Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum

Davis, Melinda B.; Arendt, Katherine W.; Bello, Natalie A.; Brown, Haywood L.; Briller, Joan; Epps, Kelly; Hollier, Lisa M.; Langen, Elizabeth S.; Park, Ki; Walsh, Mary Norine; Williams, Dominique; Wood, Malissa J.; Silversides, Candice; Lindley, Kathryn J.

doi:10.1016/j.jacc.2021.02.033

Cited by 109 publications

(129 citation statements)

References 67 publications

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“…Team-based care is recommended for individuals at risk for CVD 5 and has been described (including the emerging field of Cardioobstetrics 41 ) in detail elsewhere. 4 Clinical trial data suggest that lifestyle interventions may produce substantial and sustained improvements in CVD risk after APOs. The evidence is strongest for diabetes prevention after gestational diabetes.…”

Section: Discussionmentioning

confidence: 99%

“…1 An increasing body of evidence indicates that several common adverse pregnancy outcomes (APOs) may be important signals of CVD risk among women. [1][2][3][4] The most common such APOs are hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery, each affecting ~10% of pregnancies and associated with a doubling or more of 10-year CVD risk [1][2][3][4] (detailed descriptions in Table 1 [3][4][5][6][7][8][9][10][11][12][13][14] ). Despite the connections between APOs and future CVD, only half of patients see a primary care clinician (PCC) in the year after an APO, 15,16 and even fewer receive CVD risk counseling informed by their pregnancy history.…”

Section: Introductionmentioning

confidence: 99%

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Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

et al. 2022

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Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

et al. 2022

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“…Ultimately, optimal care of the cardiac patient during pregnancy requires a team-based approach, including practitioners from cardiology, obstetrics, anesthesia, and other medical subspecialties. 14 Concurrently, subspecialty cardio-obstetrics training necessitates dedicated exposure to and training with experts in the cardiac subspecialties of ACHD, heart failure, electrophysiology, structural/interventional, and cardiac surgery as well as with experts in the gynecological and obstetrical fields of reproductive endocrinology and infertility, general obstetrics, maternal fetal medicine (MFM), neonatology, and cardiac and obstetrics anesthesia ( Figure 2 ). Other experts, such as pulmonologists, infectious disease doctors, and lipidologists, may also be part of the patient’s care team as clinically indicated.…”

Section: Core Components Of Cardio-obstetrics Trainingmentioning

confidence: 99%

“…Multidisciplinary collaborative teams have been shown to improve outcomes in cardiac patients during pregnancy, and training for FITs in cardio-obstetrics should similarly allow exposure to a pregnancy heart team. 8 13 14 15 …”

Section: Core Components Of Cardio-obstetrics Trainingmentioning

confidence: 99%

Instituting a Curriculum for Cardio-Obstetrics Subspecialty Fellowship Training

Minhas

Goldstein

Vaught

et al. 2022

Methodist DeBakey Cardiovascular Journal

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Maternal mortality is rising in the United States, and cardiovascular disease is the leading cause. Adverse pregnancy outcomes such as preeclampsia and gestational diabetes heighten the risk of cardiovascular complications during pregnancy and the peripartum period and are associated with long-term cardiovascular risks. The field of cardio-obstetrics is a subspecialty within adult cardiology that focuses on the management of women with or at high risk for heart disease who are considering pregnancy or have become pregnant. There is growing recognition of the need for more specialists with dedicated expertise in cardio-obstetrics to improve the cardiovascular care of this high-risk patient population. Current recommendations for cardiovascular fellowship training programs accredited by the Accreditation Council for Graduate Medical Education involve establishing core competency in the knowledge of managing heart disease in pregnancy. However, little granular detail is available of what such training should entail, which can lead to knowledge gaps. Additionally, dedicated advanced subspecialty training in this area is not commonly offered. Multidisciplinary collaborative teams have been shown to improve outcomes in cardiac patients during pregnancy, and cardiovascular fellows-in-training interested in cardio-obstetrics should have the opportunity to participate in and contribute to a pregnancy heart team. In this document, we describe a proposed specialized cardio-obstetrics training pathway that could serve to adequately prepare trainees to competently and comprehensively care for women with cardiovascular disease before, during, and after pregnancy.

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“…The European Society of Cardiology (ESC) Task Force on HD during pregnancy has recently highlighted the importance of a multidisciplinary team, the Pregnancy Heart team, in managing these women to potentially improve their outcomes 5. One of the tasks of this team is to jointly assess all women with HD to define their risk of experiencing cardiac complications and, thus, to tailor their follow-up during pregnancy 8. Such risk assessment should be carried out according to the modified WHO (mWHO) classification, which comprises five classes with progressively increasing risk of mortality and morbidity 5 9.…”

Section: Introductionmentioning

confidence: 99%

Cardiac and obstetric outcomes in pregnant women with heart disease: appraisal of the 2018 mWHO classification

et al. 2022

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ObjectiveTo appraise the application of the 2018 European Society of Cardiology-adapted modified WHO (mWHO) classification to pregnant women with heart disease managed at our maternal–fetal medicine referral centre and to assess whether the lack of a multidisciplinary Pregnancy Heart team has influenced their outcomes.MethodsA retrospective cohort study including all pregnancies with heart disease managed at our centre between June 2011 and December 2020. Cardiac conditions were categorised in five classes according to the mWHO classification. An additional class, named X, was created for conditions not included in this classification. Outcomes were compared among all classes and factors potentially associated to cardiac complications were assessed.ResultsWe identified 162 women with 197 pregnancies, for a prevalence of 0.7%. Thirty-eight (19.3%) gestations were included in class X. Caesarean section was performed in 64.9% pregnancies in class X, a rate similar to that of class II, II-III, and III/IV, and mostly for obstetric indications; in turn, it was more commonly performed for cardiology reasons in class II–III and III/IV. Cardiac complications occurred in 10.7%, with class X and II pregnancies showing the highest number of events (n=30.8% and 34.6%, respectively). Multiple gestation and urgent caesarean section associated with a 5-fold and 6.5-fold increase in complication rates.ConclusionsEven in a maternal–fetal medicine referral centre, the lack of a multidisciplinary team approach to women with heart disease may negatively impact their outcomes.

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Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum

Cited by 109 publications

References 67 publications

Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

Instituting a Curriculum for Cardio-Obstetrics Subspecialty Fellowship Training

Cardiac and obstetric outcomes in pregnant women with heart disease: appraisal of the 2018 mWHO classification

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