The Cardio-obstetrics Approach to Maternal CVD Risk

Maternal outcomes in the United States are among the worst across all wealthy nations. There are 22 deaths per 100,000 births in the United States compared with zero deaths in Norway and 1.2 deaths per 100,000 in Switzerland, according to a report in BMJ. At least 80% of these deaths in the United States are due to cardiovascular disease, making them largely preventable. 

To bridge the gap between cardiology and obstetric care, the field of cardio-obstetrics has emerged in recent years. To learn more about the role of cardio-obstetrics in improving maternal outcomes, the evolving landscape of training programs, and the need for greater awareness of the role cardiovascular disease plays in maternal medicine, Medscape Medical News spoke with cardiologist Nandita Scott, MD, director of Mass General Brigham Women’s Heart Health Program in Boston. She also co-directs the Corrigan Women’s Heart Health Program there and is the co-director of Mass General Hospital’s cardiovascular medicine section.

Medscape Medical News: What is cardio-obstetrics and why is it gaining importance?

Scott: Cardio-obstetrics brings together the expertise of both cardiology and obstetrics to address maternal mortality. Our program at Mass General Brigham’s was built over a decade ago. Since then, many similar programs have been built nationwide. 

Also, since then the American College of Cardiology has recognized the importance of this field by creating the Reproductive Health and Cardio-obstetrics Section.

Medscape Medical News: Are there any other professional associations that address this subspecialty?

Scott: Obstetricians were already addressing the issue with the Society of Maternal Fetal Medicine and the American College of Obstetricians and Gynecologists, as examples. The American Heart Association has also addressed this problem and has also published scientific statements.

Medscape Medical News: Where does one go to learn about this field? Obviously, you can go to Harvard where you are, but are there centers of excellence that are considered the best places to learn cardio-obstetrics?

Scott: There are definitely centers of excellence and centers across the country that have dedicated women’s heart health fellowships.

To fill gaps in education about cardiovascular concerns in pregnancy, the ACC published a document that is a blueprint to incorporate cardio-obstetric training into cardiovascular fellowships. However, many cardiovascular fellowships across the country do not have an obstetrics department or the expertise to gain clinical exposure and experience.

In response to this, we at Mass General Brigham are developing educational modules to ensure all cardiovascular trainees and maternal fetal medicine trainees have easy access to the fundamentals of cardio- obstetrics education. Our team at Mass General Brigham, and experts across the United States and Canada, are currently in the process of building content that will ultimately be provided free of charge to all fellowships.

Medscape Medical News: Will you make this information available to others through CME?

Scott: For now, we are focusing on building the content for fellows; however, in the future, we may include continuing medical education credit for those outside of training programs.

Our aim is for fellows to gain fundamental knowledge, including when to refer a patient to a more specialized center since one of the challenges is recognizing cardiovascular disease during pregnancy and knowing when to escalate testing and therapy.

Medscape Medical News: Can you name a few places where there are cardio-obstetric fellowships for the cardiologist?

Scott: We have had a fellowship for years and graduated our first fellow over a decade ago. There are also well-established women’s heart health fellowship programs across the country including at Cedars Sinai in California and Inova in Virginia. Each fellowship has different qualification requirements; ours, in particular, requires prior completion of a core cardiovascular fellowship.

Medscape Medical News: So now let’s discuss the clinical aspects of cardio-obstetrics. What are the presentations of cardiovascular disease in pregnancy?

Scott: I suggest to ob/gyns to always have a level of suspicion since the symptoms during normal pregnancy mimic those of cardiovascular disease. We’re talking here about symptoms such as shortness of breath, ankle swelling, and difficulty breathing when lying flat.

Having a higher level of suspicion will lead to earlier testing and diagnosis. As an example, a simple blood test for natriuretic peptides has a high negative predictive value for excluding heart failure during pregnancy, but if elevated would prompt downstream testing and earlier diagnosis. This might include echocardiograms, electrocardiograms, and a cardiology consultation to determine the diagnosis.

These are the things that all primary care physicians, including ob/gyns, should be thinking about. But also, cardiologists need to be aware, too.

Medscape Medical News: Are you saying that cardiologists are generally unaware of cardiovascular disease in pregnancy?

Scott: Core competencies in the management of pregnant individuals with heart disease have not been taught in cardiovascular training programs. As such, their awareness of it has been low. Because symptoms of cardiovascular disease mimic those of normal pregnancy, it is easier to be dismissive. I do, however, believe that the increasing light being shed on this problem will continue to improve care.

Medscape Medical News: At what point can a patient who is pregnant with a cardiovascular comorbidity no longer be cared for strictly by her primary care ob/gyn?

Scott: I think most providers have no problem with referring a sick pregnant woman to a specialized center.

In addition, in the recent Medscape Medical News story about peripartum cardiomyopathy, Afshan Hameed, MD, at University of California, Irvine, was interviewed. With her work on the California Maternal Quality Care Collaborative, she helped build a risk assessment tool that embeds in the electronic medical records of pregnant women. Whenever they are seen in any clinical setting, the tool triggers a scoring system for the provider. If the score is elevated, it prompts further cardiovascular evaluation.

Medscape Medical News: Do you think it’s possible that one of the reasons cardiovascular disease in pregnancy is overlooked is because overall, it’s still not a disease that is top of mind when treating women?

Scott: Well, yes. I have been the Director of Women’s Heart Health at Mass General since 2012. This center was created with the purpose of better understanding sex specific disorders, which historically have been under detected, undertreated, and under researched.

Heart disease is the number one killer of women, so we definitely have more work to do with education. Even though centers like ours exist, we need to do a better job of increasing education and awareness to those areas without specialized expertise.

As an example, more women than men can have alternative mechanisms for their heart attacks, including coronary artery dissection — tearing — that is different from the typical plaque-mediated events.

At national meetings it is important that the sessions on sex-specific disorders occur in larger meeting rooms in visible locations, so that this kind of information is more easily accessible to all.

Medscape Medical News: What about postpartum care? Does this group of women need special monitoring?

Scott: It really depends on the condition. Women who develop complications such as preeclampsia and gestational diabetes are at elevated risk of cardiovascular disease in their lifetime, so they should be made aware of this and have attention paid to their risk factors to mitigate their risk.

In those with established heart disease, it is still unclear whether pregnancy itself accelerates the pathology of their condition.

Medscape Medical News: Why has this become an issue now — is it an indication that women’s health overall in the United States is poor?

Scott: There are many reasons that this problem is increasingly being recognized as an important issue in this country. First, maternal mortality in the United States is the worst of any developed nation in the world. Women are entering their pregnancies with greater cardiovascular risk factors, which elevate the inherent risks of pregnancy.

Many women live in maternal healthcare deserts and do not receive adequate prenatal care. Women tend to be older when entering pregnancy now and, due to fertility treatments, there is an increase in multifetal pregnancies. This creates a greater demand on the cardiovascular system.

There is also a subset of women who in the past would not have been well enough to conceive who, thanks to advances in science, are living longer and in better health. This includes those women who have survived childhood cancers and those with congenital heart disease.

In the past, many were advised to not pursue pregnancy. However, with counseling and optimization of health prior to pregnancy, many of these women can pursue pregnancy with good outcomes. The best part of my job is when those women have babies and I get to go see them after delivery.