Maternal and Fetal Outcomes in Pulmonary Hypertension During Pregnancy: A Contemporary Nationwide Analysis.

Pulmonary hypertension (PH) disproportionately affects women, presenting challenges during pregnancy. Historically, patients with PH are advised to avoid pregnancy; however, recent reports have indicated that the incidence of adverse events in pregnant patients with PH may be lower than previously reported. We conducted a retrospective cohort study in pregnant patients with PH using the National Readmission Database from January 1, 2016, to December 31, 2020. PH was categorized according to the World Health Organization classification. Primary end points include maternal mortality and 30-day nonelective readmission rate. Other adverse short-term maternal (cardiovascular and obstetric) and fetal outcomes were also analyzed. Of 9,922,142 pregnant women, 3,532 (0.04%) had PH, with Group 1 PH noted in 1,833 (51.9%), Group 2 PH in 676 (19.1%), Group 3 PH in 604 (17.1%), Group 4 PH in 23 (0.7%), Group 5 PH in 98 (2.8%), and multifactorial PH in 298 (8.4%). PH patients exhibited higher rates of adverse cardiovascular events (15.7% vs 0.3% without PH, p <0.001) and mortality (0.9% vs 0.01% without PH, p <0.001). Mixed PH and Group 2 PH had the highest prevalence of adverse cardiovascular events in the World Health Organization PH groups. Patients with PH had a significantly higher nonelective 30-day readmission rate (10.4% vs 2.3%) and maternal adverse obstetric events (24.2% vs 9.1%) compared with those without PH (p <0.001) (Figure 1). In conclusion, pregnant women with PH had significantly higher adverse event rates, including in-hospital maternal mortality (85-fold), compared with those without PH.

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites.

BACKGROUND: Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. METHODS AND RESULTS: This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (ß=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). CONCLUSIONS: These data support the use of the MAGGIC score to risk stratify black patients with HF.

Advanced Heart Failure Therapies and Cardiorenal Syndrome.

Heart failure (HF) is extremely prevalent and for those with end-stage (stage D) disease, 1-year survival is only 25-50%. Several studies have captured the mortality impact of kidney disease on patients with HF, and measures of kidney function are a component of many HF risk stratification scores. The management of advanced HF complicated by cardiorenal syndrome (CRS) is challenging, and irreversible kidney failure often limits patient candidacy for advanced HF therapies, such as transplant or left ventricular assist device therapy. Thus, prompt institution of aggressive therapy is warranted in stage D HF patients with CRS to prevent irreversible kidney failure. In this chapter, we discuss the assessment and management of patients with CRS with end-stage HF. In addition to discussing medical therapy aimed at decongestion and increased cardiac inotropy, we provide a summary of temporary circulatory support devices that can be considered for those whom hospice is not desired. In all circumstances, a close collaboration between the advanced HF specialist and nephrologist is needed to achieve the best patient outcomes.

Socioeconomic and Racial Disparities: a Case-Control Study of Patients Receiving Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis.

BACKGROUND: We sought to quantify socioeconomic disparities in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) at an urban, tertiary referral center. METHODS: This retrospective case-control study identified 67 patients with severe AS (aortic valve [AV] area ≤1 cm2 or AV area index ≤0.60 cm2/m2 or AV velocity ≥40 mmHg) who underwent TAVR from November 5, 2013 to June 10, 2014. Study subjects were matched to controls with severe AS without TAVR in a 4:1 age-frequency match. Demographic data were collected using electronic medical records. Area-based median household income was obtained by geocoding patients' addresses and linking with census data. Charlson comorbidity index for all subjects was calculated. RESULTS: Income disparity was significant in that with every $10,000 increase in income, the odds of receiving TAVR increased by 10% (p = 0.05). Non-blacks were significantly more likely to receive TAVR than blacks (odds ratio [OR] 2.812, confidence interval [CI] 1.007-7.853; p = 0.048). No differences in comorbidities were found between the two groups. Post hoc analysis to identify etiologies of the found disparities examined differences of AV area and AV area index, indication for two-dimensional echocardiography (echo), symptoms prior to echo, and action after echo within the control group. Black race significantly impacted the TAVR status despite the same AV area (OR 0.33, CI 0.09-0.97, p = 0.043). After echo, blacks were more likely to decline AVR, be lost to follow-up, and not be referred to cardiology (OR 4.41, CI 1.43-13.64; p = 0.010). CONCLUSION: Socioeconomic and racial disparities were associated with patients with severe AS receiving TAVR at a major referral center. This study emphasizes the importance of improving access to standard of care for these subgroups of cardiac patients.