Cardiovascular Fellowship Training in Cardio-Obstetrics: JACC Review Topic of the Week.

The United States has the highest maternal mortality in the developed world with cardiovascular disease as the leading cause of pregnancy-related deaths. In response to this, the emerging subspecialty of cardio-obstetrics has been growing over the past decade. Cardiologists with training and expertise in caring for patients with cardiovascular disease in pregnancy are essential to provide effective, comprehensive, multidisciplinary, and high-quality care for this vulnerable population. This document provides a blueprint on incorporation of cardio-obstetrics training into cardiovascular disease fellowship programs to improve knowledge, skill, and expertise among cardiologists caring for these patients, with the goal of improving maternal and fetal outcomes.

Eliminating Disparities in Cardiovascular Disease for Black Women: JACC Review Topic of the Week.

Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women.

Socioeconomic Determinants of Health and Cardiovascular Outcomes in Women: JACC Review Topic of the Week.

Socioeconomic disparities in cardiovascular risk factors and outcomes exist among women, particularly those of minority racial or ethnic backgrounds. Barriers to optimal cardiovascular health begin early in life-with inadequate access to effective contraception, postpartum follow-up, and maternity leave-and result in excess rates of myocardial infarction, stroke, and cardiovascular death in at-risk populations. Contributing factors include reduced access to care, low levels of income and social support, and lack of diversity among cardiology clinicians and within clinical trials. These barriers can be mitigated by optimizing care access via policy change and improving physical access to care in women with geographic or transportation limitations. Addressing structural racism through policy change and bolstering structured community support systems will be key to reducing adverse cardiovascular outcomes among women of racial and ethnic minorities. Diversification of the cardiology workforce to more closely represent the patients we serve will be beneficial to all women.

Reducing Cardiovascular Maternal Mortality by Extending Medicaid for Postpartum Women.

Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.

Severe Maternal Morbidity, Race, and Rurality: Trends Using the National Inpatient Sample, 2012-2017.

Background: Severe maternal morbidity is related to maternal mortality and an important measure of maternal health outcomes. Our objective was to evaluate differences in rates of severe maternal morbidity and mortality (SMM&M) by rurality and race, and examine these trends over time. Materials and Methods: It involves the retrospective cohort study of delivery hospitalizations from January 1, 2012 to December 31, 2017 from the National Inpatient Sample. We identified delivery hospitalizations using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedure codes and diagnosis-related groups. We used hierarchical regression models controlling for insurance status, income, age, comorbidities, and hospital characteristics to model odds of SMM&M. Results: The eligible cohort contained 4,494,089 delivery hospitalizations. Compared with women from small cities, women in the most urban and most rural areas had higher odds of SMM&M (urban adjusted odds ratio [aOR] 1.09, 95% confidence interval [1.04-1.14]; noncore rural aOR 1.24 [1.18-1.31]). Among White women, the highest odds of SMM&M were in noncore rural counties (aOR 1.20 [1.12-1.27]), while among Black women the highest odds were in urban (aOR 1.21 [1.11-1.31]) and micropolitan areas (aOR 1.36 [1.19-1.57]). Findings were similar for Hispanic, Native American, and other race women. Rates of SMM&M increased from 2012 to 2017, especially among urban patients. Conclusions: Women in the most urban and most rural counties experienced higher odds of SMM&M, and these relationships differed by race. These findings suggest particular areas for clinical leaders and policymakers to target to reduce geographic and racial disparities in maternal outcomes.

Expectant Management of Hypertensive Disorders of Pregnancy and Future Cardiovascular Morbidity.

OBJECTIVE: To test the hypothesis that a longer length of time between diagnosis of hypertensive disorders of pregnancy and delivery is associated with increased risk of cardiovascular morbidity in the years after delivery. METHODS: This is a retrospective cohort study based in the New York State Inpatient Database. The first delivery for all patients from 2005 to 2014 who delivered preterm with an International Classification of Diseases, 9th Revision, Clinical Modification code for hypertensive disorders of pregnancy (excluding isolated chronic hypertension) was included. The duration between diagnosis and delivery was divided into 7 days or less or more than 7 days. The primary outcome was admission for a composite of cardiovascular disease, stroke, or death after the index delivery through December 31, 2014. RESULTS: There were 22,594 patients with a median follow-up period of 5.2 years: 19,750 (87.4%) were delivered within 7 days of diagnosis and 2,844 (12.6%) were delivered more than 7 days from diagnosis. The primary outcome occurred in 216 (1.1%) patients in the 0-7 days group (21 events/10,000 person-years) and 67 (2.4%) patients in the more than 7 days group (46 events/10,000 person-years), adjusted hazard ratio 1.45 (95% CI 1.09 to 1.93). The findings were robust in a number of sensitivity analyses. CONCLUSIONS: Prolonged expectant management of preterm hypertensive disorders of pregnancy is associated with an increased risk of maternal cardiac disease in the ensuing years.