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Sumner JA, Kim ESH, Wood MJ, Chi G, Nolen J, Grodzinsky A, Gornik HL, Kadian-Dodov D, Wells BJ, Hess CN, Lewey J, Tam L, Henkin S, Orford J, Wells G, Kumbhani DJ, Lindley KJ, Gibson CM, Leon KK, Naderi S. Posttraumatic Stress Disorder After Spontaneous Coronary Artery Dissection: A Report of the International Spontaneous Coronary Artery Dissection Registry. J Am Heart Assoc 2024; 13:e032819. [PMID: 38533943 DOI: 10.1161/jaha.123.032819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/06/2024] [Indexed: 03/28/2024]
Abstract
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.
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Affiliation(s)
- Jennifer A Sumner
- Department of Psychology University of California, Los Angeles Los Angeles CA USA
| | - Esther S H Kim
- Division of Cardiovascular Medicine, Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Malissa J Wood
- Division of Cardiology Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Gerald Chi
- PERFUSE Study Group, Cardiovascular Division, Department of Medicine Beth Israel Deaconess Medical Center, Harvard Medical School Boston MA USA
| | | | - Anna Grodzinsky
- Saint Luke's Mid America Heart Institute, Muriel I. Kauffman Women's Heart Center University of Missouri-Kansas City Kansas City MO USA
| | - Heather L Gornik
- Harrington Heart & Vascular Institute, University Hospitals, Division of Cardiovascular Medicine Case Western Reserve University Cleveland OH USA
| | - Daniella Kadian-Dodov
- Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health Icahn School of Medicine at Mount Sinai New York NY USA
| | - Bryan J Wells
- Division of Cardiology, Department of Medicine Emory University School of Medicine Atlanta GA USA
| | - Connie N Hess
- Division of Cardiology, Department of Medicine University of Colorado School of Medicine Aurora CO USA
| | - Jennifer Lewey
- Division of Cardiovascular Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Lori Tam
- Providence Heart Institute Portland OR USA
| | - Stanislav Henkin
- Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH USA
| | - James Orford
- Intermountain Heart Institute, Intermountain Medical Center Murray UT USA
| | - Gretchen Wells
- Division of Cardiovascular Medicine, Department of Medicine University of Kentucky Lexington KY USA
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine UT Southwestern Medical Center Dallas TX USA
| | - Kathryn J Lindley
- Division of Cardiovascular Medicine, Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - C Michael Gibson
- PERFUSE Study Group, Cardiovascular Division, Department of Medicine Beth Israel Deaconess Medical Center, Harvard Medical School Boston MA USA
| | | | - Sahar Naderi
- Division of Cardiology Kaiser Permanente San Francisco CA USA
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Rosso M, Ramaswamy S, Mulatu Y, Little JN, Kvantaliani N, Brahmaroutu A, Marczak I, Lewey J, Deo R, Messé SR, Cucchiara BL, Levine SR, Kasner SE. Rising Cardiac Troponin: A Prognostic Biomarker for Mortality After Acute Ischemic Stroke. J Am Heart Assoc 2024; 13:e032922. [PMID: 38348784 PMCID: PMC11010097 DOI: 10.1161/jaha.123.032922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/04/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Elevated cardiac troponin (cTn) is detected in 10% to 30% of patients with acute ischemic stroke (AIS) and correlates with poor functional outcomes. Serial cTn measurements differentiate a dynamic cTn pattern (rise/fall >20%), specific for acute myocardial injury, from elevated but stable cTn levels (nondynamic), typically attributed to chronic cardiac/noncardiac conditions. We investigated if the direction of the cTn change (rising versus falling) affects mortality and outcome. METHODS AND RESULTS We retrospectively screened consecutive patients with AIS admitted to 5 stroke centers for elevated cTn at admission and at least 1 additional cTn measurement within 48 hours. The pattern of cTn was defined as rising if >20% increase from baseline, falling if >20% decrease, or nondynamic if ≤20% change in either direction. Logistic regression analyses were performed to assess the association of cTn patterns and 7-day mortality and unfavorable discharge disposition. Of 3789 patients with AIS screened, 300 were included. Seventy-two had a rising pattern, 66 falling, and 162 nondynamic. In patients with AIS with rising cTn, acute ischemic myocardial infarction was present in 54%, compared with 33% in those with falling cTn (P<0.01). Twenty-two percent of patients with a rising pattern had an isolated dynamic cTn in the absence of any ECG or echocardiogram changes, compared with 53% with falling cTn. A rising pattern was associated with higher risk of 7-day mortality (adjusted odds ratio [OR]=32 [95% CI, 2.5-415.0] rising versus aOR=1.3 [95% CI, 0.1-38.0] falling versus nondynamic as reference) and unfavorable discharge disposition (aOR=2.5 [95% CI, 1.2-5.2] rising versus aOR=0.6 [95% CI, 0.2-1.5] versus falling). CONCLUSIONS Rising cTn is independently associated with increased mortality and unfavorable discharge disposition in patients with AIS.
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Affiliation(s)
- Michela Rosso
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Yohannes Mulatu
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNYUSA
| | | | | | | | - Izabella Marczak
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNYUSA
| | - Jennifer Lewey
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Rajat Deo
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Steven R. Messé
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Steven R. Levine
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNYUSA
| | - Scott E. Kasner
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPAUSA
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Lewey J, Beckie TM, Brown HL, Brown SD, Garovic VD, Khan SS, Miller EC, Sharma G, Mehta LS. Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e330-e346. [PMID: 38346104 DOI: 10.1161/cir.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.
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4
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Rosso M, Ramaswamy S, Kvantaliani N, Mulatu Y, Little JN, Marczak I, Brahmaroutu A, Deo R, Lewey J, Messé SR, Cucchiara BL, Levine SR, Kasner SE. Stroke-Heart Syndrome: Does Sex Matter? J Am Heart Assoc 2023; 12:e029799. [PMID: 37850436 PMCID: PMC10727394 DOI: 10.1161/jaha.123.029799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/09/2023] [Indexed: 10/19/2023]
Abstract
Background Cardiovascular complications after acute ischemic stroke (AIS) can be related to chronic/comorbid cardiac conditions or acute disruption of the brain-heart autonomic axis (stroke-heart syndrome). Women are known to be more vulnerable to certain stress-induced cardiac complications, such as Takotsubo cardiomyopathy. We investigated sex differences in cardiac troponin (cTn) elevation, cardiac events, and outcomes after AIS. Methods and Results We retrospectively analyzed consecutive patients with AIS from 5 stroke centers. Patients with AIS with elevated baseline cTn and at least 2 cTn measurements were included, while patients with acute comorbid conditions that could impact cTn levels were excluded. Poststroke acute myocardial injury was defined as the presence of a dynamic cTn pattern (rise/fall >20% in serial measurements) in the absence of acute atherosclerotic coronary disease (type 1 myocardial infarction) or cardiac death (type 3 myocardial infarction). From a total cohort of 3789 patients with AIS, 300 patients were included in the study: 160 were women (53%). Women were older, had a lower burden of cardiovascular risk factors, and more frequently had cardioembolic stroke and right insula involvement (P values all <0.05). In multivariate analysis, women were more likely to have a dynamic cTn pattern (adjusted odds ratio, 2.1 [95% CI, 1.2-3.6]) and develop poststroke acute myocardial injury (adjusted odds ratio, 2.1 [95% CI, 1.1-3.8]). Patients with poststroke acute myocardial injury had higher 7-day mortality (adjusted odds ratio, 5.5 [95% CI, 1.2-24.4]). Conclusions In patients with AIS with elevated cTn at baseline, women are twice as likely to develop poststroke acute myocardial injury, and this is associated with higher risk of short-term mortality. Translational studies are needed to clarify mechanisms underlying sex differences in cardiac events and mortality in AIS.
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Affiliation(s)
- Michela Rosso
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
| | - Srinath Ramaswamy
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | | | - Yohannes Mulatu
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | | | - Izabela Marczak
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | | | - Rajat Deo
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Steven R. Messé
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
| | | | - Steven R. Levine
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | - Scott E. Kasner
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
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5
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Khan SS, Petito LC, Huang X, Harrington K, McNeil RB, Bello NA, Merz CNB, Miller EC, Ravi R, Scifres C, Catov J, Pemberton V, Varagic J, Zee PC, Yee LM, Ray M, Kim JK, Lane-Cordova A, Lewey J, Theilen LH, Saade GR, Greenland P, Grobman WA. Body Mass Index, Adverse Pregnancy Outcomes, and Cardiovascular Disease Risk. Circ Res 2023; 133:725-735. [PMID: 37814889 PMCID: PMC10578703 DOI: 10.1161/circresaha.123.322762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/08/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Obesity is a well-established risk factor for both adverse pregnancy outcomes (APOs) and cardiovascular disease (CVD). However, it is not known whether APOs are mediators or markers of the obesity-CVD relationship. This study examined the association between body mass index, APOs, and postpartum CVD risk factors. METHODS The sample included adults from the nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be) Heart Health Study who were enrolled in their first trimester (6 weeks-13 weeks 6 days gestation) from 8 United States sites. Participants had a follow-up visit at 3.7 years postpartum. APOs, which included hypertensive disorders of pregnancy, preterm birth, small-for-gestational-age birth, and gestational diabetes, were centrally adjudicated. Mediation analyses estimated the association between early pregnancy body mass index and postpartum CVD risk factors (hypertension, hyperlipidemia, and diabetes) and the proportion mediated by each APO adjusted for demographics and baseline health behaviors, psychosocial stressors, and CVD risk factor levels. RESULTS Among 4216 participants enrolled, mean±SD maternal age was 27±6 years. Early pregnancy prevalence of overweight was 25%, and obesity was 22%. Hypertensive disorders of pregnancy occurred in 15%, preterm birth in 8%, small-for-gestational-age birth in 11%, and gestational diabetes in 4%. Early pregnancy obesity, compared with normal body mass index, was associated with significantly higher incidence of postpartum hypertension (adjusted odds ratio, 1.14 [95% CI, 1.10-1.18]), hyperlipidemia (1.11 [95% CI, 1.08-1.14]), and diabetes (1.03 [95% CI, 1.01-1.04]) even after adjustment for baseline CVD risk factor levels. APOs were associated with higher incidence of postpartum hypertension (1.97 [95% CI, 1.61-2.40]) and hyperlipidemia (1.31 [95% CI, 1.03-1.67]). Hypertensive disorders of pregnancy mediated a small proportion of the association between obesity and incident hypertension (13% [11%-15%]) and did not mediate associations with incident hyperlipidemia or diabetes. There was no significant mediation by preterm birth or small-for-gestational-age birth. CONCLUSIONS There was heterogeneity across APO subtypes in their association with postpartum CVD risk factors and mediation of the association between early pregnancy obesity and postpartum CVD risk factors. However, only a small or nonsignificant proportion of the association between obesity and CVD risk factors was mediated by any of the APOs, suggesting APOs are a marker of prepregnancy CVD risk and not a predominant cause of postpartum CVD risk.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Rupa Ravi
- Columbia University Irving Medical Center
| | | | | | | | | | | | - Lynn M Yee
- Northwestern University Feinberg School of Medicine
| | - Mitali Ray
- University of Pittsburgh School of Medicine
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6
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Gupta R, Yang L, Lewey J, Navathe AS, Groeneveld PW, Khatana SAM. Association of High-Deductible Health Plans With Health Care Use and Costs for Patients With Cardiovascular Disease. J Am Heart Assoc 2023; 12:e030730. [PMID: 37750565 PMCID: PMC10727247 DOI: 10.1161/jaha.123.030730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
Background By increasing cost sharing, high-deductible health plans (HDHPs) aim to reduce low-value health care use. The association of HDHPs with health care use and costs in patients with chronic cardiovascular disease is unknown. Methods and Results This longitudinal cohort study analyzed 57 690 privately insured patients, aged 18 to 64 years, from a large commercial claims database with chronic cardiovascular disease from 2011 to 2019. Health care entities in which all or most beneficiaries switched from being in a traditional plan to an HDHP were identified. A difference-in-differences design was used to account for differences between individuals who remained in traditional plans and those who switched to HDHPs and to assess changes in health care use and costs. Among the 934 individuals in the HDHP group and the 56 756 in the traditional plan group, switching to an HDHP was not associated with statistically significant changes in annual outpatient visits, hospitalizations, or emergency department visits (-8.3% [95% CI, -16.8 to 1.1], -28.5% [95% CI, -62.1 to 34.6], and 11.2% [95% CI, -20.9 to 56.5], respectively). Switching to an HDHP was associated with an increase of $921 (95% CI, $743-$1099) in out-of-pocket costs but no statistically significant difference in total health care costs. Conclusions Among commercially insured patients with chronic cardiovascular disease, switching to an HDHP was not associated with a change in health care use but was associated with an increase in out-of-pocket costs. Although health care use by individuals with chronic cardiovascular disease may not be sensitive to higher cost sharing associated with HDHP enrollment, there may be a significant increase in patients' financial burden.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Hopkins Business of Health Initiative, Johns Hopkins UniversityBaltimoreMD
| | - Lin Yang
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Amol S. Navathe
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Peter W. Groeneveld
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of General Internal Medicine, Perelman School of MedicineUniversity of PennsylvaniaPAPhiladelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
| | - Sameed Ahmed M. Khatana
- Leonard Davis Institute of Health Economics, University of PennsylvaniaPhiladelphiaPA
- Center for Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPAPhiladelphia
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Jelks J, Zakama A, Lewey J, James A, Levine LD. Patient knowledge of future cardiovascular risk 10 years after a hypertensive disorder of pregnancy. Am J Obstet Gynecol MFM 2023; 5:101131. [PMID: 37597801 DOI: 10.1016/j.ajogmf.2023.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Japhe Jelks
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Arthurine Zakama
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Abike James
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104
| | - Lisa D Levine
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104.
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8
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Azizi Z, Adedinsewo D, Rodriguez F, Lewey J, Merchant RM, Brewer LC. Leveraging Digital Health to Improve the Cardiovascular Health of Women. Curr Cardiovasc Risk Rep 2023; 17:205-214. [PMID: 37868625 PMCID: PMC10587029 DOI: 10.1007/s12170-023-00728-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/24/2023]
Abstract
Purpose of Review In this review, we present a comprehensive discussion on the population-level implications of digital health interventions (DHIs) to improve cardiovascular health (CVH) through sex- and gender-specific prevention strategies among women. Recent Findings Over the past 30 years, there have been significant advancements in the diagnosis and treatment of cardiovascular diseases, a leading cause of morbidity and mortality among men and women worldwide. However, women are often underdiagnosed, undertreated, and underrepresented in cardiovascular clinical trials, which all contribute to disparities within this population. One approach to address this is through DHIs, particularly among racial and ethnic minoritized groups. Implementation of telemedicine has shown promise in increasing adherence to healthcare visits, improving BP monitoring, weight control, physical activity, and the adoption of healthy behaviors. Furthermore, the use of mobile health applications facilitated by smart devices, wearables, and other eHealth (defined as electronically delivered health services) modalities has also promoted CVH among women in general, as well as during pregnancy and the postpartum period. Overall, utilizing a digital health approach for healthcare delivery, decentralized clinical trials, and incorporation into daily lifestyle activities has the potential to improve CVH among women by mitigating geographical, structural, and financial barriers to care. Summary Leveraging digital technologies and strategies introduces novel methods to address sex- and gender-specific health and healthcare disparities and improve the quality of care provided to women. However, it is imperative to be mindful of the digital divide in specific populations, which may hinder accessibility to these novel technologies and inadvertently widen preexisting inequities.
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Affiliation(s)
- Zahra Azizi
- Center for Digital Health, Stanford University, Stanford, CA USA
- Department of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA USA
| | | | - Fatima Rodriguez
- Department of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA USA
| | - Jennifer Lewey
- Department of Medicine, Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Raina M. Merchant
- Center for Digital Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - LaPrincess C. Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN USA
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Reza N, Packard E, Goli R, Chowns JL, Owens AT, Arany Z, Lewey J. Clinical Predictors of Referral for and Yield of Genetic Testing in Peripartum Cardiomyopathy. JACC Heart Fail 2023; 11:1278-1280. [PMID: 37178081 PMCID: PMC10529608 DOI: 10.1016/j.jchf.2023.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
| | - Elizabeth Packard
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
| | - Rahul Goli
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
| | - Jessica L. Chowns
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
| | - Anjali Tiku Owens
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
| | - Zoltan Arany
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, 11th Floor South Pavilion, Philadelphia, Pennsylvania 19104, USA
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10
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Reddy KP, Faggioni M, Eberly LA, Halaby R, Sanghavi M, Lewey J, Mehran R, Coylewright M, Herrmann HC, Giri J, Fanaroff AC, Nathan AS. Enrollment of Older Patients, Women, and Racial and Ethnic Minority Individuals in Valvular Heart Disease Clinical Trials: A Systematic Review. JAMA Cardiol 2023; 8:871-878. [PMID: 37494015 DOI: 10.1001/jamacardio.2023.2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Importance Inadequate representation of older patients, women, and racial minority individuals in cardiovascular clinical trials limits both the generalizability of trial findings and inclusivity in access to novel therapies and therapeutic strategies. Objective To report on temporal trends in the representation of older patients, women, and racial and ethnic minority individuals in clinical trials studying treatments for valvular heart disease. Evidence Review All published clinical trials enrolling more than 100 adults with any valvular heart disease published between 2005 and 2020 were included after searches with PubMed and ClinicalTrials.gov. Data on age, sex, race, and ethnicity reported in the included studies were collected. Trials were assigned to 4 time periods based on the publication date, and temporal trends were analyzed in the representation of older patients, women, and racial and ethnic minority individuals. Findings A total of 139 clinical trials with 51 527 participants were identified. Of these trials, 103 (74%) investigated aortic valve disease and the remainder mitral valve disease. Overall, 63 trials (45.3%) enrolled patients only in Europe, 24 (17.3%) only in North America, and 19 (13.7%) in multiple geographical regions. The weighted mean (SD) age of enrolled patients was 68.4 (11.4) years, increasing nonsignificantly from 61.9 (5.9) years in 2005-2008 to 72.8 (9.6) years in 2017-2020 (P = .09 for trend). The overall proportion of women enrolled in valvular heart disease trials was 41.1%, with no significant changes over time. Data on race and ethnicity of trial participants were reported in 13 trials (9.4%), in which trial-level representation of American Indian/Alaska Native, Asian, Black/African American, Hispanic, and Native Hawaiian/Pacific Islander patients ranged from 0.27% to 43.9%. There were no significant temporal trends noted in the enrollment of racial and ethnic minority populations. The representation of women in clinical trials was positively associated with enrollment rates of older patients and underrepresented racial and ethnic groups. Conclusions and Relevance This review found that over the past 2 decades, women and racial and ethnic minority individuals have remained underrepresented in North American valvular heart disease clinical trials. Further work is needed to improve the reporting of race and ethnicity data and address barriers to trial enrollment for older patients, women, and racial and ethnic minority individuals.
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Affiliation(s)
- Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
| | - Michela Faggioni
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Lauren A Eberly
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Rim Halaby
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Monika Sanghavi
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jennifer Lewey
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
- Associate Editor, JAMA Cardiology
| | | | - Howard C Herrmann
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin S Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Triebwasser JE, Lewey J, Walheim L, Sehdev HM, Srinivas SK. Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2023:00006250-990000000-00779. [PMID: 37294089 DOI: 10.1097/aog.0000000000005237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Scalable interventions are needed to improve preventive care for those with increased cardiovascular disease (CVD) risk identified during pregnancy. We hypothesized that an automated reminder message for clinicians (nudge) would increase counseling at the postpartum visit on patient transitions of care. METHODS We conducted a single-center, randomized controlled trial including birthing people with a hypertensive disorder of pregnancy evaluating a nudge compared with usual care. The nudge, including counseling phrases and patient-specific information on hypertensive diagnosis, was sent to the obstetric clinician through the electronic medical record up to 7 days before the postpartum visit. The primary outcome was documentation of counseling on transitions of care to primary care or cardiology. Secondary outcomes were documentation of CVD risk, use of counseling phrases, and preventive care visit within 6 months. A sample size of 94 per group (n=188) was planned to compare the nudge intervention with usual care; given the anticipated loss to follow-up, the sample size was increased to 222. Intention-to-treat analyses were performed, with P<.05 considered significant. RESULTS From February to June 2021, 392 patients were screened, and 222 were randomized and analyzed. Of these, 205 (92.3%) attended a postpartum visit. Groups were similar, but more women in the usual care group had diabetes (16.1% vs 6.7%, P=.03). After adjustment for diabetes, patients in the nudge group were more likely to have documented counseling on transitions of care (38.8% vs 26.2%, adjusted relative risk [aRR] 1.53, 95% CI 1.02-2.31), CVD risk (21.4% vs 8.4%, aRR 2.57, 95% CI 1.20-5.49), and use of aspirin in a future pregnancy (14.3% vs 1.9%, aRR 7.49, 95% CI 1.66-33.93). Counseling phrases were used more often in the nudge group (11.2% vs 0.9%, aRR 12.27, 95% CI 1.50-100.28). Preventive care visit attendance did not differ by group (22.1% vs 24.6%, aRR 0.91, 95% CI 0.57-1.47). CONCLUSION A timely electronic reminder to obstetric clinicians improved counseling about transitions of care after hypertensive disorders of pregnancy but did not result in increased preventive care visit attendance. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04660032.
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Affiliation(s)
- Jourdan E Triebwasser
- Divisions of Maternal-Fetal Medicine and Cardiology, University of Pennsylvania Perelman School of Medicine, and the Department of Obstetrics & Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania; and the Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
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12
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Golwala S, Dolin CD, Nemiroff R, Soffer D, Denduluri S, Jacoby D, Lewey J. Feasibility of Lipid Screening During First Trimester of Pregnancy to Identify Women at Risk of Severe Dyslipidemia. J Am Heart Assoc 2023; 12:e028626. [PMID: 37183838 DOI: 10.1161/jaha.122.028626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background Dyslipidemia is an important risk factor for atherosclerotic cardiovascular disease, especially when disease presents at a young age. Despite national screening guidelines to perform a lipid profile test in children and young adults, many reproductive-age women have not undergone lipid screening. Our objective was to assess the feasibility of lipid screening during the first trimester of pregnancy as a strategy to increase lipid screening rates among women receiving prenatal care. Methods and Results A nonfasting lipid panel was incorporated into routine prenatal care among obstetricians at a single academic clinic. Educational materials and a clinical referral pathway were developed for patients with abnormal results. Over 6 months, 445 patients had a first prenatal care visit. Of the 358 patients who completed laboratory testing, 236 (66%) patients completed lipid testing. Overall, 59 (25%) patients had abnormal results. One patient with previously undiagnosed suspected familial hypercholesterolemia was identified. Barriers to ordering lipid tests included the burden of reviewing additional laboratory results and uncertainty about patient counseling. Conclusions Implementation of nonfasting lipid screening as part of routine prenatal care during the first trimester is feasible and may play a crucial role in timely diagnosis and management of lipid disorders in women of reproductive age. Future work should focus on optimizing health system workflow to minimize burden on clinical staff and facilitate follow-up with appropriate specialists.
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Affiliation(s)
- Sohil Golwala
- Division of Cardiology University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Cara D Dolin
- Department of Obstetrics and Gynecology Cleveland Clinic Cleveland OH USA
| | - Richard Nemiroff
- Department of Obstetrics and Gynecology University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Daniel Soffer
- Division of Cardiology University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Srinivas Denduluri
- Division of Cardiology University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Douglas Jacoby
- Division of Cardiology University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Jennifer Lewey
- Division of Cardiology University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
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13
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Mehta LS, Velarde GP, Lewey J, Sharma G, Bond RM, Navas-Acien A, Fretts AM, Magwood GS, Yang E, Blumenthal RS, Brown RM, Mieres JH. Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association. Circulation 2023; 147:1471-1487. [PMID: 37035919 DOI: 10.1161/cir.0000000000001139] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Cardiovascular disease is the leading cause of death in women, yet differences exist among certain racial and ethnic groups. Aside from traditional risk factors, behavioral and environmental factors and social determinants of health affect cardiovascular health and risk in women. Language barriers, discrimination, acculturation, and health care access disproportionately affect women of underrepresented races and ethnicities. These factors result in a higher prevalence of cardiovascular disease and significant challenges in the diagnosis and treatment of cardiovascular conditions. Culturally sensitive, peer-led community and health care professional education is a necessary step in the prevention of cardiovascular disease. Equitable access to evidence-based cardiovascular preventive health care should be available for all women regardless of race and ethnicity; however, these guidelines are not equally incorporated into clinical practice. This scientific statement reviews the current evidence on racial and ethnic differences in cardiovascular risk factors and current cardiovascular preventive therapies for women in the United States.
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14
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Feldbaum E, Thompson EW, Cook TS, Sanghavi M, Wilensky RL, Fiorilli PN, Lewey J. Management of spontaneous coronary artery dissection: Trends over time. Vasc Med 2023; 28:131-138. [PMID: 37025021 PMCID: PMC10084514 DOI: 10.1177/1358863x231155305] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome. Guidance regarding the optimal management of patients with SCAD has been published over the past 10 years, but the impact on clinical practice has not been evaluated. The present study aims to examine if approaches to invasive management, medical therapy, and vascular imaging have changed over time. METHODS This is a retrospective cohort study of 157 patients treated for SCAD between 2005 and 2019 at an academic health system in Philadelphia, Pennsylvania. We aimed to examine change in management over time, including rates of coronary revascularization, discharge medications, and vascular imaging. RESULTS Conservative management of SCAD increased over time from 35% before 2013 to 89% in 2019, p < 0.001. Revascularization was associated with younger age, pregnancy-associated SCAD, and lesions of the left main artery, left anterior descending artery, and multiple vessels, p < 0.05 for all. Partial imaging for extracoronary vascular abnormalities ranged from 33% before 2013 to 71% in 2018, p = 0.146. The rate of comprehensive vascular imaging (cross-sectional head to pelvis imaging) remained low in all time categories (10-18%) and did not change over time. Patients who underwent comprehensive imaging were more likely to be diagnosed with fibromuscular dysplasia (FMD) compared to those with partial imaging (63% vs 15%, p < 0.001). CONCLUSION Management of spontaneous coronary artery dissection has changed over time. More patients are being managed conservatively and undergo screening for extracoronary vascular abnormalities such as FMD. Future efforts should focus on improving rates of comprehensive vascular screening.
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Affiliation(s)
- Elliot Feldbaum
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Tessa S Cook
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Monika Sanghavi
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert L Wilensky
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Paul N Fiorilli
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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15
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Bediako H, Allison K, Leahey T, Stupp S, Riis V, Levine L, elovitz M, Shea J, Lewey J. Abstract P644: Engagement With a Weight Loss Program for Postpartum Individuals at Elevated Cardiovascular Risk: A Qualitative Study. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Background:
Rising rates of postpartum obesity increase risk for cardiovascular (CV) disease, especially among individuals with adverse pregnancy outcomes. Engagement in weight loss programs (WLP) have not been well studied in the postpartum period. Our objective was to understand barriers to engagement in an online behavioral WLP among a racially diverse postpartum population with CV risk factors.
Methods:
We conducted a qualitative study of participants enrolled in a clinical trial. We identified individuals who were 3-12 months postpartum, had a body mass index ≥ 27 kg/m2, and had ≥1 of the following: chronic hypertension, hypertensive disorder of pregnancy, gestational or pre-gestational diabetes. We randomized 60 subjects 1:2 to usual care or online WLP based on the Diabetes Prevention Program. We conducted semi-structured virtual interviews with participants in the WLP who completed final assessments to understand barriers to and facilitators of program engagement. Interviews were recorded and transcribed, a codebook was developed iteratively with concurrent interrater reliability assessment, and themes were identified using content analysis.
Results:
Of 26 eligible participants, 20 completed interviews (77%). Mean age was 35 years and 45% were Black. Common barriers to program engagement were a lack of time due to competing life priorities and stressors, coupled with insufficient program personalization and peer support (see Table). In terms of facilitators, participants discussed intentionality, creating a routine to complete program requirements (e.g., daily morning weights) and specific aspects of the program structure (e.g., weekly feedback) as playing important roles in maximizing program engagement.
Conclusion:
Participants identified several opportunities to improve program engagement and weight loss success among postpartum individuals in future studies. These strategies will be critical to the implementation of future lifestyle interventions using remote technology in this population.
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Affiliation(s)
| | | | | | | | | | | | | | - Judy Shea
- Univ of Pennsylvania, Philadelphia, PA
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16
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Khan SS, Brewer LC, Canobbio MM, Cipolla MJ, Grobman WA, Lewey J, Michos ED, Miller EC, Perak AM, Wei GS, Gooding H. Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e76-e91. [PMID: 36780391 PMCID: PMC10080475 DOI: 10.1161/cir.0000000000001124] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
This scientific statement summarizes the available preclinical, epidemiological, and clinical trial evidence that supports the contributions of prepregnancy (and interpregnancy) cardiovascular health to risk of adverse pregnancy outcomes and cardiovascular disease in birthing individuals and offspring. Unfavorable cardiovascular health, as originally defined by the American Heart Association in 2010 and revised in 2022, is prevalent in reproductive-aged individuals. Significant disparities exist in ideal cardiovascular health by race and ethnicity, socioeconomic status, and geography. Because the biological processes leading to adverse pregnancy outcomes begin before conception, interventions focused only during pregnancy may have limited impact on both the pregnant individual and offspring. Therefore, focused attention on the prepregnancy period as a critical life period for optimization of cardiovascular health is needed. This scientific statement applies a life course and intergenerational framework to measure, modify, and monitor prepregnancy cardiovascular health. All clinicians who interact with pregnancy-capable individuals can emphasize optimization of cardiovascular health beginning early in childhood. Clinical trials are needed to investigate prepregnancy interventions to comprehensively target cardiovascular health. Beyond individual-level interventions, community-level interventions must include and engage key stakeholders (eg, community leaders, birthing individuals, families) and target a broad range of antecedent psychosocial and social determinants. In addition, policy-level changes are needed to dismantle structural racism and to improve equitable and high-quality health care delivery because many reproductive-aged individuals have inadequate, fragmented health care before and after pregnancy and between pregnancies (interpregnancy). Leveraging these opportunities to target cardiovascular health has the potential to improve health across the life course and for subsequent generations.
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17
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Lewey J. Challenges and opportunities to improving research in maternal cardiovascular health. Nat Cardiovasc Res 2023; 2:6-7. [PMID: 36875777 PMCID: PMC9979619 DOI: 10.1038/s44161-022-00201-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pregnancy is associated with a substantial risk of short-term and long-term cardiovascular diseases. Here we discuss physiological and social factors that affect the risk of pregnancy-related cardiovascular diseases and opportunities to improve outcomes.
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Affiliation(s)
- Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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18
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Tan MT, Darden N, Peterson K, Trout KK, Christ L, Handley SC, Kornfield SL, Power ME, Montoya-Williams D, Lewey J, Gregory EF, Lorch SA, DeMauro SB, Levine LD, Burris HH. Bringing postpartum care to the NICU-An opportunity to improve health in a high-risk obstetric population. J Perinatol 2023; 43:1-2. [PMID: 36198771 PMCID: PMC9840660 DOI: 10.1038/s41372-022-01525-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Marie T Tan
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Niesha Darden
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karen Peterson
- KMP Doula Service, Childbirth and Postpartum Professional Association (CAPPA), Lansdowne, PA, USA
| | - Kimberly K Trout
- Univeristy of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Lori Christ
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara C Handley
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara L Kornfield
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maggie E Power
- Univeristy of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Diana Montoya-Williams
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily F Gregory
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott A Lorch
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa D Levine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Heather H Burris
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA.
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19
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Lewey J, Putt ME, Levine LD. Team-Based Digital Gamification to Improve Cardiovascular Health in Women With Hypertensive Disorders of Pregnancy-Reply. JAMA Cardiol 2022; 7:1264-1265. [PMID: 36383350 DOI: 10.1001/jamacardio.2022.4122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mary E Putt
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lisa D Levine
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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20
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Zahid S, Hashem A, Minhas AS, Bennett WL, Honigberg MC, Lewey J, Davis MB, Michos ED. Trends, Predictors, and Outcomes of Cardiovascular Complications at Delivery Associated With Gestational Diabetes: A National Inpatient Sample Analysis (2004-2019). J Am Heart Assoc 2022; 11:e026786. [PMID: 36300664 PMCID: PMC9673632 DOI: 10.1161/jaha.122.026786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Gestational diabetes (GD) is associated with increased risk of long-term cardiovascular complications. However, data on acute peripartum cardiovascular complications are not well established. Hence, we aimed to investigate the association of GD with acute cardiovascular outcomes at the time of delivery admission. Methods and Results We used data from the National Inpatient Sample (2004-2019). International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) codes were used to identify delivery hospitalizations and GD diagnosis. A total of 63 115 002 weighted hospitalizations for deliveries were identified, of which 3.9% were among individuals with GD (n=2 435 301). The prevalence of both GD and obesity increased during the study period (P trends<0.01). Individuals with GD versus those without GD had a higher prevalence of obesity, hypertension, and dyslipidemia. After adjustment for age, race or ethnicity, comorbidities, insurance, and income, GD remained independently associated with cardiovascular complications including preeclampsia (adjusted odds ratio [aOR], 1.97 [95% CI, 1.96-1.98]), peripartum cardiomyopathy (aOR, 1.15 [1.08-1.22]), acute kidney injury (aOR, 1.16 [1.11-1.21]), stroke (aOR, 1.15 [1.09-1.23]), and arrhythmias (aOR, 1.48 [1.46-1.50]), compared with no GD. Moreover, delivery hospitalizations among individuals with GD were associated with increased length (3 versus 2 days, P<0.01) and cost of hospitalization ($4909 versus $3682, P<0.01). Even in the absence of preeclampsia, GD was associated with elevated cardiovascular risk. Conclusions Individuals with GD had a higher risk of preeclampsia, peripartum cardiomyopathy, acute kidney injury, stroke, and arrhythmias during delivery hospitalizations. As rates of GD are increasing globally, efforts to improve preconception cardiometabolic health and prevent GD may represent important strategies to improve peripartum maternal outcomes and mitigate long-term cardiovascular risk.
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Affiliation(s)
- Salman Zahid
- Sands‐Constellation Heart Institute, Rochester General HospitalRochesterNY
| | - Anas Hashem
- Sands‐Constellation Heart Institute, Rochester General HospitalRochesterNY
| | - Anum S. Minhas
- Division of CardiologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Wendy L. Bennett
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Michael C. Honigberg
- Cardiology Division, Department of MedicineMassachusetts General HospitalBostonMA
| | - Jennifer Lewey
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | | | - Erin D. Michos
- Division of CardiologyJohns Hopkins University School of MedicineBaltimoreMD
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21
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Choi E, Kazzi B, Varma B, Ortengren AR, Minhas AS, Vaught AJ, Bennett WL, Lewey J, Michos ED. The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care. Curr Cardiovasc Risk Rep 2022; 16:219-229. [PMID: 36159207 PMCID: PMC9490714 DOI: 10.1007/s12170-022-00706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 01/26/2023]
Abstract
Purpose of Review The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.
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Affiliation(s)
- Eunjung Choi
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Brigitte Kazzi
- Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA
| | - Bhavya Varma
- Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA
| | | | - Anum S. Minhas
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Arthur Jason Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Wendy L. Bennett
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
- Division of Cardiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524-B, Baltimore, MD 21287 USA
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22
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Levine LD, Ky B, Chirinos JA, Koshinksi J, Arany Z, Riis V, Elovitz MA, Koelper N, Lewey J. Prospective Evaluation of Cardiovascular Risk 10 Years After a Hypertensive Disorder of Pregnancy. J Am Coll Cardiol 2022; 79:2401-2411. [PMID: 35710191 DOI: 10.1016/j.jacc.2022.03.383] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are associated with increased risk of cardiovascular disease (CVD) 20-30 years later; however, cardiovascular (CV) risk in the decade after HDP is less studied. OBJECTIVES The purpose of this study was to evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier. METHODS This is a prospective study of patients with and without a diagnosis of HDP ≥10 years earlier (2005-2007) who underwent in-person visits with echocardiography, arterial tonometry, and flow-mediated dilation of the brachial artery. RESULTS A total of 135 patients completed assessments (84 with and 51 without a history of HDP); 85% self-identified as Black. Patients with a history of HDP had a 2.4-fold increased risk of new hypertension compared with those without HDP (56.0% vs. 23.5%; adjusted relative risk: 2.4; 95% CI: 1.39-4.14) with no differences in measures of left ventricular structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function. Patients who developed hypertension, regardless of HDP history, had greater left ventricular remodeling, including greater relative wall thickness; worse diastolic function, including lower septal and lateral e' and E/A ratio; more abnormal longitudinal strain; and higher effective arterial elastance than patients without hypertension. CONCLUSIONS We found a 2.4-fold increased risk of hypertension 10 years after HDP. Differences in noninvasive measures of CV risk were driven mostly by the hypertension diagnosis, regardless of HDP history, suggesting that the known long-term risk of CVD after HDP may primarily be a consequence of hypertension development.
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Affiliation(s)
- Lisa D Levine
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Bonnie Ky
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julio A Chirinos
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica Koshinksi
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zoltan Arany
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Valerie Riis
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michal A Elovitz
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nathanael Koelper
- Center for Research on Reproduction and Patient's Health, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Kwapong YA, Boakye E, Wang G, Hong X, Lewey J, Mamas MA, Wu P, Blaha MJ, Nasir K, Hays AG, Blumenthal RS, Wang X, Sharma G. Maternal Glycemic Spectrum and Adverse Pregnancy and Perinatal Outcomes in a Multiracial US Cohort. J Cardiovasc Dev Dis 2022; 9:jcdd9060179. [PMID: 35735808 PMCID: PMC9224544 DOI: 10.3390/jcdd9060179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 02/04/2023] Open
Abstract
Diabetes mellitus (pregestational (PDM) and gestational (GDM)) is associated with adverse pregnancy outcomes (APOs). However, studies exploring the association of APOs with maternal glycemia among women without PDM/GDM are limited. We utilized data from 4119 women (307—PDM; 582—GDM; 3230—non-PDM/GDM) in the Boston Birth Cohort (1998–2016). Women in the non-PDM/GDM group were subdivided by tertiles of 1 h, 50 g oral glucose load test at 24–32 weeks: T1: 50–95 mg/dL (n = 1166), T2: 96–116 mg/dL (n = 1151), T3: 117–201 mg/dL (n = 913). Using multivariable logistic regression, we examined the association of maternal glycemia with APOs—preterm birth (PTB) and hypertensive disorders of pregnancy (HDP)—and adverse perinatal outcomes—high birth weight (HBW), cesarean section (CS), and sub-analyses by race-ethnicity. Compared to women in T1, women in T2 and T3 had a higher prevalence of pre-existing hypertension (T1: 2.8% vs. T2: 5.2% vs. T3: 6.3%) and obesity (T1: 13.3% vs. T2: 18.1% vs. T3: 22.9%). Women in T2 and T3 had higher odds of HBW (adjusted odds ratio aOR T2: 1.47 [1.01–2.19] T3: 1.68 [1.13–2.50]) compared to women in T1. Additionally, women in T2, compared to T1, had higher odds of HDP (aOR 1.44 [1.10–1.88]). Among non-Hispanic Black (NHB) women, those in T2 and T3 had higher odds of HDP compared to T1 (aOR T2 1.67 [1.13–2.51]; T3: 1.68 [1.07–2.62]). GDM and PDM were associated with higher odds of HBW, CS, PTB, and HDP, compared to women in T1. In this predominantly NHB and Hispanic cohort, moderate maternal glycemia without PDM/GDM was associated with higher odds of HBW and HDP, even more strongly among NHB women. If confirmed, a review of current guidelines of glucose screening and risk stratification in pregnancy may be warranted.
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Affiliation(s)
- Yaa Adoma Kwapong
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Guoying Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Xiumei Hong
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Jennifer Lewey
- Division of Cardiology, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mamas Andreas Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Keele ST5 5BG, UK
| | - Pensee Wu
- Division of Maternal and Fetal Medicine, Keele University, Keele ST5 5BG, UK
| | - Michael Joseph Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
- Center for Outcomes Research, Houston Methodist Hospital and DeBakey Heart & Vascular Center, Houston, TX 77030, USA
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist Debakey Heart and Vascular Center, Houston, TX 77030, USA
| | - Allison Gamboa Hays
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Roger Scott Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Garima Sharma
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
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Minhas AS, Goldstein SA, Vaught AJ, Lewey J, Ward C, Schulman SP, Michos ED. Instituting a Curriculum for Cardio-Obstetrics Subspecialty Fellowship Training. Methodist Debakey Cardiovasc J 2022; 18:14-23. [PMID: 35734150 PMCID: PMC9165665 DOI: 10.14797/mdcvj.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/24/2022] [Indexed: 01/26/2023] Open
Abstract
Maternal mortality is rising in the United States, and cardiovascular disease is the leading cause. Adverse pregnancy outcomes such as preeclampsia and gestational diabetes heighten the risk of cardiovascular complications during pregnancy and the peripartum period and are associated with long-term cardiovascular risks. The field of cardio-obstetrics is a subspecialty within adult cardiology that focuses on the management of women with or at high risk for heart disease who are considering pregnancy or have become pregnant. There is growing recognition of the need for more specialists with dedicated expertise in cardio-obstetrics to improve the cardiovascular care of this high-risk patient population. Current recommendations for cardiovascular fellowship training programs accredited by the Accreditation Council for Graduate Medical Education involve establishing core competency in the knowledge of managing heart disease in pregnancy. However, little granular detail is available of what such training should entail, which can lead to knowledge gaps. Additionally, dedicated advanced subspecialty training in this area is not commonly offered. Multidisciplinary collaborative teams have been shown to improve outcomes in cardiac patients during pregnancy, and cardiovascular fellows-in-training interested in cardio-obstetrics should have the opportunity to participate in and contribute to a pregnancy heart team. In this document, we describe a proposed specialized cardio-obstetrics training pathway that could serve to adequately prepare trainees to competently and comprehensively care for women with cardiovascular disease before, during, and after pregnancy.
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Affiliation(s)
- Anum S. Minhas
- Johns Hopkins University School of Medicine, Baltimore, Maryland, US
| | | | | | - Jennifer Lewey
- University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Cary Ward
- Duke University School of Medicine, Durham, North Carolina, US
| | | | - Erin D. Michos
- Johns Hopkins University School of Medicine, Baltimore, Maryland, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, US
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Lewey J, Murphy S, Zhang D, Putt ME, Elovitz MA, Riis V, Patel MS, Levine LD. Effectiveness of a Text-Based Gamification Intervention to Improve Physical Activity Among Postpartum Individuals With Hypertensive Disorders of Pregnancy: A Randomized Clinical Trial. JAMA Cardiol 2022; 7:591-599. [PMID: 35442393 PMCID: PMC9021982 DOI: 10.1001/jamacardio.2022.0553] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease, yet few interventions have targeted this population to decrease long-term risk. Objective To determine whether a digital health intervention improves physical activity in postpartum individuals with hypertensive disorders of pregnancy. Design, Setting, and Participants This 12-week randomized clinical trial enrolled postpartum individuals who delivered at the University of Pennsylvania and had a hypertensive disorder of pregnancy between October 2019 and June 2020. Analysis was intention to treat. Interventions All participants received a wearable activity tracker, established a baseline step count, selected a step goal greater than baseline, and were randomly assigned to control or intervention. Participants in the control arm received daily feedback on goal attainment. Participants in the intervention arm were placed on virtual teams and enrolled in a game with points and levels for daily step goal achievement and informed by principles of behavioral economics. Main Outcomes and Measures The primary outcome was change in mean daily step count from baseline to 12-week follow-up. Secondary outcome was proportion of participant-days that step goal was achieved. Results A total of 127 participants were randomized (64 in the control group and 63 in the intervention group) and were enrolled a mean of 7.9 weeks post partum. Participants had a mean (SD) age of 32.3 (5.6) years, 70 (55.1%) were Black, and 52 (41.9%) had Medicaid insurance. The mean (SD) baseline step count was similar in the control and intervention arms (6042 [2270] vs 6175 [1920] steps, respectively). After adjustment for baseline steps and calendar month, participants in the intervention arm had a significantly greater increase in mean daily step steps from baseline compared with the control arm (647 steps; 95% CI, 169-1124 steps; P = .009). Compared with the control arm, participants in the intervention arm achieved their steps goals on a greater proportion of participant-days during the intervention period (0.47 vs 0.38; adjusted difference 0.11; 95% CI, 0.04-0.19; P = .003). Conclusions and Relevance In this study, a digital health intervention using remote monitoring, gamification, and social incentives among postpartum individuals at elevated cardiovascular risk significantly increased physical activity throughout 12 weeks. Trial Registration ClinicalTrials.gov Identifier: NCT03311230.
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Affiliation(s)
- Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Samantha Murphy
- Maternal and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Dazheng Zhang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michal A. Elovitz
- Maternal and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Valerie Riis
- Maternal and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Lisa D. Levine
- Maternal and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Lewey J, Riis V, Stupp S, Levine L, Elovitz M, Allison K. Abstract 20: Recruitment Strategies To Increase Diversity And Enrollment In Behavioral Clinical Trials. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Increasing rates of obesity are a major contributor to CV disease among women of reproductive age, especially Black women. Enrollment of racially diverse populations in behavioral weight loss trials is suboptimal and may be impacted by recruitment approaches. Our objectives are to evaluate the effectiveness of recruitment strategies informed by principles of behavioral economics on the enrollment of women into a weight loss trial and to understand the impact of race and insurance.
Methods:
We tested 4 strategies to enroll postpartum women with CV risk factors into a behavioral weight loss trial. 1,047 individuals who met inclusion criteria in the electronic health record were randomized to receive one of two personalized emails. Email 1 stated that “we reserved a spot” in the study for the patient. Email 2 asked the patient to “commit to health.” Patients who did not respond or have an email address were then randomized to receive a mailer or mailer plus baby bib (gift). All groups were asked to sign up for a virtual information session. We compared response rates between the 2 email and 2 mail strategies. We identified participant characteristics associated with signing up using multivariate logistic regression.
Results:
Mean age was 31.3 years, 65% were Black and 52% had Medicaid. 1000 patients were randomized to email 1 (n=497) and email 2 (n=503). Response rates were similar in the email groups (17.7% vs. 20.3%, p=0.299). 849 patients were randomized to the mailer (n=424) or mailer plus gift (n=425). Response rates were low but did not differ by strategy (2.6% vs. 3.8%, p=0.331), and largely did not vary by race or insurance (Table). In multivariable analysis, Medicaid insurance was associated with lower odds of signing up for an info session, but race was not.
Conclusion:
A tailored email is a low-cost and time effective strategy to recruit racially diverse women in a behavioral weight loss trial, though women with Medicaid insurance may require additional outreach.
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Affiliation(s)
- Jennifer Lewey
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Valerie Riis
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Sarah Stupp
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Lisa Levine
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Michal Elovitz
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Kelly Allison
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
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Gupta R, Yang L, Lewey J, Navathe A, Groeneveld PW, Khatana SA. Abstract 74: Healthcare Utilization Among Cardiovascular Disease Patients Switching To A High-deductible Health Plan. Circ Cardiovasc Qual Outcomes 2022. [DOI: 10.1161/circoutcomes.15.suppl_1.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The majority of commercially insured individuals in the US are enrolled in high-deductible health plans (HDHPs). HDHPs aim to reduce healthcare spending by disincentivizing expensive care utilization and are associated with lower inpatient and outpatient care utilization. The association of HDHPs with healthcare utilization in patients with chronic cardiovascular (CV) disease is unclear. We studied the association of employer-mandated switching to HDHPs with inpatient and outpatient care utilization in patients with chronic CV disease.
Methods:
Data were extracted from a national commercial health insurance claims data set (Optum® Clinformatics® Data Mart). We identified employers that mandated switching from a traditional plan to an HDHP versus those that remained in traditional plans from 2011 to 2019 to reduce selection bias. We created a cohort of patients aged 18-64 with heart failure, coronary artery disease, peripheral artery disease, or stroke who were enrolled in these employer plans. Our primary outcomes were rates of all-cause hospitalizations and outpatient visits. We estimated the difference-in-differences in these outcomes between persons who switched to an HDHP after at least 1 year of enrollment in a traditional plan, compared to those who remained in a traditional plan, using a negative binomial regression model with inverse probability of treatment weighting to balance baseline patient characteristics.
Results:
A total of 1,038 individuals with chronic CV disease switched to an HDHP and 56,756 remained in a traditional plan. Switching to an HDHP was associated with a 10.4% (95% CI 4.3% to 16.2%; p=0.001) lower annual rate of outpatient visits, i.e., 0.66 (95% CI 0.25 to 1.05) fewer visits per person per year. The change in annual all-cause hospitalizations after switching to an HDHP was not statistically significant: -16.4% (95% CI -45.2% to 27.4%; p=0.41).
Conclusion:
Among patients with chronic CV disease, switching to an HDHP was associated with a significant reduction in outpatient visits and no significant change in all-cause hospitalizations. These findings suggest that HDHPs are associated with lower outpatient care utilization without significant change in utilization of inpatient services.
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Affiliation(s)
| | - Lin Yang
- Univ of Pennsylvania, Philadelphia, PA
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Grodzinsky A, Kim ES, Gornik HL, Wells BJ, Taylor AM, Lewey J, Hess CN, Henkin S, Kadian-Dodov D, Wells GL, Tam L, Vitarello C, Alkhalfan F, Chi G, Gibson M, Leon K, Naderi S, Wood M. REPRODUCTIVE HEALTH FEATURES ASSOCIATED WITH SPONTANEOUS CORONARY ARTERY DISSECTION: A REPORT OF THE ISCAD REGISTRY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Wells BJ, Wood MJ, Grodzinsky A, Gornik HL, Kadian-Dodov D, Taylor AM, Hess CN, Lewey J, Henkin S, Wells GL, Tam L, Vitarello C, Alkhalfan F, Chi G, Gibson CM, Leon K, Naderi S, Kim SH. MIGRAINE HEADACHE IN PATIENTS WITH SPONTANEOUS CORONARY ARTERY DISSECTION: A REPORT OF THE ISCAD REGISTRY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02796-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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30
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Kim SH, Naderi S, Grodzinsky A, Gornik HL, Wells BJ, Taylor A, Lewey J, Hess CN, Henkin S, Kadian-Dodov D, Wells GL, Tam L, Vitarello C, Alkhalfan F, Chi G, Gibson CM, Leon K, Wood MJ. PREVALENCE OF POTENTIAL TRIGGERS AND UNDERLYING MEDICAL CONDITIONS IN SPONTANEOUS CORONARY ARTERY DISSECTION: A REPORT OF THE ISCAD REGISTRY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01961-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Eberly LA, Sanghavi M, Julien HM, Burger L, Chokshi N, Lewey J. Evaluation of Online Patient Portal vs Text-Based Blood Pressure Monitoring Among Black Patients With Medicaid and Medicare Insurance Who Have Hypertension and Cardiovascular Disease. JAMA Netw Open 2022; 5:e2144255. [PMID: 35166788 PMCID: PMC8848204 DOI: 10.1001/jamanetworkopen.2021.44255] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This pilot randomized clinical trial evaluates the increased uptake and acceptability of a text-based model for home blood pressure monitoring compared with online portal use among Black patients with Medicaid and Medicare insurance who have hypertension and cardiovascular disease.
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Affiliation(s)
- Lauren A. Eberly
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia
| | - Monika Sanghavi
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Howard M. Julien
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Laura Burger
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neel Chokshi
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Abstract
Spontaneous coronary artery dissection (SCAD) is an uncommon but increasingly recognized cause of acute myocardial infarction (MI) among young and middle-aged women and is an important cause of pregnancy-associated MI. Over 90% of SCAD patients are women. Compared to patients with MI caused by atherosclerosis, SCAD patients have fewer cardiovascular risk factors but more often have systemic arteriopathy, most commonly fibromuscular dysplasia. Angiographically, SCAD is characterized by the presence of an intramural hematoma with or without an intimal tear. Accurate recognition of characteristic findings on coronary angiography is critical, as there are important differences in the acute and long-term management of MI caused by SCAD versus atherosclerosis. Acutely, most SCAD patients should be managed conservatively, since percutaneous revascularization is associated with more complications and SCAD-affected vessels usually heal without intervention. Randomized clinical trials and other prospective evaluations are needed, especially to clarify optimal treatment and prevention strategies.
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Affiliation(s)
- Jennifer Lewey
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104, USA;
| | - Stephanie C El Hajj
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA; ,
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA; ,
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Triebwasser JE, Lewey J, Walheim L, Srinivas SK. Nudge intervention to transition care after hypertensive disorders of pregnancy: a randomized clinical trial. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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34
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Getz KD, Lewey J, Tam V, Irizarry OC, Levine LD, Aplenc R, Arany Z. Neighborhood education status drives racial disparities in clinical outcomes in PPCM. Am Heart J 2021; 238:27-32. [PMID: 33857409 PMCID: PMC8710234 DOI: 10.1016/j.ahj.2021.03.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/24/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry. Additionally, clinical outcomes are worse in this subpopulation compared to White women with PPCM. The extent to which socioeconomic parameters contribute to these racial disparities is not known. METHODS We aimed to quantify the association between area-based proxies of socioeconomic status (SES) and clinical outcomes in PPCM, and to determine the potential contribution of these factors to racial disparities in outcomes. A retrospective cohort study was performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of Black individuals. The cohort included 220 women with PPCM, 55% of whom were Black or African American. Available data included clinical and demographic characteristics as well as residential address georeferenced to US Census-derived block group measures of SES. Rates of sustained cardiac dysfunction (defined as persistent LVEF <50%, LVAD placement, transplant, or death) were compared by race and block group-level measures of SES, and a composite neighborhood concentrated disadvantage index (NDI). The contributions of area-based socioeconomic parameters to the association between race and sustained cardiac dysfunction were quantified. RESULTS Black race and higher NDI were both independently associated with sustained cardiac dysfunction (relative risk [RR] 1.63, confidence interval [CI] 1.13-2.36; and RR 1.29, CI 1.08-1.53, respectively). Following multivariable adjustment, effect size for NDI remained statistically significant, but effect size for Black race did not. The impact of low neighborhood education on racial disparities in outcomes was stronger than that of low neighborhood income (explaining 45% and 0% of the association with black race, respectively). After multivariate adjustment, only low area-based education persisted as significantly correlating with sustained cardiac dysfunction (RR 1.49; CI 1.02-2.17). CONCLUSIONS Both Black race and NDI independently associate with adverse outcomes in women with PPCM in a single center study. Of the specific components of NDI, neighborhood low education was most strongly associated with clinical outcome and partially explained differences in race. These results suggest interventions targeting social determinants of health in disadvantaged communities may help to mitigate outcome disparities.
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Affiliation(s)
- Kelly D Getz
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Pennsylvania, Philadelphia, PA
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vicky Tam
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Olga Corazon Irizarry
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Richard Aplenc
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Pennsylvania, Philadelphia, PA; Department of Pediatrics, Division of Oncology, Children's Hospital of Pennsylvania, Philadelphia, PA
| | - Zolt Arany
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Tamrat R, Kang Y, Scherrer-Crosbie M, Levine LD, Arany Z, Lewey J. Women with peripartum cardiomyopathy have normal ejection fraction, but abnormal systolic strain, during pregnancy. ESC Heart Fail 2021; 8:3382-3386. [PMID: 33943010 PMCID: PMC8318457 DOI: 10.1002/ehf2.13323] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 03/19/2021] [Indexed: 11/21/2022] Open
Abstract
We report a case series of six women with peripartum cardiomyopathy (PPCM) who incidentally underwent echocardiography prior to the clinical presentation of PPCM. For comparison, we identified controls, matched 2:1 on age, race, body mass index, gestational age, and hypertensive disorder. Among the six cases, all were diagnosed with PPCM during the post‐partum period. Pre‐PPCM echocardiograms were performed between 17.7 weeks of gestation and 13 days post‐partum. Baseline left ventricular ejection fraction and size were normal and similar to the 12 matched controls (60% ± 6.6% vs. 61.4% ± 6.3%, P = 0.63) or left ventricular end‐diastolic dimension (4.6 cm ± 0.2 cm vs. 4.5 cm ± 0.4 cm, P = 0.689). There was a trend towards a less negative (more abnormal) mean global longitudinal strain in cases compared with controls (−14% ± 4% vs. −18.3% ± 4.5%, P = 0.0658). Mean global circumferential strain was significantly less negative (more abnormal) in cases compared with controls (−21.5% ± 5% vs. −29.3% ± 7.6%, P = 0.0329). We conclude that women who develop PPCM have normal left ventricular ejection fraction during gestation preceding PPCM, indicating that the disease develops acutely in the peripartum period. Abnormal strain can be detected, however, suggesting that strain imaging could represent a screening method in populations at high risk for PPCM if confirmed in future studies.
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Affiliation(s)
- Ruth Tamrat
- Department of Cardiology, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Yu Kang
- Division of Cardiology, Perelman Center for Advanced Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA, 19104, USA
| | - Marielle Scherrer-Crosbie
- Division of Cardiology, Perelman Center for Advanced Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA, 19104, USA
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Zoltan Arany
- Division of Cardiology, Perelman Center for Advanced Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA, 19104, USA
| | - Jennifer Lewey
- Division of Cardiology, Perelman Center for Advanced Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA, 19104, USA
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Lewey J, Murphy S, Zhang D, Putt M, Patel MS, Elovitz M, Levine L. EFFECTIVENESS OF A DIGITAL HEALTH INTERVENTION TO IMPROVE PHYSICAL ACTIVITY AMONG POSTPARTUM WOMEN WITH HYPERTENSIVE DISORDERS OF PREGNANCY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)04414-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lopes Perdigao J, Lewey J, Hirshberg A, Koelper N, Srinivas SK, Elovitz MA, Levine LD. Furosemide for Accelerated Recovery of Blood Pressure Postpartum in women with a hypertensive disorder of pregnancy: A Randomized Controlled Trial. Hypertension 2021; 77:1517-1524. [PMID: 33550824 DOI: 10.1161/hypertensionaha.120.16133] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Joana Lopes Perdigao
- From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jennifer Lewey
- Department of Cardiology, Hospital of the University of Pennsylvania (J.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Adi Hirshberg
- From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health (N.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sindhu K Srinivas
- From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michal A Elovitz
- From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lisa D Levine
- From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia
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Mszar R, Gopal DJ, Chowdary R, Smith CL, Dolin CD, Irwin ML, Soffer D, Nemiroff R, Lewey J. Racial/Ethnic Disparities in Screening for and Awareness of High Cholesterol Among Pregnant Women Receiving Prenatal Care. J Am Heart Assoc 2021; 10:e017415. [PMID: 33345544 PMCID: PMC7955491 DOI: 10.1161/jaha.120.017415] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 10/20/2020] [Indexed: 01/15/2023]
Abstract
Background Atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality among women, with younger women being disproportionately affected by traditional cardiovascular risk factors such as dyslipidemia. Despite recommendations for lipid screening in early adulthood and the risks associated with maternal dyslipidemia during pregnancy, many younger women lack access to and utilization of early screening. Accordingly, our objective was to assess the prevalence of and disparities in lipid screening and awareness of high cholesterol as an atherosclerotic cardiovascular disease risk factor among pregnant women receiving prenatal care. Methods and Results We invited 234 pregnant women receiving prenatal care at 1 of 3 clinics affiliated with the University of Pennsylvania Health System to complete our survey. A total of 200 pregnant women (86% response rate) completed the survey. Overall, 59% of pregnant women (mean age 32.2 [±5.7] years) self-reported a previous lipid screening and 79% of women were aware of high cholesterol as an atherosclerotic cardiovascular disease risk factor. Stratified by racial/ethnic subgroups, non-Hispanic Black women were less likely to report a prior screening (43% versus 67%, P=0.022) and had lower levels of awareness (66% versus 92%, P<0.001) compared with non-Hispanic White women. Non-Hispanic Black women were more likely to see an obstetrician/gynecologist for their usual source of non-pregnancy care compared with non-Hispanic White women (18% versus 5%, P=0.043). Those seeing an obstetrician/gynecologist for usual care were less likely to report a prior lipid screening compared with those seeing a primary care physician (29% versus 63%, P=0.007). Conclusions Significant racial/ethnic disparities persist in lipid screening and risk factor awareness among pregnant women. Prenatal care may represent an opportunity to enhance access to and uptake of screening among younger women and reduce variations in accessing preventive care services.
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Affiliation(s)
- Reed Mszar
- Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenCT
| | - Dipika J. Gopal
- Division of CardiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Rupa Chowdary
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Cara Lea Smith
- Division of CardiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Cara D. Dolin
- Department of Obstetrics and GynecologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Melinda L. Irwin
- Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenCT
| | - Daniel Soffer
- Division of CardiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Richard Nemiroff
- Department of Obstetrics and GynecologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Jennifer Lewey
- Division of CardiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
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Levine L, Arany Z, Kern-Goldberger A, Koelper N, Lewey J, Sammel MD, Elovitz MA, Ky B. Soluble Flt1 levels are associated with cardiac dysfunction in Black women with and without severe preeclampsia. Hypertens Pregnancy 2020; 40:44-49. [PMID: 33345653 DOI: 10.1080/10641955.2020.1861462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: We evaluate soluble fms-like tyrosine kinase-1 (sFlt-1) levels and cardiac function during pregnancy and postpartum among Black women with and without preeclampsia. Study design: Prospective longitudinal cohort study from 2015 to 2017 of Black women with preterm severe preeclampsia and normotensive pregnant controls.We obtained echocardiograms and sFlt-1 levels during pregnancy and postpartum. Results: 93 Black women were included (43 cases, 50 controls). Higher sFlt1 levels were correlated with worse longitudinal strain, diastolic dysfunction, decreased ventricular-arterial coupling, and increased chamber and arterial elastance at the time of preeclampsia diagnosis and postpartum. Conclusions: Higher sFlt1 levels are associated with cardiovascular dysfunction during pregnancy and postpartum.
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Affiliation(s)
- Lisa Levine
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Zolt Arany
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA.,Division of Cardiology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Adina Kern-Goldberger
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Nathanael Koelper
- Center for Research on Reproduction and Women's Health, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Mary D Sammel
- Center for Integrative Design and Analysis (CIDA, Colorado School of Public Health , Denver, Colorado, USA
| | - Michal A Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
| | - Bonnie Ky
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA.,Division of Cardiology, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, and Women's Health Clinical Research Center, University of Pennsylvania Perelman School of Medicine , Philadelphia, PA, USA
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40
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Fitzsimmons E, Arany Z, Howell EA, Lewey J. Differential Outcomes for African-American Women with Cardiovascular Complications of Pregnancy. Curr Treat Options Cardio Med 2020. [DOI: 10.1007/s11936-020-00863-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.
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Affiliation(s)
- Jennifer Lewey
- Division of Cardiology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA 19104, USA.
| | - Lauren Andrade
- Philadelphia Adult Congenital Heart Center, University of Pennsylvania, Children's Hospital of Philadelphia, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2- East Pavilion, Philadelphia, PA 19104, USA
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA
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Cushman M, Shay CM, Howard VJ, Jiménez MC, Lewey J, McSweeney JC, Newby LK, Poudel R, Reynolds HR, Rexrode KM, Sims M, Mosca LJ. Ten-Year Differences in Women's Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association. Circulation 2020; 143:e239-e248. [PMID: 32954796 DOI: 10.1161/cir.0000000000000907] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND High awareness that cardiovascular disease is the leading cause of death (LCOD) among women is critical to prevention. This study evaluated longitudinal trends in this awareness among women. METHODS AND RESULTS Online surveys of US women (≥25 years of age) were conducted in January 2009 and January 2019. Data were weighted to the US population distribution of sociodemographic characteristics. Multivariable logistic regression was used to evaluate knowledge of the LCOD. In 2009, awareness of heart disease as the LCOD was 65%, decreasing to 44% in 2019. In 2019, awareness was greater with older age and increasing education and lower among non-White women and women with hypertension. The 10-year awareness decline was observed in all races/ethnicities and ages except women ≥65 years of age. The greatest declines were among Hispanic women (odds ratio of awareness comparing 2019 to 2009, 0.14 [95% CI, 0.07-0.28]), non-Hispanic Black women (odds ratio, 0.31 [95% CI, 0.19-0.49]), and 25- to 34-year-olds (odds ratio, 0.19 [95% CI, 0.10-0.34]). In 2019, women were more likely than in 2009 to incorrectly identify breast cancer as the LCOD (odds ratio, 2.59 [95% CI, 1.86-3.67]), an association that was greater in younger women. Awareness of heart attack symptoms also declined. CONCLUSIONS Awareness that heart disease is the LCOD among women declined from 2009 to 2019, particularly among Hispanic and non-Hispanic Black women and in younger women (in whom primordial/primary prevention may be most effective). An urgent redoubling of efforts by organizations interested in women's health is required to reverse these trends.
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Abstract
Background Preeclampsia and gestational hypertension are hypertensive disorders of pregnancy (HDP) that identify an increased risk of developing chronic hypertension and cardiovascular disease later in life. Postpartum follow‐up may facilitate early screening and treatment of cardiovascular risk factors. Our objective is to describe patterns of postpartum visits with primary care and women's health providers (eg, family medicine and obstetrics) among women with and without HDP in a nationally representative sample of commercially insured women. Methods and Results We conducted a retrospective cohort study using insurance claims from a US health insurance database to describe patterns in office visits in the 6 months after delivery. We identified 566 059 women with completed pregnancies between 2005 and 2014. At 6 months, 13% of women with normotensive pregnancies, 18% with HDP, and 23% with chronic hypertension had primary care visits (P<0.0001 for comparing HDP and chronic hypertension groups with control participants). Only 58% of women with HDP had 6‐month follow‐up with any continuity provider compared with 47% of women without hypertension (P<0.0001). In multivariable analysis, women with severe preeclampsia were 16% more likely to have postpartum continuity follow‐up (adjusted odds ratio, 1.16; 95% CI, 1.2–1.21). Factors associated with a lower likelihood of any follow‐up included age ≥30 years, Black race, Hispanic ethnicity, and having multiple gestations. Conclusions Rates of continuity care follow‐up after a pregnancy complicated by hypertension were low. This represents a substantial missed opportunity to provide cardiovascular risk screening and management to women at increased risk of future cardiovascular disease.
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Affiliation(s)
- Jennifer Lewey
- Division of Cardiology University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Lisa D Levine
- Department of Obstetrics & Gynecology Maternal and Child Health Research Center University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Division of General Internal Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jourdan E Triebwasser
- Department of Obstetrics & Gynecology Maternal and Child Health Research Center University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Division of General Internal Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
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Abstract
Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.
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Affiliation(s)
- Marysia S Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.S.T., P.J.M.B.)
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.L.)
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (N.R.S.)
| | - Carl H Rose
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN (C.H.R.)
| | - Patricia J M Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.S.T., P.J.M.B.)
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Lewey J, Nemiroff R, Soffer D. Improving Identification and Treatment of Primary and Secondary Hyperlipidemia for Young Women at a Large Health System. J Clin Lipidol 2020. [DOI: 10.1016/j.jacl.2020.05.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Reza N, Adusumalli S, Saybolt MD, Silvestry FE, Sanghavi M, Lewey J, Ambrose M. Implementing a Women's Cardiovascular Health Training Program in a Cardiovascular Disease Fellowship: The MUCHACHA Curriculum. JACC Case Rep 2020; 2:164-167. [PMID: 34316988 PMCID: PMC8301516 DOI: 10.1016/j.jaccas.2019.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sex- and gender-specific training for cardiovascular clinicians is essential to enhance knowledge and quality of women’s cardiovascular health care. In 2016, the University of Pennsylvania cardiovascular fellowship program established a dedicated women’s cardiovascular health curriculum, motivated by the fellow-in-training desire to gain formal and focused training in this emerging field.
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Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Address for correspondence: Dr. Nosheen Reza, Perelman Center for Advanced Medicine, South Tower 11th Floor, Room 11-134, 3400 Civic Center Boulevard, Philadelphia, Pennsylvania 19104.
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew D. Saybolt
- Hackensack Meridian Health Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Frank E. Silvestry
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monika Sanghavi
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marietta Ambrose
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lauffenburger JC, Lewey J, Jan S, Lee J, Ghazinouri R, Choudhry NK. Association of Potentially Modifiable Diabetes Care Factors With Glycemic Control in Patients With Insulin-Treated Type 2 Diabetes. JAMA Netw Open 2020; 3:e1919645. [PMID: 31968115 PMCID: PMC6991273 DOI: 10.1001/jamanetworkopen.2019.19645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Numerous factors are associated with the ability of patients with type 2 diabetes to achieve optimal glycemic control. However, many of these factors are not modifiable by quality improvement interventions. In contrast, the structure of how diabetes care is delivered, such as whether patients visit an endocrinologist or how prescriptions are filled, is potentially modifiable, yet its associations with glycemic control have not been rigorously evaluated. OBJECTIVE To investigate the association of diabetes care delivery with glycemic control in patients with type 2 diabetes using insulin. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used baseline claims and laboratory insurer data within a large pragmatic trial to identify individuals with type 2 diabetes using insulin with data for at least 1 hemoglobin A1c (HbA1c) test result from before trial randomization (July 1, 2014, to October 5, 2016) and for key nonmodifiable patient factors as well as diabetes care delivery and behavioral factors measured before the HbA1c test. Analyses were conducted from February 4, 2017, to November 13, 2018. MAIN OUTCOMES AND MEASURES Multivariable modified Poisson regression was used to evaluate the independent associations of nonmodifiable patient factors and potentially modifiable diabetes care delivery and patient behavioral factors with achieving adequate diabetes control (ie, HbA1c level <8%). The extent of measured variation explained in glycemic control by these factors was also explored using pseudo R2 and C statistics. RESULTS Of 1423 patients included, 565 (39.7%) were women, and the mean (SD) age was 56.4 (9.0) years. In total, 690 (48.5%) had HbA1c levels less than 8%. Age (relative risk [RR] per 1-unit increase, 1.01; 95% CI, 1.00-1.02), persistent use of basal insulin (RR, 1.20; 95% CI, 1.00-1.43), more frequent filling of glucose self-testing supplies (RR, 1.01; 95% CI, 1.01-1.02), visiting an endocrinologist (RR, 1.41; 95% CI, 1.19-1.67), and receipt of insulin prescriptions by mail order (RR, 1.23; 95% CI, 1.03-1.48) were all independently associated with adequate control. Measured potentially modifiable diabetes care factors explained more variation in adequate glycemic control than measured nonmodifiable patient factors (C statistic, 0.661 vs 0.598; pseudo R2 = 0.11 vs 0.04). CONCLUSIONS AND RELEVANCE These findings suggest that for patients with type 2 diabetes using insulin, the way in which care is delivered may be more strongly associated with achieving adequate control of HbA1c levels than patient factors that cannot be altered are. Given the potential for intervention, these care delivery factors could be the focus of efforts to improve diabetes outcomes.
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Affiliation(s)
- Julie C. Lauffenburger
- Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Saira Jan
- Horizon Blue Cross Blue Shield, Newark, New Jersey
- Department of Pharmacy Practice and Administration, Rutgers State University of New Jersey, New Brunswick
| | - Jessica Lee
- Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Roya Ghazinouri
- Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Perdigao JL, Lewey J, Hirshberg A, Koepler NC, Srinivas SK, Elovitz MA, Levine LD. LB 4: Furosemide for Accelerated Recovery of Blood Pressure Postpartum: a randomized placebo controlled trial (FoR BP). Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.1278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Peripartum cardiomyopathy (PPCM) can lead to long-term systolic dysfunction, especially among black women. Hypertensive disorders of pregnancy (HDP) are the strongest risk factor for PPCM, but controversy remains on whether HDP predict a favorable outcome. Women with HDP are also often diagnosed with PPCM earlier than those without HDP. Our objective is to determine recovery of systolic function in patients with PPCM stratified by HDP, timing of diagnosis, and race. We conducted a retrospective cohort study of 220 patients (55% black) diagnosed with PPCM. Patients with PPCM and HDP were diagnosed earlier postpartum than patients without HDP (P=0.013), an effect that was most pronounced in nonblack patients. Rates of left ventricular ejection fraction (LVEF) recovery were similar among PPCM patients with and without HDP (68.4% versus 62.6%, P=0.425). In contrast, patients with PPCM diagnosed after 1-month postpartum had lower rates of LVEF recovery than patients diagnosed <1-month postpartum (53.7% versus 69.9%, P=0.035). LVEF at time of diagnosis is a strong predictor of LVEF recovery, and patients with PPCM diagnosed after 1-month postpartum had lower baseline LVEF compared to patients presenting earlier (P=0.041). The presence of HDP does not correlate with LVEF recovery in our racially diverse PPCM cohort. In contrast, early diagnosis portends a favorable outcome. Early diagnosis is associated with higher LVEF at presentation, likely explaining the improved outcomes in these women. These findings underscore the need for early monitoring and diagnosis, especially in at-risk and underserved populations.
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Affiliation(s)
- Jennifer Lewey
- From the Division of Cardiology (J.L., Z.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology (L.D.L., M.A.E., O.C.I.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michal A Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology (L.D.L., M.A.E., O.C.I.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Olga C Irizarry
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology (L.D.L., M.A.E., O.C.I.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Zoltan Arany
- From the Division of Cardiology (J.L., Z.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
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Irizarry OC, Levine LD, Lewey J, Boyer T, Riis V, Elovitz MA, Arany Z. Comparison of Clinical Characteristics and Outcomes of Peripartum Cardiomyopathy Between African American and Non-African American Women. JAMA Cardiol 2019; 2:1256-1260. [PMID: 29049825 DOI: 10.1001/jamacardio.2017.3574] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry, but well-powered studies to explore differences in severity of disease and clinical outcomes are lacking. Objective To compare the clinical characteristics, presentation, and outcomes of PPCM between African American and non-African American women. Design, Setting, and Participants This retrospective cohort study using data from January 1, 1986, through December 31, 2016, performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of African American individuals, included 220 women with PPCM. Main Outcomes and Measures Demographic and clinical characteristics and echocardiographic findings at presentation, as well as clinical outcomes including cardiac recovery, time to recovery, cardiac transplant, persistent dysfunction, and death, were compared between African American and non-African American women with PPCM. Results A total of 220 women were studied (mean [SD] age at diagnosis, 29.5 [6.6] years). African American women were diagnosed with PPCM at a younger age (27.6 vs 31.7 years, P < .001), were diagnosed with PPCM later in the postpartum period, and were more likely to present with a left ventricular ejection fraction less than 30% compared with non-African American women (48 [56.5%] vs 30 [39.5%], P = .03). African American women were also more likely to worsen after initial diagnosis (30 [35.3%] vs 14 [18.4%], P = .02), were twice as likely to fail to recover (52 [43.0%] vs 24 [24.2%], P = .004), and, when they did recover, recovery took at least twice as long (median, 265 vs 125.5 days; P = .02) despite apparent adequate treatment. Conclusions and Relevance In a large cohort of women with well-phenotyped PPCM, this study demonstrates a different profile of disease in African American vs non-African American women. Further work is needed to understand to what extent these differences stem from genetic or socioeconomic differences and how treatment of African American patients might be tailored to improve health outcomes.
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Affiliation(s)
- Olga Corazón Irizarry
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Theresa Boyer
- Zanvyl Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Valerie Riis
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michal A Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zolt Arany
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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