- Division of Cardiology, Research Centre for Cardiovascular Diseases, Magna Graecia University, Catanzaro
| | - Savina Nodari
- Department of Medical Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, ASST Spedali Civili, Brescia
| | | | - Paolo Guccione
- Department of Cardiology, Cardiac Surgery, Cardio-pulmonary Transplantation, IRCCS Bambino Gesu'Paediatric Hospital, Rome
| | - Giovanni Di Salvo
- Division of Paediatric Cardiology, Department of Women's and Children's Health, University of Padua, Padua
| | - Massimo Chessa
- ACHD UNIT, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, San Donato Milanese, Vita Salute San Raffaele University, Milan
| | - Roberto Pedrinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa
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50
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Wild RA, Edwards RK, Zhao D, Hansen KR, Kim AS, Wrenn DS. Highly Atherogenic Lipid Particles are Associated with Preeclampsia After Successful Fertility Treatment for Obese Women who have Unexplained Infertility. Reprod Sci 2023; 30:2495-2502. [PMID: 36813973 PMCID: PMC10442456 DOI: 10.1007/s43032-023-01197-w] [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: 08/19/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
Atherogenic dyslipidemia-before or during pregnancy-may contribute to preeclampsia and subsequent cardiovascular disease risk. We performed a nested case-control study to further understand dyslipidemia associated with preeclampsia. The cohort consisted of participants in the randomized clinical trial "Improving Reproductive Fitness Through Pretreatment with Lifestyle Modification in Obese Women with Unexplained Infertility" (FIT-PLESE). FIT-PLESE was designed to study the effect of a pre-fertility treatment 16-week randomized lifestyle intervention program (Nutrisystem diet + exercise + orlistat vs. training alone) on improvement in live birth rate among obese women with unexplained infertility. Of the 279 patients in FIT-PLESE, 80 delivered a viable infant. Maternal serum was analyzed across five visits: before and after lifestyle interventions and also at three pregnancy visits (16, 24, and 32 weeks gestation). Apolipoprotein lipids were measured in a blinded fashion using ion mobility. Cases were those who developed preeclampsia. Controls also had a live birth but did not develop preeclampsia. Generalized linear and mixed models with repeated measures were used to compare the mean lipoprotein lipid levels of the two groups across all visits. Complete data were available for 75 pregnancies, and preeclampsia developed in 14.5% of the pregnancies. Cholesterol/high-density lipoprotein (HDL) ratios (p < 0.003), triglycerides (p = 0.012), and triglyceride/HDL ratios, all adjusted for BMI, were worse in patients with preeclampsia (p < 0.001). Subclasses a, b, and c of highly atherogenic, very small, low-density lipoprotein (LDL) particles were higher during pregnancy for the preeclamptic women (p < 0.05). Very small LDL particle subclass d levels were significantly greater only at 24 weeks (p = 0.012). The role of highly atherogenic, very small LDL particle excess in the pathophysiology of preeclampsia awaits further investigation.
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Affiliation(s)
- R A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- Biostatistics and Clinical Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - R K Edwards
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - D Zhao
- Biostatistics and Clinical Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - K R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - A S Kim
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - D S Wrenn
- Quest Diagnostics, Secaucus, NJ, USA
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