It Takes a Village: Expanding Women's Cardiovascular Care to Include the Community as well as Cardiovascular and Primary Care Teams.

PURPOSE OF REVIEW: Our aim is to highlight some of the current issues that prevent women from getting sex-specific and gender-specific cardiovascular care and provide recommendations for new approaches and delivery models to improve cardiovascular care for all women. RECENT FINDINGS: Cardiovascular disease remains the number one cause of death for women in the US. Many women remain unaware of cardiovascular risk factors and many healthcare providers who care for women are also poorly informed and feel ill prepared to assess women for cardiovascular risk. Women's Heart Centers have tried to bridge the gaps in women's care between primary care and cardiology. Many of the impediments to care in the current models are lack of comprehensive care and socioeconomic societal limitations. New models of care and delivery are essential to change cardiovascular outcomes for all women, especially women at high risk.

Heart Centers for Women: Historical Perspective on Formation and Future Strategies to Reduce Cardiovascular Disease.

Heart Centers for Women (HCW) developed as a response to the need for improved outcomes for women with cardiovascular disease (CVD). From 1984 until 2012, more women died of CVD every single year in comparison with men. Initially, there was limited awareness and sex-specific research regarding mortality or outcomes in women. HCW played an active role in addressing these disparities, provided focused care for women, and contributed to improvements in these gaps. In 2014 and 2015, death from CVD in women had declined below the level of death from CVD in comparison with men. Even though awareness of CVD in women has increased among the public and healthcare providers and both sex- and gender-specific research is currently required in all research trials, not all women have benefitted equally in mortality reduction. New strategies for HCW need to be developed to address these disparities and expand the current HCW model. The HCW care team needs to direct academic curricula on sex- and gender-specific research and care; expand to include other healthcare professionals and other subspecialties; provide new care models; address diversity; and include more male providers.

Socioeconomic characteristics of African American women attending community blood pressure screenings.

Study objective: To examine the associations of education and income and blood pressure (BP) in a socioeconomically diverse cohort of African-American (AA) women attending community BP screenings. Design setting and participants: This cross-sectional analysis used data from AA women (n = 972) 53 ± 14 years, enrolled between 2015 and 2019 in the 10,000-women hypertension community screening project in the metropolitan Atlanta area. OLS linear regression were used to examine the associations between SES (education and income) and BP after adjusting for age, body mass index (BMI), smoking, and lipids. Main outcomes and measures: Outcomes were systolic and diastolic BP (SBP, DBP). Measures of SES included education [high school ≤(HS), some college, and ≥college] and income-[<$24,000, $24,000-<$48,000, $48,000-$96,000, and ≥$96,000]. Sociodemographics, health history, anthropometrics and point of care non-fasting lipids were obtained. Results: Compared to women earning <$24,000, an income of ≥$96,000 (ß = -5.7 mmHg, 95% CI: -9.9, -1.5, p = .01) was associated with a lower SBP in the minimally adjusted model. Subsequent adjustment for cardiovascular risk factors attenuated the association and was no longer significant. College and above versus ≤HS education was associated with a higher DBP in the minimally (ß = 2.7 mmHg, 95% CI: 0.2, 5.2, p = .03) and fully adjusted models (ß = 3.4 mmHg, 95% CI: 0.2, 6.5, p = .04). Conclusion: Income of ≥$96,000 was associated with a lower SBP while a college and above education was associated with a higher DBP. Findings underscore the need for increased cardiovascular risk awareness and education targeting higher SES AA women attending community BP screenings.

In-Hospital Complications in Pregnancies Conceived by Assisted Reproductive Technology.

Background Assisted reproductive technology (ART) has emerged as a common treatment option for infertility, a problem that affects an estimated 48 million couples worldwide. Advancing maternal age with increasing prepregnancy cardiovascular risk factors, such as chronic hypertension, obesity, and diabetes, has raised concerns about pregnancy complications associated with ART. However, in-hospital complications following pregnancies conceived by ART are poorly described. Methods and Results To assess the patient characteristics, obstetric outcomes, vascular complications and temporal trends of pregnancies conceived by ART, we analyzed hospital deliveries conceived with or without ART between January 1, 2008, and December 31, 2016, from the United States National Inpatient Sample database. We included 106 248 deliveries conceived with ART and 34 167 246 deliveries conceived without ART. Women who conceived with ART were older (35 versus 28 years; P<0.0001) and had more comorbidities. ART-conceived pregnancies were independently associated with vascular complications (acute kidney injury: adjusted odds ratio [aOR], 2.52; 95% CI 1.99-3.19; and arrhythmia: aOR, 1.65; 95% CI, 1.46-1.86), and adverse obstetric outcomes (placental abruption: aOR, 1.57; 95% CI, 1.41-1.74; cesarean delivery: aOR, 1.38; 95% CI, 1.33-1.43; and preterm birth: aOR, 1.26; 95% CI, 1.20-1.32), including in subgroups without cardiovascular disease risk factors or without multifetal pregnancies. Higher hospital charges ($18 705 versus $11 983; P<0.0001) were incurred compared with women who conceived without ART. Conclusions Pregnancies conceived by ART have higher risks of adverse obstetric outcomes and vascular complications compared with spontaneous conception. Clinicians should have detailed discussions on the associated complications of ART in women during prepregnancy counseling.

In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses.

OBJECTIVE: To assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery. METHODS: We analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database. RESULTS: We included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth. CONCLUSION: Women with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.

Cardiovascular Risk Factors in Younger Black Women: Results from the 10,000 Women Community Screening Project.

Background: Cardiovascular Disease (CVD) risk factors are prevalent in black women, but when these risk factors arise is not clear. We aimed to determine when obesity, hypertension, and hyperlipidemia appear in black women within a community screening program. Methods: 945 black women who enrolled in the 10,000 Women community screening project in the metro Atlanta area were included (2015-2018). Socioeconomic, lifestyle, and traditional CVD risk factor information was patient-reported and measured. Characteristics of three cohorts stratified by age, 20-39 years old (yo), 40-59 yo, and ≥60 yo, were compared using pairwise analysis. Results: All cohorts had class 1 obesity. Mean systolic blood pressure was higher in older cohorts [20-39 yo: 122 ± 15; 40-59 yo: 133 ± 19; ≥60 yo: 142 ± 20 mmHg; p < 0.001]. All age groups had mean total cholesterol levels below 200 mg/dL and were lowest in women 20-39 yo, (p < 0.001). All age groups had mean LDL levels below 100 mg/dL and were highest in women 20-39 yo, (p < 0.01). All age groups had mean HDL levels greater than 50 mg/dL and were highest in women ≥60 yo, (p-value = 0.03). A higher proportion of ≥60 yo limited salt intake, (p ≤ 0.001), and ate fast food less than three times a week, (p < 0.001), compared to younger women. Conclusion: We report that CVD risk factors, like elevated blood pressure and obesity, are prevalent at young ages in black women, which could be due to lifestyle practices. Earlier initiation of CVD preventive care in black women could be beneficial; however, this needs to be studied further.

Women in Cardiology Twitter Network: An Analysis of a Global Professional Virtual Community From 2016 to 2019.

Background Social media is an effective channel for the advancement of women physicians; however, its use by women in cardiology has not been systematically studied. Our study seeks to characterize the current Women in Cardiology Twitter network. Methods and Results Six women-specific cardiology Twitter hashtags were analyzed: #ACCWIC (American College of Cardiology Women in Cardiology), #AHAWIC (American Heart Association Women in Cardiology), #ilooklikeacardiologist, #SCAIWIN (Society for Cardiovascular Angiography and Interventions Women in Innovations), #WomeninCardiology, and #WomeninEP (Women in Electrophysiology). Twitter data from 2016 to 2019 were obtained from Symplur Signals. Quantitative and descriptive content analyses were performed. The Women in Cardiology Twitter network generated 48 236 tweets, 266 180 903 impressions, and 12 485 users. Tweets increased by 706% (from 2083 to 16 780), impressions by 207% (from 26 755 476 to 82 080 472), and users by 440% (from 796 to 4300), including a 471% user increase internationally. The network generated 6530 (13%) original tweets and 43 103 (86%) amplification tweets. Most original and amplification tweets were authored by women (81% and 62%, respectively) and women physicians (76% and 52%, respectively), with an increase in original and amplification tweets authored by academic women physicians (98% and 109%, respectively) and trainees (390% and 249%, respectively) over time. Community building, professional development, and gender advocacy were the most common tweet contents over the study period. Community building was the most common tweet category for #ACCWIC, #AHAWIC, #ilooklikeacardiologist, #SCAIWIN, and #WomeninCardiology, whereas professional development was most common for #WomeninEP. Conclusions The Women in Cardiology Twitter network has grown immensely from 2016 to 2019, with women physicians as the driving contributors. This network has become an important channel for community building, professional development, and gender advocacy discussions in an effort to advance women in cardiology.

Temporal Trends in Pregnancy-Associated Stroke and Its Outcomes Among Women With Hypertensive Disorders of Pregnancy.

Background Stroke is a serious complication of hypertensive disorders of pregnancy (HDP), with potentially severe and long-term sequelae. However, the temporal trends, predictors, and outcomes of stroke in women with HDP at delivery remain unknown. Methods and Results All HDP delivery hospitalizations with or without stroke event (ischemic, hemorrhagic, or unspecified) between 2004 and 2014 in the United States National Inpatient Sample were analyzed to examine incidence, predictors, and prognostic impact of stroke. Of 4 240 284 HDP delivery hospitalizations, 3391 (0.08%) women had stroke. While the prevalence of HDP increased over time, incident stroke rates decreased from 10 to 6 per 10 000 HDP delivery hospitalizations between 2004 and 2014. Women with stroke were increasingly multimorbid, with some risk factors being more strongly associated with ischemic strokes, including congenital heart disease, peripheral vascular disease, dyslipidemia, and sickle cell disease. Delivery complications were also associated with stroke, including cesarean section (odds ratio [OR], 1.58; 95% CI, 1.33-1.86), postpartum hemorrhage (OR, 1.91; 95% CI, 1.33-1.86), and maternal mortality (OR, 99.78; 95% CI, 59.15-168.31), independently of potential confounders. Women with stroke had longer hospital stays (median, 6 versus 3 days), higher hospital charges (median, $14 655 versus $4762), and a higher proportion of nonroutine discharge locations (38% versus 4%). Conclusions The incidence of stroke in women with HDP has declined over time. While a relatively rare event, identification of women at highest risk of ischemic or hemorrhagic stroke on admission for delivery is important to reduce long-term sequelae.

Improving Cardiovascular Workforce Competencies in Cardio-Obstetrics: Current Challenges and Future Directions.

Maternal mortality in the United States is the highest among all developed nations, partly because of the increased prevalence of cardiovascular disease in pregnancy and beyond. There is growing recognition that specialists involved in caring for obstetric patients with cardiovascular disease need training in the new discipline of cardio-obstetrics. Training can include integrated formal cardio-obstetrics curricula in general cardiovascular disease training programs, and developing and disseminating joint cardiac and obstetric societal guidelines. Other efforts to help strengthen the cardio-obstetric field include increased collaborations and advocacy efforts between stakeholder organizations, development of US-based registries, and widespread establishment of multidisciplinary pregnancy heart teams. In this review, we present the current challenges in creating a cardio-obstetrics community, present the growing need for education and training of cardiovascular disease practitioners skilled in the care of obstetric patients, and identify potential solutions and future efforts to improve cardiovascular care of this high-risk patient population.

Childbearing Decisions in Residency: A Multicenter Survey of Female Residents.

PURPOSE: To characterize how female residents make decisions about childbearing, factors associated with the decision to delay childbearing, and satisfaction with these decisions. METHOD: In 2017, the authors sent a voluntary, anonymous survey to 1,537 female residents enrolled across 78 graduate medical education programs, consisting of 25 unique specialties, at 6 U.S. academic medical centers. Survey items included personal, partner, and institutional characteristics, whether the respondent was delaying childbearing during residency, and the respondent's satisfaction with this decision. RESULTS: The survey response rate was 52% (n = 804). Among the 447 (56%) respondents who were married or partnered, 274 (61%) were delaying childbearing. Residents delaying childbearing were significantly more likely to be younger (P < .001), not currently a parent (P < .001), in a specialty with an uncontrollable lifestyle (P = .001), or in a large program (P = .004). Among self-reported reasons for delaying childbearing, which were not mutually exclusive, the majority cited a busy work schedule (n = 255; 93%) and desire not to extend residency training (n = 145; 53%). Many cited lack of access to childcare (n = 126; 46%), financial concerns (n = 116; 42%), fear of burdening colleagues (n = 96; 35%), and concern for pregnancy complications (n = 74; 27%). Only 38% (n = 103) of respondents delaying childbearing were satisfied with this decision, with satisfaction decreasing with increasing age. CONCLUSIONS: Decisions to delay childbearing are more common in certain specialties, and many residents who delay childbearing are not satisfied with that decision. These findings suggest that greater attention is needed overall, and particularly in certain specialties, to promote policies and cultures that both anticipate and normalize parenthood in residency, thus minimizing the conflict between biological and professional choices for female residents.

Addressing the Gap in Physician Preparedness To Assess Cardiovascular Risk in Women: a Comprehensive Approach to Cardiovascular Risk Assessment in Women.

PURPOSE OF REVIEW: Increased recognition of risk factors and improved knowledge of sex-specific presentations has led to improved clinical outcomes for women with cardiovascular disease (CVD) compared to two decades ago. Yet, CVD remains the leading cause of death for women in the USA. Women have unique risk factors for CVD that continue to go under-recognized by their physicians. RECENT FINDINGS: In a nationwide survey of primary care physicians (PCPs) and cardiologists, only 22% of PCPs and 42% of cardiologists reported being extremely well prepared to assess CVD risk in women. A presidential advisory from the American Heart Association (AHA) and American College of Obstetrics and Gynecologist (ACOG) recommends that cardiologists and obstetricians and gynecologists (Ob/Gyns) collaborate to promote CVD risk identification and reduction throughout a woman's lifetime. We suggest a comprehensive approach to identify unique and traditional risk factors for CVD in women, address the gap in physician knowledge, and improve cardiovascular care for women.

Maternity Leave in Residency: A Multicenter Study of Determinants and Wellness Outcomes.

PURPOSE: To characterize determinants of resident maternity leave and the effect of length of leave on maternal well-being. METHOD: In 2017, the authors sent a voluntary, anonymous survey to female residents at 78 programs, in 25 unique specialties, at 6 institutions. Survey items included personal, partner, and child demographics, and logistics of leave, including whether leave was paid or vacation or sick leave was used. Outcomes were maternity leave length; duration of breastfeeding; burnout and postpartum depression screens; perceptions of support; and satisfaction with length of leave, breastfeeding, and childbearing during residency. RESULTS: Fifty-two percent (804/1,537) of residents responded. Among 16% (126) of respondents who were mothers, 50% (63) had their first child during residency. Seventy-seven maternity leaves were reported (range, 2-40 weeks), with most taking 6 weeks (32% of leaves; 25) and including vacation (81%; 62) or sick leave (64%; 49). Length of leave was associated with institution, use of sick leave or vacation, and amount of paid leave. The most frequently self-reported determinant of leave was the desire not to extend residency training (27%; 59). Training was not extended for 53% (41) of mothers; 9% (7) were unsure. Longer breastfeeding duration and perceptions of logistical support from program administration were associated with longer maternity leaves. Burnout affected approximately 50% (38) of mothers regardless of leave length. CONCLUSIONS: This study illustrates variability in administration of resident maternity leaves. Targets for intervention include policy clarification, improving program support, and consideration of parent wellness upon return to work.

Specialized Care for Women: the Impact of Women's Heart Centers.

PURPOSE OF THE REVIEW: Cardiovascular disease (CVD) has been and remains the leading cause of mortality in women in the United States. For decades, more women died every year of CVD compared to men. Heart centers for women (HCW) are developed in response to the need for greater patient and physician awareness of CVD in women and to conduct sex-specific research in women. Today, many HCW provide multispecialty and focused areas of cardiovascular care for women. HCW provide their female patients with expertise over the many stages of a woman's life. And HCW partner with national organizations to advance research and education through specialized and focused care for women. The purpose of this review is to review the historical development of heart centers for women and discuss the types of care they provide for women. RECENT FINDINGS: Mortality rates from cardiovascular disease in women are finally reaching the levels of men after decades of focus on awareness, prevention, and evidence-based guideline-directed care for women. Heart centers for women have evolved to provide subspecialty and comprehensive care for women that includes education and research. Heart centers for women are partnering with many other disease-based and patient advocacy organizations to provide care for all women at all stages of life. Alarmingly, there has been increasing CVD mortality in both men and women recently.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps.

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

JCL roundtable: Cardiovascular disease risk reduction in menopausal women.

Ovarian failure occurs in most women during the late fifth decade or early sixth decade of life. This causes a number of changes in physiology as estrogen and progestin concentrations decline. These involve lipoprotein metabolism and the vasculature. The risk factors for large vessel disease increase, and dysfunction of the small resistance vessels responds with changes in blood flow to the skin causing unpleasant symptoms. These and other changes result in visits to the physician. A reassessment of risk factors and symptoms is needed to develop a new plan for effective management, both short term and long term.

Guidelines for the Reduction of Cardiovascular Disease in Women.

Since 1984, more women than men have died each year from cardiovascular disease. Various organizations, such as the American Heart Association and the American College of Cardiology, have published prevention guidelines for heart disease and stroke that may improve care for women. In this article, we review these guidelines, the results of new studies on emerging risk factors, and new approaches for reducing cardiovascular disease in women.