Cardio-obstetrics deserves better training and wider adoption: survey

Responses from 501 cardiologists, CV team members and fellows paint a picture of the emerging specialty.

Cardio-obstetrics, a transversal specialty that covers the dual needs of cardiovascular diseases and pregnancy, has become a better known entity in recent years. Still, a 2020 survey of U.S. clinicians shows there’s plenty of room for growth in training, expertise, and team-based care in this area.

Only three in 10 cardiologists who responded to the survey said they had formal training in cardio-obstetrics, as did 12% of fellows-in-training (FIT). Many cited gaps in knowledge about how best to meet the needs of pregnant and postpartum women.

The clinical need here is great—a substantial segment of women have poor metabolic health before becoming pregnant, and pregnancy-related preeclampsia and other cardiovascular complications are known to pose a risk to both mother and baby – in the short term and the long term. Four years ago, in 2018, cardio-obstetrics was emerging as a potential fix.

Lead author Natalie A. Bello, MD, MPH (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA), whose research focuses on hypertensive disorders of pregnancy, said the survey was derived from discussion with his colleagues. Conversations revealed that there is little information about what constitutes a cardio-obstetrics team and who has access to this specialized expertise. “There seems to be a lot of variability among what’s available to people in different parts of the country and in different clinical settings,” she told TCTMD.

“As we realize that cardiology is increasingly a team sport, with the advent of heart [team in structural disease] and all these other team-based models, cardio-obstetrics is pretty similar, but we just didn’t have the data on what’s happening in the real world,” Bello noted. “So that was really the motivation behind it.”

The results of the survey were recently published in the Journal of the American Heart Association.

Gaps to be filled

Bello and his colleagues developed their survey in conjunction with the American College of Cardiology (ACC), sending it to approximately 5,000 ACC members in June/July 2020. Ultimately, the response rate was by 10% – 311 cardiologists and 139 FITs responded, as well as 51 cardiologists. members of the CVT team, a group that included nurse practitioners, pharmacists, physician assistants and registered nurses.

Three-quarters of survey respondents said they did not have access to a specialized cardio-obstetrics team. Those who had such a team at work were more likely to practice in a medical school (54%), while 37% were in a cardiovascular or multispecialty group, 6% worked in a non-governmental hospital, 3 % in a government hospital, and 1% in solo practice. Team members varied, but generally included cardiologists, maternal-fetal medicine specialists, and obstetricians. Less common team members were nurse practitioners, physician assistants, anesthesiologists, care coordinators, social workers, and internal/family medicine physicians.

Among the cardiologists, 71% declared that they had not received cardio-obstetrics instruction during the training. For the current FIT, 83% have not received formal training in this area. For members of the CVT, the rate reaches 94%.

Thirty percent of cardiologists said they saw a pregnant or breastfeeding woman at least once a month, and 86% said they did so at least once a year. Most often, cardiologists and FIT see these patients every 3 to 6 months. Still, “much of the cardiology workforce feels uncomfortable providing care to these patients,” the authors note. Half of CVT members said they had never been involved in caring for pregnant or postpartum women.

Clinicians cited large knowledge gaps regarding their level of knowledge of care for pregnant patients compared to non-pregnant patients. Specifically, these gaps related to medication safety (42%), acute coronary syndromes (39%), aortopathy (40%) and valvular heart disease (30%).

Many of these same disease states were the reason patients needed care. The most common reasons for consultation were hypertension, history/management of arrhythmia, valvular heart disease, heart failure and preeclampsia. Less common were congenital heart disease, pulmonary hypertension, ACS/CAD and connective tissue disorders.

In better news, just over half of cardiologists describe themselves as very or extremely confident in their ability to prescribe CV medication to pregnant or breastfeeding patients. CVT and FIT members were less confident in this area. The topics of complex congenital heart disease and contraception for women with CVD were more difficult for both cardiologists and other respondents.

A “silver lining”

Bello pointed out that a “silver lining to all of this” is interest in the specialty: 92% of those surveyed “thought positively about the inclusion of cardio-obstetrics in the ACC educational product directory”, the journal notes, adding that 46% of FITs believed in the importance of including this information in the requirements of the Core Cardiovascular Training Statement.

Bello et al conclude: “Increased training in cardio-obstetrics at all career stages is necessary to reduce these deficits. These survey results are a first step toward developing a standard expectation for training clinicians in cardio-obstetrics.

The ACC currently has a dedicated cardio-obstetrics task force, for which Bello is co-chair, that hosts ongoing journal clubs and webinars to address specific knowledge gaps. More formal continuing medical education is also in the works, she said, designed for clinicians with basic to intermediate knowledge of the subject.

It’s hard to track exactly the number of cardio-obstetrics programs in the United States, Bello said. Some may lack an online presence, for example, or be part of a private practice rather than an academic medical center. In addition to word of mouth, #CardioObstetrics hashtags on Twitter can help forge bonds between colleagues, she suggested. “There is no directory there” yet.

For cardiologists interested in applying these concepts, the first step should be to “ask your new patients, and even your old patients if you’ve never done it before, about their pregnancy history,” Bello advised. This information can be added “into your cardiovascular risk assessment, because we know that all kinds of adverse pregnancy outcomes like preeclampsia are associated with an increased risk of cardiovascular disease. We don’t know if it’s because of shared risk factors or if it’s something about these processes themselves that indicates higher risk. But it’s [helpful] if you’re on the fence, they’re considered risk factors in the guidelines and might prompt you to start someone on a statin.

For those unsure how to start the conversation, Bello said, questions can include, “Have you had high blood pressure? Did you have diabetes, even when you were pregnant? Did you deliver early? Do you know why that was? Did you give birth to a baby that was small or premature? All of these are risk factors for cardiovascular disease, and we are beginning to learn more that they may also be risk factors for the baby’s future health.

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