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Wolfe DS, Guerrero K. The contemporary cardio-obstetrics team: The path to improving maternal outcomes in high-risk patients. Am Heart J 2025; 281:140-148. [PMID: 39674523 DOI: 10.1016/j.ahj.2024.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/04/2024] [Accepted: 12/05/2024] [Indexed: 12/16/2024]
Abstract
The field of Cardio-Obstetrics is focused on mitigating cardiovascular risk among pregnant and post-partum individuals. Due to the complexity of caring for pregnant people with acquired or congenital cardiac disease, patients with these conditions are increasingly managed in multidisciplinary Cardio-Obstetrics teams, which are now considered essential to optimize maternal care in high-risk patients. Cardio-Obstetrics teams are composed of multiple subspecialists and have at least 3 roles: (1) provide preconception counseling and risk stratification to patients with known cardiac disease, (2) organize prenatal and postpartum care for patients who develop or present with cardiac disease during pregnancy, and (3) plan for emergent care for patients whose pregnancy "unmasks" cardiac disease, whether acquired disease or an unknown ACHD. Here we describe our experience at Einstein/Montefiore to aid other institutions in developing their own programs.
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Affiliation(s)
- Diana S Wolfe
- Maternal Fetal Medicine Cardiology Joint Program, Division of Maternal Fetal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
| | - Kerly Guerrero
- Maternal Fetal Medicine Cardiology Joint Program, Division of Maternal Fetal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
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Justin Paul G, Anne Princy S, Jeemon P. Routine Antenatal Echocardiography in Low- and Middle-Income Countries: Ready for a Rollout? JACC. ADVANCES 2024; 3:101334. [PMID: 39817097 PMCID: PMC11733812 DOI: 10.1016/j.jacadv.2024.101334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2025]
Affiliation(s)
| | - Steaphen Anne Princy
- Department of Cardiology, Tamil Nadu Government Multi Super Speciality Hospital, Chennai, Tamil Nadu, India
| | - Panniyammakal Jeemon
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Briller J, Trost SL, Busacker A, Joseph NT, Davis NL, Petersen EE, Goodman DA, Hollier LM. Pregnancy-Related Mortality Due to Cardiovascular Conditions: Maternal Mortality Review Committees in 32 U.S. States, 2017 to 2019. JACC. ADVANCES 2024; 3:101382. [PMID: 39583867 PMCID: PMC11585746 DOI: 10.1016/j.jacadv.2024.101382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 08/13/2024] [Accepted: 09/23/2024] [Indexed: 11/26/2024]
Abstract
Background Cardiomyopathy (CM) and other cardiovascular conditions (OCVs) are among the most frequent causes of pregnancy-related death in the United States. Objectives The purpose of this paper was to report demographic and clinical characteristics, preventability, contributing factors, and Maternal Mortality Review Committee (MMRC) recommendations among pregnancy-related deaths with underlying causes of CM, OCVs, and the 2 combined (cardiovascular conditions, CV). Methods We analyzed pregnancy-related death data from MMRCs in 32 states, occurring during 2017 to 2019, with MMRC-determined underlying causes of CVs. We describe distributions of demographic characteristics, present the most frequent contributing factor classes, and provide example MMRC prevention recommendations. Results Among 210 pregnancy-related deaths due to CVs, 84 (40%) were due to CM and 126 (60%) to OCVs. More than half (51.2%) of CM deaths were among non-Hispanic Black persons. Two-thirds (66%) of all CV deaths occurred among people <35 years old. Approximately 53% of CM deaths and 31% of OCV deaths occurred 43 to 365 days postpartum. Over 75% of pregnancy-related deaths due to CVs were determined by MMRCs to be preventable. The 5 most frequent contributing factor classes accounted for 50% of the total MMRC-identified contributing factors. MMRC prevention recommendations occur at multiple levels. Conclusions Most pregnancy-related deaths due to CM and OCV are preventable. Example MMRC recommendations provided in this report illustrate prevention opportunities that address contributing factors, including broader awareness of urgent warning signs, improved handoffs for care coordination and continuity, and expanded accessibility of community-based comprehensive and integrated care services.
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Affiliation(s)
- Joan Briller
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Susanna L. Trost
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ashley Busacker
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Naima T. Joseph
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nicole L. Davis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily E. Petersen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, USA
| | - David A. Goodman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lisa M. Hollier
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Briller JE, Jayaram A. Can Artificial Intelligence Make Maternal Cardiac Risk Prediction a Walk in the Park? JACC. ADVANCES 2024; 3:101100. [PMID: 39156116 PMCID: PMC11326885 DOI: 10.1016/j.jacadv.2024.101100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Joan E. Briller
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Aswathi Jayaram
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
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Hameed AB, Tarsa M, Graves CR, Grodzinsky A, Thiel De Bocanegra H, Wolfe DS. Universal Cardiovascular Disease Risk Assessment in Pregnancy: Call to Action JACC: Advances Expert Panel. JACC. ADVANCES 2024; 3:101055. [PMID: 39372368 PMCID: PMC11450966 DOI: 10.1016/j.jacadv.2024.101055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/25/2024] [Accepted: 05/07/2024] [Indexed: 10/08/2024]
Abstract
The United States has the highest maternal mortality rate among developed countries, with cardiovascular disease (CVD) being one of the leading causes of maternal deaths. Diagnosing CVD during pregnancy may be challenging as symptoms of normal pregnancy overlap with those of CVD. Delays in recognition and response to the diagnosis of CVD is a missed opportunity for timely intervention to improve maternal outcomes. Implementing universal CVD risk assessment for all pregnant and postpartum patients across clinical care settings presents a pivotal opportunity to address this issue. Integrating a validated risk assessment tool into routine obstetric care, clinicians, including obstetricians, primary care, and emergency healthcare providers, can enhance awareness of cardiovascular risk and facilitate early CVD diagnosis. Consensus among stakeholders underscores the importance of screening and education on cardiovascular health strategies for pregnant and postpartum patients to reduce CVD-related maternal mortality. This comprehensive approach offers a pathway to identify at-risk individuals and intervene promptly, potentially saving lives and advancing maternal healthcare equity.
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Affiliation(s)
- Afshan B. Hameed
- Maternal-Fetal Medicine, Obstetrics & Gynecology, Cardiology, University of California, Irvine, California, USA
| | - Maryam Tarsa
- Division of Maternal-Fetal Medicine, University of California, San Diego, California, USA
| | - Cornelia R. Graves
- Division of Maternal-Fetal Medicine, University of Tennessee, Nashville, Tennessee, USA
| | - Anna Grodzinsky
- Cardiology, Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Heike Thiel De Bocanegra
- Maternal-Fetal Medicine, Obstetrics & Gynecology, Cardiology, University of California, Irvine, California, USA
| | - Diana S. Wolfe
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
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Ray CB, Maher JE, Sharma G, Woodham PC, Devoe LD. Cardio-obstetrics de novo: a state-level, evidence-based approach for addressing maternal mortality and severe maternal morbidity in Georgia. Am J Obstet Gynecol MFM 2024; 6:101334. [PMID: 38492640 DOI: 10.1016/j.ajogmf.2024.101334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/27/2024] [Indexed: 03/18/2024]
Abstract
Georgia has a higher rate of severe maternal morbidity and mortality when compared with the rest of the United States. Evidence gained from the Georgia Maternal Mortality Review Committee identified areas of focus for high-yield clinical initiatives for improvement in maternal health outcomes. Cardiovascular disease, including cardiomyopathy, coronary conditions, and preeclampsia with or without eclampsia, is the most common cause of pregnancy-related death in non-Hispanic Black women in Georgia. The development of a cardio-obstetrics program is an initiative to advance health equity by decreasing cardiovascular morbidity and mortality. This report describes the following: (1) state-level advocacy for improving maternal health outcomes with funding gained through the legislative process and partnership with a governmental agency; (2) cardio-obstetrics program development based on evidence gained from the maternal mortality review process; and (3) implementation of a cardio-obstetrics service, beginning with a focused approach for capacity building and understanding barriers to care.
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Affiliation(s)
- Chadburn B Ray
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, GA (Drs Ray, Maher, Woodham, and Devoe).
| | - James E Maher
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, GA (Drs Ray, Maher, Woodham, and Devoe)
| | - Gyanendra Sharma
- Department of Cardiology, Medical College of Georgia, Augusta, GA (Dr Sharma)
| | - Padmashree C Woodham
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, GA (Drs Ray, Maher, Woodham, and Devoe)
| | - Lawrence D Devoe
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta, GA (Drs Ray, Maher, Woodham, and Devoe)
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Alliance for Innovation on Maternal Health: Consensus Bundle on Cardiac Conditions in Obstetric Care. Obstet Gynecol 2023; 141:253-263. [PMID: 36649333 PMCID: PMC9838734 DOI: 10.1097/aog.0000000000005048] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/21/2022] [Indexed: 01/18/2023]
Abstract
Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.
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Hameed AB, Tarsa M, Graves CR, Chang J, Billah M, Hatfield T, Thiel de Bocanegra H. Cardiovascular Risk Assessment as a Quality Measure in the Pregnancy and Postpartum Period. JACC. ADVANCES 2023; 2:100176. [PMID: 38939026 PMCID: PMC11198421 DOI: 10.1016/j.jacadv.2022.100176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/21/2022] [Accepted: 12/01/2022] [Indexed: 06/29/2024]
Abstract
Background Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. Contributing factors such as lack of recognition and delayed diagnosis of CVD are primarily due to the overlap of signs and symptoms of a normal pregnancy with those of CVD. Objectives This study aimed to demonstrate the feasibility of introducing CVD risk assessment into clinical practice using the California Maternal Quality Care Collaborative algorithm to detect CVD during pregnancy and postpartum periods. Methods We implemented the CVD risk assessment algorithm into electronic health records at 3 large hospital networks serving over 14,000 patients at 23 sites. We determined the percentage of pregnant and/or postpartum patients who were screened for CVD risk and the follow-up rate for patients in whom the tool recommended a follow-up assessment. Rates were stratified according to clinical site characteristics. We obtained clinician feedback regarding the feasibility and acceptability of the tool. Results The rate of patients screened for CVD risk in the 3 hospital networks was 57.1%, 71.5%, and 98.7%. For those with a positive screen, follow-up rates were 65.8%, 72.5%, and 55.9% in the 3 networks. The rates of screening and follow-up varied based on the clinic size and specialty. Clinician-identified barriers were busy clinics, competing priorities, and the type of clinical practice. Conclusions This innovative population-based approach for universal CVD risk assessment during pregnancy is feasible and may be a helpful strategy to decrease CVD-related maternal morbidity and mortality.
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Affiliation(s)
- Afshan B. Hameed
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, University of California, Irvine, California, USA
- Division of Cardiology, Department of Medicine, School of Medicine, University of California, Irvine, California, USA
| | - Maryam Tarsa
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Diego, California, USA
| | - Cornelia R. Graves
- Department of Obstetrics and Gynecology, University of Tennessee, Nashville, Tennessee, USA
| | - Jenny Chang
- Department of Medicine, School of Medicine, University of California, Irvine, California, USA
| | - Manija Billah
- Health Services Research, Department of Obstetrics and Gynecology, University of California, Irvine, California, USA
| | - Tamera Hatfield
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Irvine, California, USA
| | - Heike Thiel de Bocanegra
- Health Services Research, Department of Obstetrics and Gynecology, School of Medicine, University of California, Irvine, California, USA
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Briller JE. Echocardiographic Screening in Hypertensive Pregnancy Disorders. J Am Coll Cardiol 2022; 80:1477-1479. [DOI: 10.1016/j.jacc.2022.08.717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
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Screening for Cardiovascular Disease in Pregnancy: Is There a Need? J Cardiovasc Dev Dis 2022; 9:jcdd9030089. [PMID: 35323636 PMCID: PMC8953180 DOI: 10.3390/jcdd9030089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Maternal mortality in the United States has been on the rise. Every year, about 700 women die from pregnancy-related complications. Cardiovascular disease (CVD) accounts for a large majority of pregnancy-related deaths driven by the lack of recognition and delays in diagnosis due to the overlap of normal pregnancy symptoms with those of CVD. Risk factors for CVD including race, advanced maternal age, hypertension, diabetes, obesity, socioeconomic status, and geographic region play an important role in CVD-related deaths. Several risk assessment models are available to stratify women with a known diagnosis of CVD. However, most women who die from CVD during pregnancy or the postpartum period do not have a prior diagnosis of CVD, and cardiomyopathy is an important contributor. The California Maternal Quality Care Collaborative (CMQCC) developed an algorithm to screen all pregnant and postpartum women to allow stratification into low or high risk for CVD. The algorithm has been validated in diverse patient populations. We propose universal CVD screening for all women in the antepartum and postpartum period to identify women at risk and to provide education and awareness for both patients and healthcare providers. This screening tool would work to reduce the increasing rates of severe maternal mortality and morbidity while having a significant impact on healthcare costs in the United States.
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Focus on today's evidence while keeping an eye on the future: lessons derived from hypertension in women. J Hum Hypertens 2022; 36:882-886. [PMID: 35082377 DOI: 10.1038/s41371-021-00652-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 12/17/2022]
Abstract
While evidence-based medicine has contributed enormously to the uniformity and rationale of patient care, it is necessary that we anticipate changes in order to implement their rapid translation to practice. The purpose of this review is to expose three issues regarding cardiovascular health in women, including milestones to reflect the pace at which these are incorporated into public policies. Two of these matters, as changes in the thresholds of normal blood pressure in gestation and in nonpregnant women, need further evidence and deserve to be retrospectively analyzed in high-quality databases. The third subject derives from the association of remote cardiovascular complications of hypertensive pregnancies, an example of the unnecessary delay of more than two decades to install a wide prevention strategy when the health system is not on the watch.
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Wolfe DS, Yellin S. Maternal cardiology team: How to build and why it is necessary. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Keepanasseril A, Pfaller B, Metcalfe A, Siu SC, Davis MB, Silversides CK. Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies. Can J Cardiol 2021; 37:1969-1978. [PMID: 34600086 DOI: 10.1016/j.cjca.2021.09.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/16/2022] Open
Abstract
There has been an increase in maternal deaths from cardiovascular disease in many countries. In high-income countries, cardiovascular deaths secondary to cardiomyopathies, ischemic heart disease, sudden arrhythmic deaths, aortic dissection, and valve disease are responsible for up to one-third of all pregnancy-related maternal deaths. In low- and middle-income countries, rheumatic heart disease is a much more common cause of cardiac death during pregnancy. Although deaths occur in women with known heart conditions or cardiovascular risk factors such as hypertension, many women present for the first time in pregnancy with unrecognised heart disease or with de novo cardiovascular conditions such as preeclampsia, peripartum cardiomyopathy, spontaneous coronary artery dissection. Not only has maternal cardiovascular mortality increased, but serious cardiac morbidity, or "near misses," during pregnancy also have increased in frequency. Although maternal morbidity and mortality are often preventable, many health professionals remain unaware of the impact of cardiovascular disease in this population, and the lack of awareness contributes to inappropriate care and preventable deaths. In this review, we discuss the maternal mortality from cardiovascular causes in both high- and low- and middle-income countries and strategies to improve outcomes.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Birgit Pfaller
- Department of Internal Medicine 1, University Hospital of St Pölten, Karl Landsteiner University of Health Sciences, Karl Landsteiner Institute for Nephrology, St Pölten, Austria
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, Department of Community Health Sciences and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada.
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