Cardio-Obstetrics Merits Better Training, Wider Uptake: Survey

Cardio-obstetrics, a cross-disciplinary specialty that covers the dual needs of cardiovascular disease and pregnancy, has in recent years become a better-known entity. Yet a 2020 survey of US clinicians shows that there’s much room for growth when it comes to training, expertise, and team-based care in this area.

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

The clinical need here is great—a substantial segment of women have poor metabolic health prior to becoming pregnant, and it’s known that pregnancy-related preeclampsia and other cardiovascular complications carry risk to both mom and baby—in the short term and the long term. Four years ago, in 2018, cardio-obstetrics emerged as a potential solution.

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 emerged out of discussions with her colleagues. The conversations revealed there is scant information about what constitutes a cardio-obstetrics team and who has access to this specialized expertise. “There seems to be a lot of variability amongst what’s available to people in different areas of the country and in different clinical settings,” she told TCTMD.

“As we realize cardiology is more and more of a team sport, with the advent of the 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 out there about what’s going on in the real world,” Bello noted. “So that was really the motivation behind this.”

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

Gaps to Fill

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

Fully three-quarters of the survey respondents reported they lacked access to a dedicated cardio-obstetrics team. Those who did have such a team at their workplace were most likely to practice at a medical school (54%), while 37% were part of a cardiovascular or multispecialty group, 6% worked at a nongovernment hospital, 3% at a government hospital, and 1% in solo practice. Team members varied, but typically included cardiologists, maternal-fetal medicine specialists, and ob-gyns. Less-frequent team members were nurse practitioners, physician assistants, anesthesiologists, care coordinators, social workers, and internal/family medicine physicians.

Among cardiologists, 71% said they did not receive cardio-obstetrics didactics during training. For current FIT, 83% did not receive formal training in this area. For CVT members, the rate reached 94%.

Thirty-percent of cardiologists said they saw a pregnant or lactating woman at least once monthly and 86% said they did so at least yearly. Most often, cardiologists and FIT saw such patients every 3 to 6 months. Still, “a large proportion of the cardiology workforce feels uncomfortable providing care to these patients,” the authors note. Half of CVT members said they’d never been involved in caring for pregnant or postpartum women.

Clinicians cited wide knowledge gaps regarding how well versed they were in caring for pregnant versus nonpregnant patients. Most notably, these gaps related to medication safety (42%), acute coronary syndromes (39%), aortopathies (40%), and valvular heart disease (30%).

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

In better news, slightly more than half of cardiologists described themselves as being very or extremely confident in their ability to prescribe a CV medication to pregnant or lactating patients. CVT members and FIT were less confident in this area. More challenging, both for cardiologists and for the other respondents, were the topics of complex congenital heart disease and contraception for women with CVD.

A ‘Silver Lining’

Bello pointed out that a “silver lining to all of this” is the interest in the specialty: 92% of the survey takers “thought positively about the inclusion of cardio-obstetrics in the ACC repertoire of educational products,” the paper notes, adding that 46% of FIT believed in the importance of including such information in the Core Cardiovascular Training Statement requirements.

Bello et al conclude: “Augmentation of cardio-obstetrics education across career stages is needed to reduce these deficits. These survey results are an initial step toward developing a standard expectation for clinicians’ training in cardio-obstetrics.”

The ACC currently has a work group devoted to cardio-obstetrics, for which Bello serves as co-chair, that organizes ongoing journal clubs and webinars to address specific knowledge gaps. Also in the works, she said, is more-formal continuing medical education designed for clinicians with basic-to-intermediate knowledge about the topic.

It’s hard to track exactly how many cardio-obstetrics programs there are around the United States, said Bello. Some may lack an online presence, for instance, or be part of private practice rather than an academic medical center. Other than word of mouth, the #CardioObstetrics hashtag on Twitter can help forge connections among colleagues, she suggested. “There’s no directory out there” as of yet.

For cardiologists interested in applying these concepts, the first step should be “asking your new patients, and even your old patients if you’ve never done this before, about their pregnancy history,” Bello advised. This information can be added “into your cardiovascular risk assessment, because we know all sorts 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 those processes themselves that are indicative of higher risk. But it’s [helpful] if you’re on the fence—they’re considered risk enhancers in the guidelines and could tip you towards starting a statin in somebody.”

For those unsure how to start the conversation, Bello said, questions can include: “Did you have high blood pressure? Did you have diabetes, if only when you were pregnant? Did you deliver early? Do you know why that was? Did you deliver a baby who was small or premature? All of those are risk factors for cardiovascular disease, and we’re starting to learn more that they might be risk factors for the baby’s future health also.”