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1.
JACC Adv ; 3(4): 100901, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38939671

RESUMEN

Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.

2.
J Am Coll Cardiol ; 83(17): 1702-1712, 2024 Apr 30.
Artículo en Inglés | MEDLINE | ID: mdl-38658109

RESUMEN

Cardiovascular disease affects 37% of Hispanic women and is the leading cause of death among Hispanic women in the United States. Hispanic women have a higher burden of cardiovascular risk factors, are disproportionally affected by social determinants of health, and face additional barriers related to immigration, such as discrimination, language proficiency, and acculturation. Despite this, Hispanic women show lower rates of cardiovascular disease and mortality compared with non-Hispanic White women. However, this "Hispanic paradox" is challenged by recent studies that account for the diversity in culture, race, genetic background, country of origin, and social determinants of health within Hispanic subpopulations. This review provides a comprehensive overview of the cardiovascular risk factors in Hispanic women, emphasizing the role of social determinants, and proposes a multipronged approach for equitable care.


Asunto(s)
Enfermedades Cardiovasculares , Hispánicos o Latinos , Humanos , Enfermedades Cardiovasculares/etnología , Enfermedades Cardiovasculares/epidemiología , Femenino , Estados Unidos/epidemiología , Determinantes Sociales de la Salud/etnología , Factores de Riesgo , Salud de la Mujer/etnología
3.
JACC Case Rep ; 29(4): 102217, 2024 Feb 21.
Artículo en Inglés | MEDLINE | ID: mdl-38379658

RESUMEN

Secondary hypertension can occur from a variety of renal and endocrine disorders. Pheochromocytoma, a rare catecholamine-secreting neuroendocrine tumor, is associated with adverse maternal and fetal outcomes in the absence of a timely diagnosis and a coordinated multidisciplinary approach. Clues to diagnosis include resistant hypertension or an adrenal mass on imaging.

4.
J Am Coll Cardiol ; 82(9): 817-827, 2023 08 29.
Artículo en Inglés | MEDLINE | ID: mdl-37612014

RESUMEN

Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes. A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.


Asunto(s)
Enfermedades de la Aorta , Disección Aórtica , Embarazo , Femenino , Humanos , Masculino , Caracteres Sexuales , Aorta , Disección Aórtica/epidemiología
5.
Curr Cardiol Rep ; 25(2): 77-87, 2023 02.
Artículo en Inglés | MEDLINE | ID: mdl-36745273

RESUMEN

PURPOSE OF REVIEW: The purpose of the review is to summarize the unique cardiovascular disease (CVD) risk factors encountered during pregnancy and to provide the reader with a framework for acquiring a comprehensive obstetric history during the cardiovascular (CV) assessment of women. RECENT FINDINGS: Individuals with a history of pregnancies complicated by hypertensive disorders of pregnancy (HDP), gestational diabetes (GDM), preterm delivery, low birth weight, and fetal growth restriction during pregnancy are at a higher risk of developing short- and long-term CV complications compared to those without adverse pregnancy outcomes (APOs). Women with a history of APOs can be at increased risk of CVD even after achieving normoglycemia and normal blood pressure control postpartum. Risk assessment and stratification in women must account for these APOs as recommended by the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the primary prevention of CVD. Early recognition, monitoring, and treatment of APOs are key to limiting CVD complications late in maternal life. Recognition of APOs as female-specific cardiovascular risk factors is critical for risk stratification for women and birthing persons. Further research is needed to understand the complex interplay between genetics, environmental, behavioral, and maternal vascular health, and the association between APOs and CVD risk.


Asunto(s)
Enfermedades Cardiovasculares , Embarazo , Recién Nacido , Femenino , Humanos , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etiología , Factores de Riesgo , Resultado del Embarazo , Presión Sanguínea , Factores de Riesgo de Enfermedad Cardiaca
7.
JACC Adv ; 1(3): 100057, 2022 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-35967591

RESUMEN

Cardiovascular complications are frequently present in coronavirus-2019 (COVID-19) infection. These include microvascular and macrovascular thrombotic complications such as arterial and venous thromboembolism, myocardial injury or inflammation resulting in infarction, heart failure, and arrhythmias. Data suggest increased risk of adverse outcomes in pregnant compared with nonpregnant women of reproductive age with COVID-19 infection, including need for intensive care unit admission, mechanical ventilation, and extracorporeal membrane oxygenation utilization. Current statements addressing COVID-19-associated cardiac complications do not include pregnancy complications that may mimic COVID-19 complications such as peripartum cardiomyopathy, spontaneous coronary artery dissection, and preeclampsia. Unique to pregnancy, COVID-19 complications can result in preterm delivery and modify management of the pregnancy. Moreover, pregnancy has often been an exclusion criterion for enrollment in research studies. In this review, we summarize what is known about pregnancy-associated COVID-19 cardiovascular complications.

8.
JACC Clin Electrophysiol ; 8(1): 120-135, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-35057977

RESUMEN

Increasing maternal mortality and incidence of arrhythmias in pregnancy have been noted over the past 2 decades in the United States. Pregnancy is associated with a greater risk of arrhythmias, and patients with a history of arrhythmias are at significant risk of arrhythmia recurrence during pregnancy. The incidence of atrial fibrillation in pregnancy is rising. This review discusses the management of tachyarrhythmias and bradyarrhythmias in pregnancy, including management of cardiac arrest. Management of fetal arrhythmias are also reviewed. For patients without structural heart disease, ß-blocker therapy, especially propranolol and metoprolol, and antiarrhythmic drugs, such as flecainide and sotalol, can be safely used to treat tachyarrhythmias. As a last resort, catheter ablation with minimal fluoroscopy can be performed. Device implantation can be safely performed with minimal fluoroscopy and under echocardiographic or ultrasound guidance in patients with clear indications for devices during pregnancy. Because of rising maternal mortality in the United States, which is partly driven by increasing maternal age and comorbidities, a multidisciplinary and/or integrative approach to arrhythmia management from the prepartum to the postpartum period is needed.


Asunto(s)
Fibrilación Atrial , Sotalol , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Femenino , Flecainida , Humanos , Embarazo , Taquicardia/tratamiento farmacológico
9.
Acupunct Med ; 40(2): 152-159, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-34856826

RESUMEN

PURPOSE: Stable angina is ischemic chest pain on exertion or with emotional stress. Despite guideline-directed therapy, up to 30% of patients have suboptimal pain relief. The aims of this study were to: (1) determine the feasibility and acceptability of a randomized controlled trial (RCT) of acupuncture; and (2) evaluate preliminary efficacy of acupuncture with respect to reduction of pain and increased functional status and health-related quality of life (HRQoL). METHODS: Participants with stable angina for ⩾1 month received either a standardized acupuncture protocol, twice per week for 5 weeks, or an attention control protocol. Measures included the McGill Pain Questionnaire (average pain intensity (API), pain now) and the Seattle Angina Questionnaire-7 (functional status, symptoms, and HRQoL). Feasibility was defined as ⩾80% recruitment, ⩾75% retention following enrollment, and ⩾80% completion. Descriptive statistics and mixed-effects linear regression were used for analysis. RESULTS: The sample (n = 24) had a mean age of 59 ± 12 years, was predominantly female (63%), and represented minority groups (8% White, 52% Black, 33% Hispanic, and 8% Other). Feasibility was supported by 79% retention and 89% completion rates. The recruitment rate (68%) was slightly lower than expected. Acceptability scores were 87.9% for the acupuncture group and 51.7% for the control group. Outcomes were significantly better for the acupuncture versus control groups (API, b = -2.1 (1.1), p = 0.047; functional status, b = 27.6 (7.2), p < 0.001; and HRQoL, b = 38.8 (11.9), p = 0.001). CONCLUSIONS AND IMPLICATIONS: Acupuncture was feasible and acceptable in our diverse sample. We were slightly under the recruitment target of 80%, but participants who started the study had a high likelihood of completing it. Acupuncture shows promise for stable angina, but its effectiveness needs to be confirmed by a larger, adequately powered RCT. TRIAL REGISTRATION NUMBER: NCT02914834 (ClinicalTrials.gov).


Asunto(s)
Terapia por Acupuntura , Terapia por Acupuntura/métodos , Anciano , Estudios de Factibilidad , Femenino , Humanos , Persona de Mediana Edad , Dimensión del Dolor , Calidad de Vida , Resultado del Tratamiento
10.
JACC Adv ; 1(3): 100064, 2022 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-38938393

RESUMEN

Cardiac biomarkers are widely used in the nonpregnant population when acute cardiovascular (CV) pathology is suspected; however, the behavior of these biomarkers in the context of pregnancy is less well understood. Pregnant individuals often have symptoms that mimic those of cardiac dysfunction, and complications of pregnancy may include CV disease. This paper will summarize our current knowledge on the use of cardiac biomarkers in pregnancy and provide suggestions on how to use these tools in clinical practice based on the available evidence. Natriuretic peptides and troponin should not be measured routinely in uncomplicated pregnancy, where values should remain low as in the nonpregnant population. In the context of pre-existing or suspected CV disease, these biomarkers retain their negative predictive value. Elevations of both natriuretic peptides and troponin may occur without clear clinical significance in the immediate postpartum period. Elevations of these markers should always prompt further investigation into possible CV pathology.

11.
JACC Adv ; 1(4): 100124, 2022 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-38939707
12.
J Am Coll Cardiol ; 78(19): 1919-1929, 2021 11 09.
Artículo en Inglés | MEDLINE | ID: mdl-34736568

RESUMEN

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.


Asunto(s)
Enfermedades Cardiovasculares , Determinantes Sociales de la Salud , Salud de la Mujer , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Femenino , Humanos , Salud de las Minorías , Salud Rural , Determinantes Sociales de la Salud/economía , Determinantes Sociales de la Salud/etnología , Determinantes Sociales de la Salud/normas
13.
J Am Coll Cardiol ; 77(14): 1763-1777, 2021 04 13.
Artículo en Inglés | MEDLINE | ID: mdl-33832604

RESUMEN

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.


Asunto(s)
Enfermedades Cardiovasculares , Grupo de Atención al Paciente/organización & administración , Complicaciones Cardiovasculares del Embarazo , Ajuste de Riesgo/métodos , Enfermedades Cardiovasculares/clasificación , Enfermedades Cardiovasculares/fisiopatología , Enfermedades Cardiovasculares/terapia , Femenino , Factores de Riesgo de Enfermedad Cardiaca , Humanos , Periodo Periparto , Embarazo , Complicaciones Cardiovasculares del Embarazo/clasificación , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Complicaciones Cardiovasculares del Embarazo/terapia
14.
J Card Fail ; 27(2): 143-152, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33388469

RESUMEN

BACKGROUND: Cardiovascular conditions are leading contributors to increasing maternal morbidity and mortality. Heart failure with preserved ejection fraction (HFpEF) results in the majority of HF admissions in women, yet its impact in pregnancy is unknown. We examined the prevalence rates, risk factors and adverse pregnancy outcomes in women with HFpEF during pregnancy-related hospitalizations in the United States. METHODS AND RESULTS: We conducted a cross-sectional analysis of pregnancy-related hospitalizations from 2002 through 2014 using the National Inpatient Sample. HFpEF cases were identified using the 428.3 International Classification of Diseases, 9th edition, Clinical Modification code. Weighting variables were used to provide national estimates, unconditional survey logistic regression to generate odds ratios and 95% confidence intervals (CI) representing adjusted associations with adverse pregnancy outcomes and Joinpoint regression to estimate temporal trends. Among 58,732,977 hospitalizations, there were 3840 HFpEF cases, an overall rate of 7 cases per 100,000 pregnancy-related hospitalizations; 56% occurred postpartum, 27% during delivery, and 17% antepartum. The temporal trend for hospitalization increased throughout the timeframe by 19.4% (95% CI 13.9-25.1). HFpEF hospitalizations were more common for Black, older, or poor women. Risk factors included hypertension (chronic hypertension and hypertensive disorders of pregnancy), anemia, obesity, diabetes, renal disease and coronary atherosclerosis; all known risk factors for HFpEF. Women with HFpEF were 2.61-6.47 times more likely to experience adverse pregnancy outcomes. CONCLUSIONS: The pregnancy-related HFpEF hospitalization prevalence has increased and is associated with adverse pregnancy outcomes. Risk factors resemble those outside pregnancy, emphasizing the need for screening and monitoring women with risk factors during pregnancy for HFpEF.


Asunto(s)
Insuficiencia Cardíaca , Estudios Transversales , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Hospitalización , Humanos , Embarazo , Factores de Riesgo , Volumen Sistólico , Estados Unidos/epidemiología
15.
Cardiol Clin ; 39(1): 21-32, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33222812

RESUMEN

Cardiovascular disease is a major contributor to maternal morbidity and mortality and frequently preventable. Women with known cardiovascular disease should undergo cardiac evaluation before pregnancy. Many women with pregnancy-associated cardiac complications are not previously known to have cardiac disease. Women at high risk or who have signs or symptoms suggestive of heart failure, angina, or arrhythmias should undergo prompt evaluation. This article describes various diagnostic imaging modalities that can be used in pregnancy, including indications, strengths, and limitations.


Asunto(s)
Técnicas de Imagen Cardíaca/métodos , Cardiopatías/diagnóstico , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Femenino , Humanos , Embarazo , Ajuste de Riesgo/métodos
16.
Clin Obstet Gynecol ; 63(4): 893-909, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33044247

RESUMEN

The cardiomyopathies are a diverse group of disorders characterized by structural abnormalities of heart muscle, many of which have a genetic component. They are associated with substantial morbidity and mortality in pregnancy. We review the distinct forms of cardiomyopathy (dilated, hypertrophic, and functional) which can be seen during pregnancy, discuss complications associated with each distinct group such as heart failure, arrhythmias, and transmission to offspring, and address management strategies for stable and unstable patients.


Asunto(s)
Cardiomiopatías , Cardiomiopatías/etiología , Cardiomiopatías/terapia , Femenino , Humanos , Embarazo
18.
Womens Health Rep (New Rochelle) ; 1(1): 463-467, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33786512

RESUMEN

Some women have underlying cardiovascular disease that leads to increased morbidity and mortality with pregnancy. These women may choose to terminate a pregnancy rather than face this increased risk. The optimal approach for pregnancy termination in women with cardiomyopathy is not well defined. We present two women with peripartum cardiomyopathy, both modified World Health Organization (mWHO) class IV and with elevated Cardiac Disease in Pregnancy (CARPREG II) pregnancy risk stratification scores who are at the highest risk for pregnancy continuation. Both underwent induced abortion, although the procedure was performed in very different settings. These cases illustrate factors that influence the mode and setting of pregnancy termination performance.

20.
J Am Soc Echocardiogr ; 32(12): 1565-1573, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31563436

RESUMEN

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a serious complication of pregnancy associated with variable degrees of left ventricular (LV) recovery. The aim of this study was to test the hypothesis that global LV strain at presentation has prognostic value in patients with PPCM. METHODS: One hundred patients with PPCM aged 30 ± 6 years were enrolled in the multicenter Investigation in Pregnancy Associated Cardiomyopathy study along with 21 normal female control subjects. Speckle-tracking global longitudinal strain (GLS) and global circumferential strain (GCS) analysis was performed. The predefined primary combined outcome variable was death, transplantation, LV assist device implantation, or evidence of persistent LV dysfunction (LV ejection fraction [LVEF] < 50%) at 1 year. RESULTS: GLS measurement was feasible in 110 subjects: 89 of 90 patients with PPCM (99%) with echocardiographic data and all 21 control subjects. Of 84 patients (94%) with 1-year follow-up, 21 (25%) had unfavorable primary outcomes: four LV assist device placements, two deaths, and 15 patients with persistent LV dysfunction. GLS at presentation with a cutoff of 10.6% (absolute value) was specifically associated with the subsequent primary outcome with 75% sensitivity and 95% specificity. GCS at presentation with a cutoff of 10.1% was associated with the primary outcome with 78% sensitivity and 84% specificity. GLS and GCS remained significantly associated with outcomes after adjusting for LVEF (GLS odds ratio, 2.07; P < .001; GCS odds ratio, 1.37; P = .005). GLS was significantly additive to LVEF (C statistic = 0.76-0.91, net reclassification improvement = 1.32, P < .001). CONCLUSIONS: GLS and GCS in patients with PPCM at presentation were associated with subsequent clinical outcomes, including death, LV assist device implantation, and evidence of persistent LV dysfunction. Strain measures may add prognostic information over LVEF for risk stratification.


Asunto(s)
Cardiomiopatías/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Contracción Miocárdica/fisiología , Periodo Periparto , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Adulto , Cardiomiopatías/diagnóstico , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Embarazo , Pronóstico , Estudios Prospectivos
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