Posttraumatic Stress Disorder After Spontaneous Coronary Artery Dissection: A Report of the International Spontaneous Coronary Artery Dissection Registry.

BACKGROUND: Myocardial infarction secondary to spontaneous coronary artery dissection (SCAD) can be traumatic and potentially trigger posttraumatic stress disorder (PTSD). In a large, multicenter, registry-based cohort, we documented prevalence of lifetime and past-month SCAD-induced PTSD, as well as related treatment seeking, and examined a range of health-relevant correlates of SCAD-induced PTSD. METHODS AND RESULTS: Patients with SCAD were enrolled in the iSCAD (International SCAD) Registry. At baseline, site investigators completed medical report forms, and patients reported demographics, medical/SCAD history, psychosocial factors (including SCAD-induced PTSD symptoms), health behaviors, and health status via online questionnaires. Of 1156 registry patients, 859 patients (93.9% women; mean age, 52.3 years) completed questionnaires querying SCAD-induced PTSD. Nearly 35% (n=298) of patients met diagnostic criteria for probable SCAD-induced PTSD in their lifetime, and 6.4% (n=55) met criteria for probable past-month PTSD. Of 811 patients ever reporting any SCAD-induced PTSD symptoms, 34.8% indicated seeking treatment for this distress. However, 46.0% of the 298 patients with lifetime probable SCAD-induced PTSD diagnoses reported never receiving trauma-related treatment. Younger age at first SCAD, fewer years since SCAD, being single, unemployed status, more lifetime trauma, and history of anxiety were associated with greater past-month PTSD symptom severity in multivariable regression models. Greater past-month SCAD-induced PTSD symptoms were associated with greater past-week sleep disturbance and worse past-month disease-specific health status when adjusting for various risk factors. CONCLUSIONS: Given the high prevalence of SCAD-induced PTSD symptoms, efforts to support screening for these symptoms and connecting patients experiencing distress with empirically supported treatments are critical next steps. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04496687.

Validation of a noninvasive cardiac output monitor in maternal cardiac disease: comparison of NICOM and transthoracic echocardiogram.

BACKGROUND: The physiological changes to the cardiovascular system during pregnancy are considerable and are more pronounced in those with cardiac disease. In the general population, noninvasive hemodynamic monitoring is a valid alternative to pulmonary artery catheterization, which poses risk in the pregnant population. There is limited data on noninvasive cardiac output monitoring in pregnancy as an alternative to pulmonary artery catheterization. OBJECTIVE: We sought to compare transthoracic echocardiography with a noninvasive cardiac output monitor (NICOM, Cheetah Medical) in pregnant patients with and without cardiac disease. STUDY DESIGN: This was a prospective, open-label validation study that compared 2-dimensional transthoracic echocardiography with NICOM estimations of cardiac output in each trimester of pregnancy and the postpartum period. Participants with and without cardiac disease with a singleton gestation were included. NICOM estimations of cardiac output were derived from thoracic bioreactance and compared with 2-dimensional transthoracic echocardiography for both precision and accuracy. A mean percentage difference of ±30% between the 2 devices was considered acceptable agreement between the 2 measurement techniques. RESULTS: A total of 58 subjects were enrolled; 36 did not have cardiac disease and 22 had cardiac disease. Heart rate measurements between the 2 devices were strongly correlated in both groups, whereas stroke volume and cardiac output measurements showed weak correlation. When comparing the techniques, the NICOM device overestimated cardiac output in the control group in all trimesters and the postpartum period (mean percentage differences were 50.3%, 52.7%, 48.1%, and 51.0% in the first, second, and third trimesters and the postpartum period, respectively). In the group with cardiac disease, the mean percentage differences were 31.9%, 29.7%, 19.6%, and 35.2% for the respective timepoints. CONCLUSION: The NICOM device consistently overestimated cardiac output when compared with 2-dimensional transthoracic echocardiography at all timepoints in the control group and in the first trimester and postpartum period for the cardiovascular disease group. The physiological changes of pregnancy, specifically the mean chest circumference and total body water, may alter the accuracy of the cardiac output measurement by the NICOM device as they are currently estimated. Although NICOM has been validated for use in the critical care setting, there is insufficient data to support its use in pregnancy.

Spontaneous Coronary Artery Dissection (SCAD) in an Atypical Patient Without Risk Factors and Prior Asymptomatic COVID-19 Infection.

Spontaneous coronary artery dissection (SCAD) is a condition primarily seen in young women and is characterized by non-atherosclerotic arterial damage. It can occur with or without conventional risk factors for coronary heart disease and is often associated with chronic inflammatory conditions. Here, we present a unique instance of a 67-year-old woman without known risk factors who developed sudden onset chest pain in the setting of an asymptomatic coronavirus 2019 (COVID-19) infection three weeks earlier. Subsequent evaluation revealed SCAD in the distal left anterior descending (LAD) artery.

An Overlooked Cause of Myocardial Infarction With Normal Coronaries Presenting as Stress Cardiomyopathy in Females.

Spontaneous coronary artery dissection (SCAD) should be considered in the differential diagnosis of patients with provisional Takotsubo cardiomyopathy (TTS). However, because of overlapping clinical features, SCAD with subtle angiographic findings and wall motion abnormality like TTS can be easily missed. Therefore, our case highlights the importance of further investigation for SCAD.

Management of May Thurner Syndrome in Pregnant Patients.

May Thurner Syndrome contributes to thromboembolic disease and can cause significant morbidity in pregnant patients secondary to exaggerated anatomic relationships and physiologic changes in the hematologic system favoring thrombogenesis. Because this condition is both underrecognized and underreported, management in pregnant and postpartum patients is based on expert opinion without any formal evidence-based guidance. Herein, we review five pregnancies in four patients with May Thurner Syndrome and general management strategies. Through collaborative and multidisciplinary care, patients with May Thurner Syndrome can be safely and successfully managed during pregnancy and the postpartum period with appropriate anticoagulation.

Patient-Perceived Satisfaction and Knowledge Uptake in a Combined Cardio-Obstetrics Clinic.

Heart disease is the leading cause of pregnancy-related mortality in the United States and has led to the development of combined cardio-obstetrics (COB) clinics as a model for prenatal care. In other areas of medicine, these types of collaborative care models have shown improvement in morbidity, mortality, and patient satisfaction. There is some data to suggest that a combined COB clinic improves maternal outcomes but there is no data to suggest patients prefer this type of care model. This study aims to evaluate patient satisfaction in a combined COB clinic and whether this type of model enhances perceived communication and knowledge uptake. A quality questionnaire was developed to assess patient perceptions regarding communication, satisfaction, and perceived knowledge. Patients who attended the clinic (n = 960) from 2014-2020 were contacted by email, with a response received from 119 (12.5%). Participants completed a questionnaire assessing satisfaction and perceived knowledge uptake with answers based on a Likert scale (7 representing very satisfied and 1 representing very unsatisfied). Safe and effective contraceptive use was evaluated by multiple choice options. Knowledge was also assessed by comparing contraceptive use before and after the clinic. Participants reported high levels of satisfaction with the clinic (6.2 ± 1.5), provider-to-patient communication (6.1 ± 1.6), and with the multidisciplinary appointment approach (6.3 ± 1.5). As well, participants reported an increase in knowledge about heart disease a result of collaborative counseling. In summary, a multidisciplinary approach to cardio-obstetrics not only improves outcomes but is a patient satisfier.

Survival outcomes and resuscitation process measures in maternal in-hospital cardiac arrest.

BACKGROUND: Maternal in-hospital cardiac arrest is a rare event with the potential for resuscitation treatment delays because of the difficulty accessing hospital obstetrical units and limited simulation training or resuscitation experience of obstetrical staff. However, it is unclear whether survival rates and processes of care differ between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. OBJECTIVE: We aimed determine whether to there are delays in process measures and differences in survival outcomes between pregnant and nonpregnant women who have in-hospital cardiac arrest. STUDY DESIGN: Using data from 2000 to 2019 in the Get With The Guidelines-Resuscitation registry, we compared resuscitation outcomes between women aged 18 to 50 years with a maternal or nonmaternal in-hospital cardiac arrest. Using a nonparsimonious propensity score, we matched patients with a maternal in-hospital cardiac arrest to as many as 10 women with a nonmaternal in-hospital cardiac arrest. We constructed conditional logistic regression models to compare survival outcomes (survival to discharge, favorable neurologic survival [discharge cerebral performance score of 1], and return of spontaneous circulation) and processes of care (delayed defibrillation [>2 minutes] and administration of epinephrine [>5 minutes]) between women with a maternal in-hospital cardiac arrest vs those with a nonmaternal in-hospital cardiac arrest. RESULTS: Overall, 421 women with a maternal in-hospital cardiac arrest were matched by propensity score to 2316 women with a nonmaternal in-hospital cardiac arrest. The mean age among propensity score-matched women with a maternal in-hospital cardiac arrest was 31.4 (standard deviation, 6.5) years, where 33.7% were of Black race and 86.9% had an initial nonshockable cardiac arrest rhythm. Unadjusted survival rates were higher in women with a maternal in-hospital cardiac arrest than in women with a nonmaternal in-hospital cardiac arrest: survival to discharge of 45.1% vs 26.5%, survival with cerebral performance category 1 status of 36.1% vs 17.7%, and return of spontaneous circulation of 75.8% vs 70.6%. After adjustment, there was no difference in the likelihood of survival to discharge (odds ratio, 1.19; 95% confidence interval, 0.82-1.73) or return of spontaneous circulation (odds ratio, 0.94; 95% confidence interval, 0.65-1.35) between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. However, women with a maternal in-hospital cardiac arrest were more likely to have favorable neurologic survival (odds ratio, 1.57; 95% confidence interval, 1.06-2.33). Compared with women with a nonmaternal in-hospital cardiac arrest, women with a maternal in-hospital cardiac arrest had similar rates of delayed defibrillation (42.5% vs 34.4%; odds ratio, 1.14 [95% confidence interval, 0.41-3.18]; P=.31) and delayed administration of epinephrine (13.8% vs 10.6%; odds ratio, 0.96 [95% confidence interval, 0.50-1.86]; P=.09). CONCLUSION: Although concerns have been raised about resuscitation outcomes in women with a maternal in-hospital cardiac arrest, the rates of survival and resuscitation processes of care were not worse in women with a maternal in-hospital cardiac arrest.

Cardiology perspective on seizure-related bradyarrhythmias and SUDEP: A survey study.

OBJECTIVE: To determine cardiologist knowledge of and experience with seizure-related bradyarrhythmias and sudden unexpected death in epilepsy (SUDEP). BACKGROUND: Autonomic changes related to acute seizures are common and can occur during the ictal or postictal period. Two concerning changes in these periods are significant bradycardia and asystole. Postictal asystole has been investigated as a potential mechanism for SUDEP. METHODS: A 27-question survey delivered to cardiologists and cardiology fellows assessed demographics, personal experience, and training involving SUDEP and seizure-related bradycardia and asystole. Following IRB approval, a list of US cardiology fellowships was constructed using the AAMC public website. Surveys were distributed by email to all programs whose program director or coordinator's email was readily available on their website. They were asked to forward the survey to both cardiology fellows and practicing cardiologists. RESULTS: Fifty one surveys were completed: 23 from fellows and 28 from practicing cardiologists. Forty nine were from academic centers. Twenty four respondents (47%) reported being consulted for ictal bradycardia or asystole. Nine and 13 recommended treatment for ictal bradycardia or ictal asystole, respectively. Nineteen respondents (37%) reported being consulted for postictal bradycardia or asystole. Eight recommended treatment for postictal bradycardia or asystole, respectively. Treatment recommendations included medical management and/or pacemaker. None reported a substantial knowledge of SUDEP. The most common response interrogating SUDEP awareness (63%) was "no knowledge of SUDEP". Formal SUDEP education was not reported by any participant with only one reporting formal didactics regarding seizure-related arrhythmias. DISCUSSION: Our results suggest ictal bradyarrhythmias are less commonly known to cardiologists, with SUDEP awareness being far less. Formal education to cardiologists on these two topics could prove beneficial at the intersection of cardiology and care for patients with epilepsy.

Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health.

Following decades of decline, maternal mortality began to rise in the United States around 1990-a significant departure from the world's other affluent countries. By 2018, the same could be seen with the maternal mortality rate in the United States at 17.4 maternal deaths per 100 000 live births. When factoring in race/ethnicity, this number was more than double among non-Hispanic Black women who experienced 37.1 maternal deaths per 100 000 live births. More than half of these deaths and near deaths were from preventable causes, with cardiovascular disease being the leading one. In an effort to amplify the magnitude of this epidemic in the United States that disproportionately plagues Black women, on June 13, 2020, the Association of Black Cardiologists hosted the Black Maternal Heart Health Roundtable-a collaborative task force to tackle the maternal health crisis in the Black community. The roundtable brought together diverse stakeholders and champions of maternal health equity to discuss how innovative ideas, solutions and opportunities could be implemented, while exploring additional ways attendees could address maternal health concerns within the health care system. The discussions were intended to lead the charge in reducing maternal morbidity and mortality through advocacy, education, research, and collaborative efforts. The goal of this roundtable was to identify current barriers at the community, patient, and clinician level and expand on the efforts required to coordinate an effective approach to reducing these statistics in the highest risk populations. Collectively, preventable maternal mortality can result from or reflect violations of a variety of human rights-the right to life, the right to freedom from discrimination, and the right to the highest attainable standard of health. This is the first comprehensive statement on this important topic. This position paper will generate further research in disparities of care and promote the interest of others to pursue strategies to mitigate maternal mortality.

Creating a maternal cardiac center of excellence: a call to action.

In contrast to most industrialized countries, maternal mortality in the USA is rising. Cardiovascular disease, both acquired heart disease (e.g. coronary disease, arrhythmias, and heart failure), as well as congenital heart disease survivors, are all potentially important factors in explaining this worrisome trend. Increase in acquired cardiac disease is likely attributable to greater rates of obesity, diabetes, hypertension, and an increase in the incidence of advanced maternal age, while congenital heart disease in pregnancy is increasing due to advances in pediatric cardiovascular surgery. Despite the growing cardiovascular risk of pregnant women, most obstetricians and cardiologists have limited experience in caring for women with heart disease. Accordingly, management is largely guided by expert opinion likely to vary greatly across centers. To address these challenges, a multidisciplinary approach to care that includes both cardiologists and obstetricians could leverage the knowledge of both specialties and support streamlined communication between the patient and her providers. Our experience highlights the necessary components and essential infrastructure for building a center of excellence in treating pregnant women with heart disease.Condensation: A guide for creating a center of excellence for prenatal care for women with cardiovascular disease.The problem: Cardiac disease is the leading cause of maternal mortality, and pregnancies affected by cardiac disease continue to rise, both congenital and acquired.The solution: Maternal fetal medicine, obstetricians, and cardiologists can join together in tertiary facilities to create Maternal Cardiac Centers of Excellence to provide multidisciplinary, structured care for these high-risk patients.

Cardiovascular Contribution to Maternal Mortality.

The United States is the only industrialized nation with an increasing maternal mortality. Many factors contribute to this worrisome US trend; among them, social and demographic factors, and congenital and acquired cardiac conditions. Cardiovascular disease is the leading cause of maternal mortality, and adverse outcomes related to cardiovascular disease disproportionately affect black and Hispanic mothers. This article addresses knowledge gaps related to the treatment of heart disease in pregnancy, initiatives to address these gaps, and guidelines and best practices surrounding the care of women affected by cardiovascular disease and their babies affected by cardiovascular disease.

Evolution of Diagnostic and Treatment Patterns of Cardiac Sarcoidosis.

Cardiac sarcoidosis (CS) may impart substantial morbidity and mortality, and novel imaging modalities are now available to aid in early diagnosis of this clinically silent disease. A better understanding of the clinical experience with CS is important. Twenty-eight patients were diagnosed with the aid of multimodality imaging techniques and were treated by a multidisciplinary team. Demographics, symptomatology, imaging, and therapeutic interventions were compiled from our referral center. In patients with CS, nuclear and MR techniques were often the first studies performed. Echocardiographic findings differed widely. Immunosuppressive therapy and cardiac devices were frequently used. Importantly, isolated CS was not an infrequent finding.

Longevity in a Patient With Hypertrophic Cardiomyopathy, Anomalous Coronary Artery, and Gastrointestinal Bleeding.

We report an unusual case of an elderly woman who presented to the hospital with melena of five-day duration. She has a past medical history of hypertrophic cardiomyopathy diagnosed three years before presentation. She was found to have arteriovenous malformations in the stomach and the duodenum, causing gastrointestinal bleeding. An association between hypertrophic cardiomyopathy and arteriovenous malformations in the gastrointestinal tract was felt likely. The patient was treated with beta-blocker therapy. Later, she was incidentally found to have an anomalous right coronary artery. We discussed potential medical and surgical options, and the patient chose to be treated medically. She was successfully treated with beta-blocker therapy with no further gastrointestinal bleeding. Her clinical course was uncomplicated without cardiac arrhythmia, heart failure, or sudden cardiac death.

Importance of the Cardio-Obstetrics Team.

PURPOSE: In the USA, maternal mortality has been rising since the 1980s. Cardiovascular disease is recognized as the leading cause of this worrisome trend, and a multidisciplinary approach to the care of patients with cardiovascular conditions during pregnancy is becoming increasingly important. We outline the literature supporting this multidisciplinary approach, highlight our center's experience in building and expanding an integrated cardio-obstetrics practice, and provide guidance regarding patient selection and management within a combined practice. Antenatal management patterns and delivery planning for patients with cardiovascular disease during pregnancy vary substantially among cardiovascular and obstetric and maternal fetal medicine practices in the USA. The need for multidisciplinary care between cardiologists and obstetricians is evident and has been supported by best practice statements from the American Heart Association, the American College of Obstetrics and Gynecology, and the Cardiac Disease in Pregnancy Study (CARPREG) investigators, whose CARPREG II risk score included "late first antenatal visit" as a predictor of adverse outcomes of pregnancy. CONCLUSIONS: We have solid evidence supporting a multidisciplinary approach to the care of patients with cardiac conditions in pregnancy. This approach is optimal because it facilitates a consistent and clear message to the patient (and those caring for each patient) regarding management and risks associated with pregnancy, as well as subsequent risk and postpartum follow-up. We support the extension of clinical collaboration between obstetricians and cardiologists to the research realm and know that working together to investigate the outcomes of moms with heart conditions and their babies will provide clinically meaningful information to support the care of these unique patients.

Maternal Mortality in the United States and the HOPE Registry.

PURPOSE OF REVIEW: Maternal mortality in the United States is highest among all developed nations and continues to rise. The leading cause of morbidity and mortality during pregnancy and the postpartum period is cardiovascular disease. While there are large European and Canadian studies exploring the care and outcomes of moms with heart disease in pregnancy, there are no large prospective studies to guide the care of this growing group of patients in the US. We review the current approach to the management of patients with heart disease in pregnancy and the gaps in knowledge thereof. RECENT FINDINGS: Currently, antenatal management and delivery planning are highly variable for patients with heart disease in pregnancy and maternal risk models' application to the US patient population is limited by their derivation from an international cohort of patients and their focus on patients with congenital heart disease. As the need for interdisciplinary care between cardiologists and obstetricians becomes evident, and as broad research efforts within this space are very much needed, we propose a research collaborative called the Heart Outcomes in Pregnancy: Expectations (HOPE) for Mom and Baby Registry. The HOPE Registry aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of these unique patients. We have made progress in recent years by recognizing the clinical need to address and standardize the management of patients with heart disease in pregnancy. We now must initiate and propel US-based cardio-obstetrics research to address key gaps in knowledge and variability in the care of patients with heart disease in pregnancy.

The clot thickens: an incompletely ligated left atrial appendage.

SummaryOur patient presented with known mechanical mitral valve endocarditis documented by 2D transesophageal echocardiogram (TOE) from a recent hospitalization at an outside facility. On admission to our center, there was no prior knowledge of an incompletely ligated left atrial appendage (LAA) according to patient- or family-reported history, review of outside records or the outside facility's 2D TOE report. A 3D TOE performed at our center to assess her pathology, since a month had passed from her prior hospitalization, revealed a LAA ligation with evidence of communication to the left atrium and with clot present in the appendage. This case report highlights the common finding of incomplete closure of the LAA following surgical ligation, thus making it inadequate for stroke prevention in patients with atrial fibrillation, and that 3D TOE plays a valuable role in assessing the durability of LAA ligation. LEARNING POINTS: 3D transesophageal echocardiography (TOE) is a valuable tool in assessing the durability of left atrial appendage (LAA) ligation given the superior image granularity as compared with 2D TOE.LAA ligation may not be adequate for stroke prevention in patients with atrial fibrillation as incomplete closure is common following surgical ligation.LAA occlusion should be considered in these cases.