Chapters Transcript Video Pregnancy: A Window into Future Cardiovascular Disease Prevention Sure people see. All right, everybody. It's 730. So I'm gonna go ahead and get started. Uh Thank you guys for coming to our HP I grand rounds. Just a few housekeeping items before we get started. Uh I'm Jordan Brown. I am the admin assistant for the HV I. And uh uh these are just gonna be the um disclosures for the presentation coming up and then just a quick reminder that there will be a QR code at the end of the presentation to claim your CME credit. And with that, I'm gonna introduce Doctor Pria to come introduce, where's our first slide? Good morning. Uh This slide was uh premeditated and intent to uh get our attention this morning uh as to why we're here uh under the big umbrella of women's health and cardios. Uh And uh I think we will all leave here uh energized, uh educated uh and uh animated uh to uh recognize uh the epidemic that exists in this country as it pertains to uh women's cardiovascular disease. Good morning and welcome uh to the US F Marani College of Medicine, Tampa General Hospital, Heart and Vascular Institute. Grand rounds. I'm Doctor Xavier Pria and this morning's grand rounds will be delivered by Doctor Daniela Kat, who is Assistant Professor of Medicine in the Department of Internal Medicine in our cardiovascular disease Sciences section. And in the Department of OBGYN, Doctor Kat as a strategic recruitment joined our system in October 2021 and with lightning speed and impactful effect has inaugurated nurtured and established the woman's Heart program and cardios sets program as director of both in partnership with us FM soI College of Medicine and Tampa General Hospital. Doctor Kaat uh encompasses a theme that I've employed during our fellowship recruitment season. And that's the power of three. The power of three is exemplified by Doctor Kusa and these three domains, pedigree professionalism and potential allow me to explain by pedigree. Uh Doctor C is a bilingual Lady of Venezuelan heritage who is a gator, by the way, a graduate of the University of Florida where she earned where she earned a Bachelor of Science and Food sciences and human nutrition. And then she proceeded to attain her MD degree from uh New York University School of Medicine. Uh a premier medical education, I think it's in the Ed Education Institution. I believe it's in the top 10 in the country where she was elected to uh Alpha Omega Alpha A O A, our National Medical Honor Society. And that society signifies which doctor K has displayed in her time here. To me, a lasting commitment to professionalism, leadership, scholarship, research, and community service. She then proceeded and completed her training in medicine at Harvard Medical School. Brigham and Women's Hospital and then proceeded to do cardiovascular disease training. And then uniquely in her third year of fellowship, uh she uh double headed her position as a chief medical resident in internal medicine at Brigham and Women's Hospital. It was during that Harvard medical system epic that Doctor Ky had developed her academic and scholarly legs and in particular, in a mentee mentor relationship with somebody who's familiar to our system. That's Doctor Melissa Wood amongst many others. Of course, number two professionalism by my personal observation, faculty, acclaim and unanimous endorsement by our cardiology fellows. Doctor CIA displayed the clinical acumen and wisdom which belies her career stage requiring most of most of us many years and decades of experience to achieve. If today we were to invoke the traditional Hopkins model of grand rounds. Having identified a patient on the inpatient services at four K or anywhere in our system. Um I could uh similarly uh approach doctor uh cr yesterday or have approached her and have her discuss that patient at hand. And by Ryman verse, she would be able to describe pathophysiology, evaluation of management, natural history and generate next level of questions necessary inquiry, inquiry, and investigation of the clinical problem posed. And that's the old Hopkins model day before tap, the faculty member, they had to come in and discuss the case at hand. The third P is potential. Uh Doctor CIA has a limitless ceiling with unfairly support from our academic medical system. Us FM Marani College of Medicine, Tampa General Hospital Heart and Vascular Institute. I envision a future of national if not international prominence by serving our patient population, those from our community and those necessitating the tertiary and Quain care that we can provide so that we can become best in nation. I know that what has come before beginning with Doctor Kr's seminar that she delivered uh during her faculty recruitment in 2021 through her maternal fetal medicine lectures here. And our fellows didactic that her presentation shall be visually pleasing content rich and illustrate to us the necessity of women's health and cardio obstetrics, its progress, its shortcomings and its future needs to improve the quality and length of life of women. Doctor Kuia Chow, present today on Nature Stress Tests and it is entitled Pregnancy, a Window into cardiovascular disease. Doctor Kusiak, everyone hear me. OK. Oh, I feel like I have big shoes to fill. Good morning everybody. It's truly, I'm so grateful to be here and I'm really grateful for the opportunity to have the chance to speak to you guys about about really two of my favorite things, pregnancy and cardiovascular disease prevention. So thank you for everybody for joining early. And I'm so grateful to everyone who's here and everyone who's also joined us from abroad, even though I can't see you. I know you're there. Um So let's go ahead and get started and thank you to doctor Pria honestly for that. Um I don't know if well deserved but fantastic introduction. Um I really have no words. So let's jump right in. So today I really have, I'm gonna move this up so you can hear me better. Today, we have really four main objectives as you go through our journey together this morning through what pregnancy actually means and what it means for women longitudinally. And these are women, you know, 50% of the population that we really take care of both as cardiovascular clinicians, but also hopefully, some of the generalists and O BS who are joining us today. So I'm hoping that we can kind of set the tone and the context for the talk to talk a little bit about the growing burden of cardiovascular disease as really the leading cause of maternal death in the United States. We want to recognize sort of at what stage women are at when they're reaching reproduced of age, meaning what's prepregnancy health look like? And how do we think that's actually affecting women when they're pregnant and potentially increasing the risk of complications? We will talk a lot about what's called A P OS or adverse pregnancy outcomes and these are now complications that we know um that are rising in prevalence and that are directly probably linked to increasing the risk of future cardiometabolic um risk among women. And then last, but not least, I think this is really where um hopefully most of our efforts should really be focused. And that's in how do we risk stratify these women? How do we figure out who's at highest risk? And then most importantly, for women who do unfortunately have a complication. What do we do then as their caretakers to help them in their transition from motherhood longitudinally to the rest of their care. But I went backwards. Here we go. So unfortunately, us maternal mortality is on the rise in the United States. On the left, you see a graph here from the CDC. The USA is depicted in black and what you can tell is from the early 19 nineties. This is what's depicted here is called the maternal mortality ratio. What is that? That means the number of deaths that occur for every 100 live births. But you can tell from the early 19 nineties that maternal mortality ratio in the United States has really increased from about 10 or 12 and really is peaking in the high 20. So that's almost doubling. And that's really in stark um difference to developing and developed regions worldwide where we see that that mortality ratio has really sort of plateaued and may be on the uptrend. And unfortunately, what we also know is that these disparities don't affect the women of the diverse communities that we serve equally. So, unfortunately, when we look at pregnancy related deaths and this is really just in the USA, we see that American Indian women and black women are 3 to 4 times the risk of dying from a pregnancy related death compared to a white woman. And this is both through pregnancy and in the first year of postpartum. So, cardiovascular related causes account for really up to one third to almost 50% of the causes of why women die. So, if you look at this donut up here, we know that cardiovascular disease is the number one cause of death from um sort of delivery to about six weeks. And hypertensive disorders of pregnancy are should be bucketed into that. Cardiomyopathy is really the leading cause from six weeks to about a year. But if you look at the rest of this donut, which I've highlighted in bold hypertensive disorders of pregnancy, thromboembolic disease and even stroke or ti a probably account for about 50%. And this has really been a trend in the opposite direction where many of the o bees here could tell us that he things like hemorrhage and infection used to be more common causes of postpartum complications. Whereas now sort of in the last decade, we've really seen an increase in the cardiovascular related causes. And I think there's sort of two humbling take homes from this slide. One, most states have a um state level uh maternal review committee that sits down quarterly and reviews all the deaths of all women who died from pregnancy related causes. And really, they have two roles. One is to determine the cause and two is to determine whether there's anything that could have altered the outcome, meaning prevent ability. And um the latest report in 2019 showed that 80% of the deaths that occurred in the United States that were reported as pregnancy related deaths could have been truly preventable. And a lot of the factors they cited were things like having knowledge and awareness, um awareness of things like red flags and symptoms, both from the provider and the patient perspective and then appropriate care and management when these patients present after they delivered to an urgent um to urgent care. The other thing I would highlight is that I know we worry a lot about our uh patients who have cardiovascular disease while they're pregnant and labor and delivery. And that's probably the scariest thing for both the women and a lot of the providers who don't feel comfortable with their care. But the reality is that what we label the fourth trimester sort of the year. Postpartum is where patients are the highest risk. So in 2019, the CDC reported that about 50% of deaths of all women in the United States happened after delivery. So Florida is no different and really mirrors the trends that we're seeing from a nationwide perspective. Um The latest data released by our um Morbidity and Mortality Review Committee is from 2020. Um So here on the left, we had 44 total deaths in Florida. That may not sound like a lot, but that's 44 deaths and 80% of those that could have been potentially prevented. So, in 2020 as you can see here, sort of this, um sorry, it's an orange bar in 2020 hypertensive disorders of pregnancy were the number one cause of pregnancy related death in the state of Florida. And when the committee took a look at what was our chance actually alter the outcome? If you look at all those eight deaths, 100% were deemed by the committee to be absolutely preventable. When they looked at all comers, meaning thrombotic embolism, cardiovascular disorders, the total amount preventable here in the State of Florida in 2020 was 68%. And I think this really highlights and kind of tells the story of the maternal crisis but also of our chance and our opportunity to try and shift this and make a change for our mothers. So the other thing I would highlight is that the disparities that we see nationwide are seen here in the State of Florida as well. So here's just pregnancy related mortality again, that same ratio that we introduced um at the beginning based on race and ethnicity. And what you see down here below is that the ratios are similar to what we spoke about ratios of about 20 per 100,000 live births. And this is all comers, non-hispanic, white and Hispanics. This sort of light blue and gray line are non-hispanic black women who have really seen since 2016 an uptick, um, really mirroring the national trends and I really can't give a talk without talking about maternal health equity, which as many of, you know, is sort of my, um, um, I don't know the bane of my existence. My favorite thing to talk about what I hope to conquer um during my career, but we know that there's really an equity divide, particularly when it comes to maternal care. So I want us to sort of as we weave through this talk and we talk about what pregnancy means, how we take care of these patients in the long term. We can't do that unless we look at it health equity lens. So that means we take care of very vulnerable populations. TGH, included um in Hillsboro County and Tampa Bay, which is one of the reasons why I'm really here and it's not just race and ethnicity, it's patients who unfortunately are incarcerated. They have a history of um housing or financial instability, substance abuse, mental health. We know all these patients are really minor um and vulnerable in different ways. There's really a growing recognition of social determinants of health and how that actually impacts the ability of patients to get the care that they need including our pregnant moms that includes things like speaking a different language, not having access to um health insurance or even access to a provider. Um And then structural ra racism and bias, I think of sort of an overlay on top of all these risk factors and they're really things like um interpersonal bias, both conscious and unconscious bias in a lot of um places in the United States, we have what we call maternity care deserts. Um And that means that really in a county, there's just no provider or no obstetrical facility for these patients to actually even get a prenatal, let alone postpartum care. So my hope is that we could at least view some of the trends we're talking about and sort of how we can improve the situation with the health equity lens in mind today. So we'll move on to our second objective for today. And this is really about how did we wind up here? There's a lot of discussion as to why the maternal mortality is just so bad in the United States compared to other places. And there's different factors that are commonly cited, things like women are getting pregnant and at um later age. So we have a higher percentage of what we call a ma advanced maternal age. Um There's some good things such as um women with congenital heart disease that previously were not surviving to reproductive age, who are now getting old enough to think about potentially um expanding their families. But I think kind of the crux of it from the prevention standpoint um really comes at what is the health of women when they're starting on that journey? Meaning what does their prepregnancy health look like? So I want to explore that a little bit as a potential cause and also as a way where we could really, I think um put our efforts into to really make a change. So as doctor Pria alluded to, we think, you know, as cardiologists, we stress people all the time. And but the reality is that about 80% of women at some point in their reproductive life will become pregnant. Um and this is probably natures and life's toughest and hardest stress test for a woman. So on the left hand side, these are sort of uh percent changes. So I've highlighted some of the significant physiological changes that take place. And again, this is a normal pregnancy. So we know that we have a very robust increase in cardiac output, that's mostly by an increase in stroke volume, but also heart rate, which is here in the gray. And uh we have a compensatory decrease in systemic vascular resistance. And all these sort of cardiovascular adaptations are really to improve flow to the uteroplacental unit, right, to allow the baby um to grow and develop. However, we know that there are some and who will not tolerate this and who will quote unquote fail their stress test in a different type of way than what um cardiologists typically think about. So I invite you to look at sort of this graph on the right and kind of walk through it with me. So here we're comparing sort of in blue, a healthy population and in red a population who probably has some higher degree of vascular dysfunction um going into pregnancy. And what we can see is that the healthy population may have some perturbations that are associated with normal pregnancy. And then they go on sort of in the middle later age, which is really where we see cardiovascular disease take off in general. Uh for women around sort of postmenopause, we then have this population of patients who have baseline, has a higher degree of vascular dysfunction who then get pregnant and they cross this threshold. This threshold is our clinical ability to pick something up, right. This is vast or metabolic disease and pregnancy. This is commonly things like preeclampsia, preterm birth or what we commonly call now A P OS or adverse pregnancy outcomes. There's a little debated whether people actually go back to normalcy after each pregnancy or not because now, um we're seeing that a lot of these implications are actually associated with longer term endothelial dysfunction. So it's not that maybe women don't actually return to baseline, but we do know that they sort of have this steep acceleration earlier in life. These are women who have baseline degree of vascular dysfunction who have had pregnancy complications. We're really seeing an increased association between pregnancy complications and future cardiometabolic disease. Um So this my umbrella wasn't big enough here, but this umbrella is meant to cover um all, um, you know, this is for us to really define what is an adverse pregnancy outcome or an A po so the most common ones that I think we're all familiar with. And really, so we said 30% of women will fail it. About 10 to 20% of those women will develop what we call a quote unquote hypertensive disorder, pregnancy or HDP. And that really kind of encompasses women with pre-existing chronic hypertension, the gestational hypertension, which is when you develop it de novo after 20 weeks and then the more severe kinds like preeclampsia, eclampsia and hal, which are um associated with um organ dysfunction. But we can't forget about the other sort of emerging A P OS other than just you had high blood pressure in pregnancy and it went away. So these are things like new onset, which we call gestational diabetes, having a preterm birth uh before 37 weeks or what we call intrauterine growth restriction or small for gestational age baby, meaning small babies um when they're born or in uterus or following them. And you know what's under this umbrella may look a little weird like how are all these things really interrelated? Like how is their preterm birth like having a hypertensive disorder or pregnancy. And the reality is that we think these are all kind of interrelated phenotypic disorders that really share a very similar underlying um pathogenesis. So, without getting too much into the itty bitty cause I promised it'd be a very clinical and hopefully applicable. Um talk I did for a second. It may be the first time you looked at the uterine artery and the spiral arteries. I want for a second to just show you guys what we actually think is happening and how this is linked to uh future cardiovascular disease. So let's step all the way to the right. Actually, let's go to the left. This is a nonpregnant patient. So this is their uterine um artery coming, these are their spiral arteries coming down. This is what a normal person looks like when they are not pregnant in normal pregnancy. What happens is that you get invasion of the trophoblast and like the body with all its physiological adaptations. The adaptation here is to kind of um get a little bit bigger, meaning dilate to reduce resistance and increase the amount of flow that goes to the uteral placental unit. And I feel like that kind of makes sense. Um When we look at patients who have these placental syndromes, which is sort of what they're also called, this is sort of the shared pathogenesis for a lot of these A P OS, we see when the um trophoblast actually invades, it invades a little more shallow and you have kind of this adverse remodeling of the, of the um spiral arteries. Now, what does this actually mean? Right. We think that this probably causes some degree of placental dysfunction and probably placental infarction. Um and all of that leads to sort of a release of toxins. So, toxins are things like inflammatory mediators, adhesion molecules. There's a molecule called SL one that's been understudy. And these are all things that can be picked up in the maternal circulation. So how does this all sort of come together? It's not that the actual insult, right? The abnormal placentation, um the infarction um and the ischemia releases these inflammatory mediators. And that is sort of what mediates the hypertension that we clinically see the proteinuria, the hypercoagulability and the endothelial dysfunction. It used to be thought that once like the gravid gets out of the body, like everything is done, right? Or maybe the gestational diabetes went away. Um So did the um preeclampsia. But now we're starting to realize that maybe some of these changes are actually persisting even after women are no longer pregnant. So I want to go back a little bit to talk about why we're sort of in this crisis, how we think and why maybe adverse pregnancy outcomes are now increasing in prevalence. And I think for that, we have to look at the state of the health of a reproductive women. So this is um a graph that shows for all live births in the United States from 2011 to 2019. If we look at the prevalence of what good meaning optimal cardiovascular health is, the authors took a look at four things. It was BM I for obesity, hypertension, diabetes and smoking. Um And if you didn't have any of those four risk factors, you were considered to have quote unquote optimal cardiovascular health. And what this graph shows essentially down Philippine curves for everybody from 2011 to 2019. You'll also notice here that this goes to 65 meaning the large majority of our women and overall, this blue line, less than 50% of women have quote unquote what we call optimal cardiovascular health. Meaning most women are heading into pregnancy with at least one of those quote unquote factors that we talked about. And that's really just the tip of the iceberg. And again, we see this persistent and pervasive racial and ethnic disparities are non-hispanic black women who are getting pregnant, maybe about 25 to 30% of them have optimal cardiovascular health. And we know that this is uniquely tied to an increased risk of having an adverse pregnancy outcome. So, on the left, we've definitely seen just rises and trends of just prepregnancy. This is prepregnancy hypertension in the United States from 2007 to 2018. The different color here is to show you rural and urban disparities and the reality is is that we haven't been able to close this gap and that these gaps still exist on the curve. On the right. You see, these are the rates of sort of chronic hypertension, which we see on the left are increasing but not enough to account for this market and accelerated increase. We're seeing in the hypertensive disorders of pregnancy, meaning that it's probably being driven by something other than just chronic hypertension. Um This is one of my favorite slides because I think it just tells you a little bit about the biggest risk factor that we know that all of our patients have when they're becoming pregnant and that's obesity. So this was a large meta analysis of over um 30 cohorts, 200,000 women. The numbers are small but all the numbers across here BM I from 17.5 to 40 which we consider essentially morbidly obese. And what you can see is that really across the spectrum of BM I, you see a sharp increased risk of gestational hypertension, preeclampsia and gestational diabetes. I mean, you could superimpose these on themselves. They look very similar in terms of preterm. Birth is really at risk of both low BMIs, but also um higher BMIs as well. And what the authors looked like um is that not only prepregnancy BM I, but the amount of weight that you gain during pregnancy also place women at higher risk. And they found that non-hispanic black women who entered, um, pregnancy obese who had more than sort of the recommended gestational weight gain. Those women were at two times increased risk than women who again were non obese. Um, and, um, gained sort of what they were supposed to during pregnancy. So, um, the other thing the authors did is they just said, well, how much does obesity account for these A P OS? We're seeing and it was about 25%. So I think that even just having that one risk factor is really not inconsequential in terms of the complications that it puts our um moms at risk for. So I'd like to kind of move on. I know we've talked and kind of danced a little bit about what adverse pregnancy outcomes mean. But for a lot of the cardiologists in this room, you're probably like, I don't take care of women while they're pregnant and I really don't see them a month after. But you guys all really see these women when they show up in the Cath lab with their first demo, when they show up with new onset heart failure and they're 50 or 60. And I want to make sure that all of us kind of have this hat on where we really have a growing appreciation of what these events mean for a woman's um future cardiovascular health. So this is a little diagram that kind of puts together a lot of what we've been talking about, we know that women have a lot of CV D risk factors before they're entering pregnancy and that puts them at increased risk for adverse pregnancy outcomes. But I feel like that's really not the end of the story. All of us have seen women who get an adverse pregnancy outcome, who really, we can't really come up with a cause as to why they would have um because they really don't have any of these traditional risk factors. So, um people have looked into this and recently, there's some nice data that's coming out on genome wide association studies, looking at genetic polymorphisms and looking whether there's actually some sort of um genetic predisposition that is latent and then sort of comes to light as really the clinical phenotype that we see, which is the adverse pregnancy outcome. So all that means is these are women who for us are kind of obvious you're definitely at increased risk, but we're still kind of building the puzzle together as to what are the true risk factors. Um And then how do we risk stratify those women when we counsel them about what their risk is of maybe developing an A po um in pregnancy. And then here's sort of the link that I want to make. Um the second half of the talk, which is what happens after pregnancy, what happens in that fourth trimester, but really longitudely for the remainder of this woman's life. Um And down here below. We've sort of discussed what we think is underlying and I know it sounds a little bit hand wavy in terms of vascular dysfunction, inflammatory cytokines. But this is really um where the hypothesis um are headed in terms of how these pregnancy outcomes are linked to overt cardiometabolic uh disease in the future. So, this is a great work done by one of my colleagues um at N DH doctor uh Michael Honing beg that he released in 2019. And he essentially just looked at the UK Bio Bank and he looked at women between the ages of 4070. And he said, why don't we say if you had a hypertensive disorder, pregnancy versus not, what was your risk of developing heart disease in the coming years? And I think he was quite surprised when he first presented his results because he saw things that are things like atherosclerotic disease, which we tend to think are more kind of vascular um disorders. But he also noted there was increased risk of things that were nonvascular. So things like aortic stenosis with a hazard ratio of three and things like micro regurgitation. And I think that these are merely associations. Unfortunately, much of the data that I'll present to you today is all retrospective. So it's really hard to find like what is the true causal mechanism. But there's really interesting work going into things like slit one, which we talked to, talked about a bit about being one of the toxins that's released by the placenta. It's actually been linked to probably progression of calcified aortic stenosis. So I think this is really just the beginning and as I mentioned before, kind of like the tip of the iceberg and it's associations like this that make people want to delve a little bit further as to why, right? How does a hypertensive disorder or pregnancy put you at um increased risk for things like calcified aortic stenosis and micro regurgitation in the long term here, I'm highlighting it's not just, oh, let me go back for a second. So I think coronary artery disease, I would mention or what we call atherosclerotic disease is probably um the link that's been the strongest in terms of an adverse pregnancy outcome and future cardiovascular disease. But now there's sort of mounting evidence looking at also things like heart failure, um which is really one of the most common diagnosis we see um as cardiologists. So, in this study and looking at a again big population based cohort, um this is from the Norwegian registry. They looked at women um who had multiple births and no history of having any kind of hypertension or HDP. Um And then compare them to women who did have a hypertensive disorder of pregnancy. And they saw that women who had preeclampsia in multiple births. So more than two were like almost at five times, the increased risk of developing heart failure even women who just had one birth that was complicated by preeclampsia were at almost at four times increased risk of having heart failure. So um after this data came out, there's a lot of discussion about is this HEF path which is more common in women across the lifespan is this ischemic, non ischemic and this is hot off the press um published Jack Heart failure this month. Uh This is also data from the Swedish medical birth um registry. Taking a look over like almost 30 years. They took a look at 80,000 women who develop pregnancy and do hypertensive disorders of pregnancy. And they compared them to normal intensive women and they looked at heart failure, but specifically, they looked at both ischemic and non ischemic heart failure and they looked at them over time. And what they found was that the first six years after a complicated pregnancy was where we had the highest risk of heart failure in these patients. And it was really here in orange is ischemic just so you can follow along and with the colors. I know this is a cluttered um figure, but they remained at higher risk throughout and then the median time for them to develop heart failure was around 15 years, whether it was ischemic or non ischemic. People are very interested in coronary artery calcium as is like I think every other um kind of specialty um within cardiology. This is data from a cohort of about 300 women who were then matched with age and um race cohorts from the framing and heart study. And what they found is if you had preeclamptic pregnancy, you had a much higher risk and there was a higher prevalence of having any degree of coronary artery. Um calcium, of course, the author is always um control for things like hypertension and diabetes and the risk factors that we know are associated with development of atherosclerotic disease. But across the board where they looked, it seemed that having a preclinical pregnancy puts you at increased risk of having a higher degree of coronary calcium. Now, when you look specifically among the ages, they looked at broken down here from 40 to 63 the most accelerated increase in coronary artery, calcium was found in women between the ages of 45 and 50. I highlight the age ranges a little bit because I think we always, you know, when we look at a 20 or 30 year old woman who has a complicated pregnancy, we're like, ok, maybe it puts them at increased risk. And we're thinking, is that at 50 is that at 60 or is it really within the next 5 to 10 years? And I think data like this starts to highlight, where do we intervene? How early do we need to risk stratify? Should we be getting coronary artery? You know, calcium scores in women? And when should we be doing that? And those are a lot of the questions that are sort of flooding the field right now. This is one of the last studies that I'll show. And again, I'm just trying to um show you guys the real link of these adverse pregnancy outcomes in future cardiovascular disease. This is a study from Sweden looking at if you had a preterm delivery, which O BS consider below 37 or earlier than 37 weeks, what was your risk of developing ischemic heart disease? Long term? This graph is a little confusing. So I'm gonna try explain it. So extremely preterm are babies that are like peri viability 22 to 27. But that's the blue line up here and it goes all the way down to green. These patients are patients who had full term deliveries between 39 and 41. And what you can see that these are adjusted hazard ratio. So your hazard ratio, if you had an extremely preterm delivery is about four and it does decline over time. This is time after delivery. So 40 years out, but look the curve never actually come together. So what that means is having a preterm delivery is associated with an increased risk of ischemic heart disease. Even when you follow women. 40 years out, these dash lines are a bit confusing to me. All this means is that even though your risk of developing ischemic heart disease goes down, when you look at the actual absolute risk difference between people who had a preterm delivery versus not, it's still much higher. And there are curves that continue to increase as women get older and that's not terribly unexpected. So, really having a preterm birth, whether it's spontaneous or medically induced, um, puts you at almost four times the risk of having ischemic heart disease in the next 10 years. Oh, my favorite last but not least because I know, um, Doctor Ashley Mary Kane is sitting with us today, but this is uh work done from our own institution here um at us f and published in 2016. So what Doctor Kane and her team did is they essentially looked at um women during their first time in pregnancy like between the ages of 15 and 40 they looked to see whether they have what she calls here and you're probably seeing on the graph PS or placental syndrome that meant they either had placental infarction, um places abruption or any of the hypertensive disorders of pregnancy. And then they just looked five years out and they said of those women who had a PS or placental syndrome, how many of them develop cardiovascular disease, even just in the short term, right? This is looking at five years. And so when you look at the graphs here, the black line, which is the highest line here, this is survival time to cardiovascular disease. The black line are patients who don't, didn't have a placental syndrome and also didn't have a small baby or P TB, which is a preterm birth when you start kind of walking down, meaning worse, sitting, worse or earlier. Um, cardiovascular is used after delivery. You find that to no surprise patients that had any kind of placental syndrome. And if they had a small baby or preterm birth again, kind of like a conglomeration of, um, or additive, I don't wanna say s but additive risk factors were at highest risk for developing cardiovascular disease within five years after delivery. And this risk was quantified as 20% increased risk if you just had a placental syndrome. But if you had a placental syndrome and delivered early or had a small baby, your risk was really up to almost 40 to 45%. And I think these statistics are quite um striking and actually quite sobering. So last, but not least as I promised because I don't want to be somber about the state of our maternal health crisis. What are women look like when they're becoming pregnant? And then unfortunately, all these pregnancy complications that we're now uncovering that we're like, are really putting our women at risk in the long term. Um We really need to discuss where I think the need of the work that we need to do to kind of turn this crisis around. Um So this is a slide I showed at the beginning about how pregnancy is a window really and an opportunity for cardiovascular disease prevention. So this was the current state we went through and this is really our future goal. And I would probably say that this needs to be moved back even earlier to like the preconception to when primary and other physicians are seeing these women. Yes, we identify women after an adverse pregnancy outcome and there's all this um uh research and efforts are going into. Well, you know, how can we do targeted screening? What do we do for lifestyle modification? How do we start early treatment to hopefully kind of put them under and that green line and keep them to follow sort of what a healthy population would look like. But I think even before catching a woman with an adverse pregnancy outcome, there's a lot of work to be done upfront before women are even uh getting pregnant. Um, we unfortunately, really don't have any guidelines to tell us what to do in the fourth trimester or postpartum. Um There's been multiple, particularly by the American Heart Association. There's been multiple publications about A P OS and cardiovascular risk interventions, but they're mostly just summarizing the literature and really summarizing the gaps. Um And the fact that we just don't know how to care for these women. So I think we've addressed the problem, but we really haven't gotten to the point where we know um how to deliver the care that they need and how to catch them unfortunately, in time, and I just want to highlight a lot of this work has been done by Dr Haywood Brown who's here at US. F he's one of our professors and deans at US F and he wrote, he wrote this joint statement um that was OBGYN essentially cardiology coming together and saying we need to collaborate. This is not your problem or my problem. This is really everyone's problem and I 100% agree with that. So the way that sort of postpartum care looks like now is that we know that women probably need to come in early. Most women usually have a six week visit with their obgyn and now the American College of Obstetrics and Gynecology and really a lot of the um um I, I should say associations or committees are now pushing to like a two week follow up or seeing a patient within three weeks after they deliver, essentially making sure that we're um catching women and maybe even pre uh preventing complications and preventing um readmissions here at us. F we're trying to build a transitional clinic. You may think like, what does that mean? It means that a lot of these women don't stay in cardiology care, maybe don't need to. Um But there's a lot of women this age that use their Obgyns as like their primary care doctor. Um but obgyns in many um states after they see patients at six weeks, they just, I really don't see you again, unless you call them and you say you're pregnant. Um again. So there's this loss of follow up. Um that's particularly um prevalent among young women of reproductive age. It's what we call the fourth trimester. And as I highlighted before, it's really the most vulnerable time for women and where I think we need to do the most work in terms of how to address the health, health care delivery and how to reach women um that need it the most. So this is sort of um what I would say, expert consensus is what we envision maybe multidisciplinary care for women should really look like. And I highlight primary care being in cardiology. It's really all care providers um for women of reproductive age. And as mentioned before, I really think this is something that needs to start in the preconception period, the interpart prevention, our obgyns are fantastic at doing this. Actually, I tip my hat to them. They're fantastic at doing the whole thing. This is what they've been doing for years. And I think now we've realized that it really takes um a village to try and sort of turn this um crisis around. Um So as we're building our cardio obstetrical program, we love seeing patients preconception. I'm gonna say that again, we love seeing patients preconception uh before they're pregnant. This is really the prime time um to see patients and try and optimize their cardiovascular health as much as possible. The intrapartum prevention, I really leave to the O BS. They're doing a fantastic job. And then the postpartum risk stratification is really where we have a lot of work um to do. And now we're building and sort of strengthening our postpartum clinic here and trying to build ties with our um primary providers to really provide that sort of continuity of care um for women and for all sort of the cardiologists out there who may not necessarily take care of women um that are young, although I think everybody does. But if you're seeing them later in life, it's really about the incorporation of pre, not just pregnancy, I would say, but reproductive health factors when we're um thinking about risk assessment for cardiovascular disease among women. So it's really continuous and it's really about the long term um prevention of cardiovascular disease. So this is sort of our little algorithm um that we use in our postpartum clinic here. You see, we don't necessarily see all women at 126, 12 weeks and really longitudinal. There's really no guidance into when women should be seen and how often. So a lot of this is sort of unexplored territory, but we definitely think that it needs to be um defined. And when you look at the things we assess for, you may think like this is pretty mundane, right? We're checking a blood pressure, we're looking at their BM I, we're asking if they have any symptoms. We're talking about family planning, potentially, um, and things like birth control. But I'll tell you, even though this looks mundane, the large majority of women are not getting, um, this preventative care. The, um, follow up rates at most postpartum clinics, you know, across the nation is probably near 30 to 40%. Um, those percentages are probably mirrored here and that's usually for like a six week, um, follow up clinic and it's even less when you look across different sort of diverse communities and racial and ethnic groups who clearly have different social determinants of health and different um barriers to access care. The only um I'm like, oh now I'm breastfeeding. So the there's really no pharmacotherapy, there's been no medication that's been studied to try and sort of reverse the evil humors that have now occurred because of an adverse pregnancy outcome. But there's a lot of interest in sort of how breastfeeding could be a potential link to cardiovascular disease prevention. So, some of the earlier data with breastfeeding was a little bit inconclusive. There was this really nice meta analysis published last year. Um that took a look at um if you ever breastfed at all and then also tried to look at breastfeeding duration and then look at long term outcomes, things like cardiovascular disease, ischemic heart disease and stroke. And there's definitely sort of a linear relationship between if you breastfeed ever, probably up to 12 months total lifetime accumulated um, breastfeeding, there's really a decreased risk um, of future cardiovascular health. So here's sort of a, like a normal healthy population looks like, which is not reality for any of us or maybe only, you know, 10% of women have an adverse pregnancy outcome. There's maybe no barriers to lactation and they have optimal cardiovascular health. That's not the reality that we're living in. We live in this reality where there's women who are obese, who have cardiovascular risk factors. Some will some won't develop an A po but no one's really looked at breastfeeding among women who who have had an adverse pregnancy outcome and what that means for them. But we also know which is a common theme in the talk today is that there's a lot of racial and ethnic disparities even in the amount of women that breastfeed and things like obesity are actually um factors that um are detrimental in terms of promotion of breastfeeding. So I think that this is an area um of of real inquiry and where some of um our fellows and residents really have some interest in saying we think breastfeeding somehow resets kind of like that thermostat from all the weird vascular um and inflammatory and hormonal changes that happen in pregnancy. We see women have better fasting glucose or lipids improve. Um There really are some really dynamic and positive effects to breastfeeding. We just don't know what that looks like and whether it actually resets the thermostat for women who have had a P OS or have that high degree of vascular dysfunction. So this is hopefully something um really cool that we'll have more information on, um as we move forward in the next couple of years. So in my last two slides here, I just want everyone to sort of take something away, hopefully more than one thing um from today's talk, but I really wanna sort of shift the paradigm. I think to really um dismantled this crisis. We need to kind of shift from thinking of pregnancy is like just 40 week self-limiting episode um to thinking about it as sort of um a window of unique opportunity really for cardiovascular disease prevention and it's really kind of spans the whole lifetime of women. So here, the A P Os, we obviously spend a long time talking about that, but it's really about not just what is their prepregnancy health, but knowing that there's actually sex specific risk factors that go from really um pre per pregnancy such as early or actually late monarchy PC OS, spontaneous pregnancy loss, adverse pregnancy outcomes. And then women who are a little bit older asking them uh about menopause use of hormone replacement therapy. Um because we know that all those things have been linked to an increased risk of cardiovascular disease. And then for the clinicians in this room, we typically, when people come to us, one of the things that we calculate is kind of like their 10 year A S CV D risk score. We're like, well, what is your risk of having heart disease in the next 10 years? Um Obviously, the A S CV D risk score for people who are familiar with it is like age gender, your cholesterol, are you a smoker or not in diabetes? And that's kind of where it ends. That's what I call the traditional risk factors, right? So none of the really sex specific risk factors are accounted for in there. So somebody said, well, what if we put hypertensive disorders of pregnancy into the calculator? And what happened? It really just didn't improve discrimination. So it didn't allow us to say like these women are at higher risk or not. And the thought behind that, although we were pretty glum when that came out is just that in this patient population, there's obviously the reference model has risk factors like hypertension, diabetes and things that are a lot more prevalent than hypertensive disorders of pregnancy. So it's not that they really don't help us discriminate women. So I think we shouldn't take this as a negative. We should take this as a, we need to find a better risk stratifying tool that can actually account for all those sex specific risk factors. So this is how far we've made it the AC C and the A H A, the only way that you really incorporate these sex specific risk factors. Um or A P OS are kind of in this little box that A S CV D risk enhancers, which I really harp on the fellows and anyone who comes to the clinic with me to ask about. So when we're really quantifying someone's risk for having a S CBD, we really need to think about, does that patient have a risk enhancer? Did they have early menarch? Did they have premature uh menopause? Did they have just facial diabetes or preterm delivery in one of their pregnancies? Because if so there are occurring guideline recommendations to consider using a statin a little bit earlier. And again, that's for prevention of future atherosclerotic disease. We really don't have much guidelines. As I mentioned, this is kind of it for sex specific every time a new guideline comes out, I'm like, I just like control fine sex or control fine female to see if there's a mention of like, well, how is this different in women? And we've actually come a long way like the AORTA guidelines. True and turn related to what we're talking about today, came out in November 2022 and they had a section on pregnancy and if you control fine, it was like 40 control fine females. I was like, this is fantastic. You know, so I think there really is growing recognition even within the cardiology um world as to what this means. I would love for the slide to look very different. A couple of years from now, meaning not just have preeclampsia and A PS into our 2018 AC CH A cholesterol guidelines, but for example, the hypertension guidelines don't even make a mention of like what is our goal after a woman delivers and they have preeclampsia. Um Are there certain meds that we should use? How do we titrate these? When do we risk stratify them? And then for many of us who take care of these patients, obviously, there's very good data for low low dose aspirin as being sort of the number one treatment, we have to reduce the risk of preeclampsia probably by about 30% once started after 12 weeks um of gestation. So here's sort of what I think about is maybe a way to move forward and I hope no one's disheartened after hearing today's talk, I really do think this is a window of opportunity for all of us in this room, for clinicians, for researchers, for people across all collaborations who are interested in this work to really take this on and say this is really an arena where we could do. I think some substantial work. So I definitely think education um is key both the providers, clinicians. Um our patients, I think not a lot of people know the link between pregnancy and adverse pregnancy outcomes and cardiovascular disease. Um We really don't know how to risk assess these patients. Obviously, their pooled cohort equation for 10 year risk doesn't really work that well, maybe we ask them the risk factors in clinic. But then what do we do with that information? Um Is there a role for um earlier testing? It's a role for imaging for coronary artery calcium scoring. And at what age and when do we do that? Um Even when we check cholesterol levels in the postpartum period, there's really no data um to guide that transition, particularly in women of reproductive age. Um One of the biggest things is really health care delivery. And I think this has to do a lot with social determinants of health. How do we get to the people that need it the most? That's really the bottom line. And I think we need to be novel about how we deliver equitable care to the women in our diverse communities. And then the last thing would be just having more evidence based prevention strategy so that we actually have some sort of guidance and that we know what we're doing instead of making it up until the data arrives, which is sort of the game that we play. Um sometimes and these are really just sort of the when I think about inequities and the care of women, not just maternal care through pregnancy, the long term, I think these are really sort of the, you know, if I had to pick top five areas where I really think we need to uh focus our efforts. So this is really the bottom line. And hopefully the takeaway from today, every single woman and family deserves respectful equitable care. That's evidence based not just through um their pregnancy but longitudinally. And that's really what women's heart centers and clinics like the one we're trying to build here are really trying to do. I'm really lucky to be surrounded by a fantastic group of people. I hate putting slides together like this because really all I wanted to do was put like the picture of every single faculty member in OBGYN in primary care and in cardiology. But I wanted you to know some of like the key stakeholders that um I'm lucky to be surrounded by and who are really supporting these efforts. So, um I'm lucky that I feel like I have a mom and a dad. I have Doctor Oliveira and Dr Louie from OBGYN. And this has really been sort of a marriage between our two specialties and trying to move this program forward. So cardio setris really um falls under sort of our larger umbrella tree of the women's cardiology program. We have a new nurse navigator who's not here today. So I want to introduce Ashley Young Ali Cook is now spending some part time uh with us in clinic and we have Catherine and Joe who hopefully is um coming on to our program and really gonna lead our efforts for our postpartum uh prevention clinic and CBD reduction. Um We have a stellar group of obgyns and MF MS who are near and dear to me. And I have to mention Doctor Tolu because thank God there's someone who feels comfortable taking care of complex congenital heart patients who get pregnant because it is not me. And last but not least we have uh our small but mighty cardio cric research work group. We meet quarterly. These are fantastic fellows. I'll name them because they're just as important as everything else. I've talked about today, Claudio Scone, Viviana, Diasy, Catherine Pressman, Valerie Nemov and Aldon Dunham. And they are doing incredible work um and really energize in these efforts and I look forward to um seeing what they, what they're able to accomplish during their time here in our program. So hopefully, we've done a pretty good job in going over our main objectives. Um I hope everyone in this room walks away with a little better appreciation of both pregnancy, but also the importance of cardiovascular prevention. Thank you. I'm happy to take questions. Oh, yeah. Do you want this? Ok. This you can ask a question. So doctor C at uh will entertain any questions that you may have question and perhaps while the mic is being delivered, uh the opening slide, I think bears some explanation. Uh Tori Bowie uh was a Olympic Medalist uh who on May 2nd was found dead in her home, eight months pregnant um uh with a child that was crowning in the birth canal uh and was identified as having uh preeclampsia and uh pulmonary congestion and probably died in a rhythmic death related to that. So, uh that's a, a crowning example of what Doctor Kat has uh has really explicated this morning. Doctor MSER. Doctor C Yeah, that was a excellent lecture. Thank you for uh thanks for doing that. Um But uh so on Tuesday, actually, with Doctor Cohen, I ran into a situation where we had a patient um punch in the athero cardiovascular wrist for having chest pain and pre GSA or uh gestational diabetes was actually the question because if we would count that on the A S CBD score, then she would be in a moderate risk bucket. And if we didn't, then she was in like very low risk, no further testing, possibly doing a coronary arty calcium score at that time. So I know there's no risk score now. But what would you do in a certain situation like that? Given the fact that we don't really have a adequate risk score? Yeah, that's a great question. So that's a little bit about like what do I do now before we have data to support um uh risk stratification and potentially early treatment that's much better um in women. So I do as you would when I have any woman who comes to our clinic, I assess their traditional risk factors. I always calculate their A S CV D knowing that it's not perfect that it has some weaknesses. I do a comprehensive sort of sex specific risk factors. And then I'm like, oh, what to do about that. So, it kind of depends and it allows me to, to sort of re risk stratify them, as you mentioned. So, like, maybe they would be low risk or maybe they're less than 5%. But, you know, they had gestational diabetes and a preterm birth. It's like, I don't know, how much does that increase a month? Does it go from 5 to 75 to 8? So I'm actually pretty coronary artery calcium friendly. It's like non inconsequential, you know, to talk about starting someone on a statin. Statin is also currently um as it stands, are not used in pregnancy, although that may change in coming years and they're also not used in lactation. So there is some resistance, I think in the community to just like see a woman who had just facial diabetes, she's 32 she's showing up and like the start of sta is not, you know, without risks, right to like start it and stop it and what that tells for future pregnancy. But I have found that coronary calcium, as we sort of saw the data, at least for preeclampsia, no one's looked at it in preterm. But if we think that the pathophysiology is the same potentially and we think they increase risk for ischemic heart disease. And I think it's really there too. So for those young women, I usually risk stratify based on history taking. But then I am actually pretty. Um the word is not aggressive. The word is uh uh I usually seek to find a reason that would put me in one direction or the other, right. So, um there are some women who will have a low risk score who then get reri stratified with a cor coronary artery calcium if they're up for that or just based on history that I'm then sort of using the risk enhancer to start preventative therapy such as statin therapy, but no one has really looked at that. So this is a very important question. Uh And the way I'd like our, all of us to think about this, these are risk enhancing factors that have not been yet incorporated into any score. Things like previous radiation therapy to the chest migraine syndromes, uh These uh disorders of pregnancy. Uh All those are are integrated into our decision making to tip uh that decision in in favor of uh utilizing statin therapy upfront and uh daily discussions in our clinic, let's say one more thing. Sorry, Doctor Pria, there is a 30 year risk score because obviously the pooled corporate equation starts at the age of four. It's like, I don't know, 50% of the women I see are more below the age of 40. So like I can't, I like try to use the calculator. It's like you can't, sometimes I fake it. I pretend they're 40. Like what if they were 40. Um, but there's a 30 year lifetime and, uh, risk score that was developed by Donna Lloyd Jones in like 2006 and published in Circ. And it's been used and when I sort of spoke to other women, women's heart centers who are seeing some of these really young women, they incorporate the 30 year risk score. It really has the traditional risk factors. Like if you just pull it up on Google, it's the same thing, hypertension diabetes and you know, age um and sex. So it doesn't account for the risk enhancing factors. But at least it like gives you a uh parameter for someone in that age group and that's invalidated. Doctor Chandra Seeker. Hey, Doctor Christian. Uh excellent talk. I had a quick question about um the role of echocardiography and sort of longing assessment of these patients and sort of your recommendations and practice pattern. And um even the role potentially of strain. I know at least in the cardio oncology sphere, we try to use that a lot as sort of a pre and post exposure way of trying to delineate patients at increased risk or when you intervene. So I just want to see, you know, what are your thoughts in this population? What do you, what do you do in your practice? Yeah. So um as an echocardiographer, I love strain. No data that I know of looking at strain in pregnancy or in patients with adverse pregnancy outcomes. There is data now coming out in terms of LV, remodeling LVH, which are things that are kind of like, OK, you would expect that in patients who for example, have hypertensive disorders of pregnancy and then have adverse um remodeling. But I think strain is one of the of the modalities that could be incorporated into echo and I know some centers that are taking a look at that now, mostly in pregnancy. So I think Doctor Scomo will remember this anecdote. We interviewed a fellow uh two years ago who had done some collaborative work in London, looking at LV and RV geometry and preemies. They were breastfed and not breastfed. Uh the preemies that were not breastfed, they retain these abnormal RV and LV geometries that c childs that were breastfed normalize their geometry. So there's also an effect on on uh hearts of Children uh with respect to lactation. And I know we didn't talk much about the fetal perspective for the kids and this adult focused talk. But a lot of these A P OS also put kids at increased risk and that's been well studied of like having future diabetes, having future hypertension, having been exposed to a pregnancy with those risk factors. So, um it's not inconsequential and I think has um adverse effects um including on their offspring. Doctor Sera, all fellows. I love it. It's good. It should be Hi, Doctor Cruz. Thank you so much for that. Wonderful talk. Um, my question kind of refers to the first objective you had when you mentioned the racial disparities, um, that we see in women. To what extent do you think it's being driven by kind of genotypic genetic factors versus the social determinants of health? It's like the million dollar question. Um, I don't know the answer to that. My guess would be that, um there's probably some influence for both, meaning what we're looking at is multifactorial as we know, like most things in life are. But um I do think that there is a very strong um contribution from the social determinants of health. I think people, you know, a lot, a lot of the research and equity takes a look at race almost like as if race was like some predetermined, you know, there's something, there's a genetic polymorphism. It's like the way that you're born, but not particularly in this patient population. But when we look across the board like that, it's probably not true. It's more about where people live, what they're exposed to their access to health care, um their social determinants of health that I think are really sort of underpinning the differences that we're seeing. So I tend to fall more on the, it's probably less so genetic and more so the way you live, breathe and are exposed to health care delivery. Yeah, the, the term rurality has been coined that uh is also a tangent of uh one of those many factors that may determine this Doctor Quimby. Um I'm in attending this week, by the way, just so you can mix it up. Did you fall asleep just this week? Um So my question is for the patients coming in to the clinic, let's say I'm a, this is a new patient coming in that I'm seeing that's, you know, had multiple pregnancies in the past. And you convinced me now, I'll screen them all for a P history of A P OS and I, and she, she has a history of A P OS. Do we have any active registries or studies that are going on? That should be in the back of my mind to potentially get this patient involved in and, and reach out to you all in the, the um the advanced program for. That's great. It gives me another idea. So currently, we do not have a mechanism for that right now. We have a um cardios Setris registry, which we started, those are really people with like structural heart disease valve disease, um cardiomyopathy that we're tracking, we're tracking both um al and pregnancy and postpartum. What it makes me think of a little bit and I see Doctor Shon Almeida sitting right behind you um in our audience is that we've been talking a lot about sort of the initiation of a cardiometabolic program. And what that could potentially mean for the women's heart health program and particularly for the postpartum period. So it would be a way of sort of getting these women assessed in the best way possible. A 30 year risk score. A SUVD, you name it, we just make it up and we go with it and we do the same thing um, for everybody and potentially having something like coronary artery calcium or something else that can be, um, hopefully made a part of their um both risk assessment and their treatment plan. We currently don't have a pathway for those patients other than I'm always more than happy to see them. If you think that like a or a discussion with me or something like that would be helpful, but I'm an end of one. So really, my role is to educate everyone out there so that everyone has some baseline level of comfort because 50% of your patients are female and you should be screening all of them because they're probably coming to you with cardiovascular disease and you want to know why. Um But it's, it's ever an area of discomfort or you're like, not sure like, oh my gosh, I'm always happy to see them in clinic, but I'm hopeful that exactly what you mentioned, meaning a more streamlined pathway is probably where we should be headed. Uh Doctor K, uh We have an online question. Let me read it from Doctor Me Vivek Meta, one of our fellows. Uh Thank you. Thank you for the excellent grand rounds. I have a question regarding durability of medical interventions for this population. We often see these patients months or years after their pregnancy and related complications. Can you speak to the challenge of maintaining patients on their guideline, directed medical therapy or any hypertensive, let's say three or six months. And do you have buy in from these patients to continue necessary therapies? And if not, how do we address this? How do we address that? Wow, that's a, that's like 10 questions in one. Thank you. I, if you can hear me. Um So I think he's talking about how we keep patients engaged. I think that's basically the, the summary that I heard meaning, I mean, I have a lot of patients who I see and they're like, I haven't seen someone in six years. I haven't seen someone in seven years. So I think it's the fact that a lot of reproductive age women almost including myself when I moved to Tampa, like literally didn't have a primary care doctor and when you call it where they're like, you can wait a year. So I think for um I think it's finding that opportunity. So what we're trying to do now as we're building both the cardio set and the women's heart program is if we kind of capture these women, it sounds like we're seizing them. But if we capture them at the time of their pregnancy and we make a diagnosis of whatever it may be, preeclampsia or peripartum card apathy. That is a moment, right? That is like golden where you can educate, you can maybe start therapies. I know he's talking about like, you know, how do we keep them on there and meds? And that is a golden moment to try and kind of reel them in when, I mean, reel them in. It's not in a bad way. I mean, like keep them within health care so that you build that trust with them so that you educate them that this is something that um could cause complications. So we have actually a pretty good rate of women who are seen in the cardio program because they're pregnant, they had a po so they have true structural heart disease. We're now kind of rolling into our women's cardiology program. Why? Because they no longer have a baby in their uterus, but they've had complications. So they have true cardiovascular disease. And I think by catching them in that moment with the pregnancy and developing that relationship, we're able to sort of um keep them. We haven't looked at that in terms of vic's question is adherence. Are they staying on their meds? Are they continuing to see me? We definitely have lost to follow up. And they're exactly all the patients that I mentioned in that first slide of our vulnerable patient populations. We see patients from everywhere. We see patients that are incarcerated and brought in. We see patients that are homeless and living out of their car and those are the patients that are just really hard um to provide care to. So I hope that us f and both TG A help us to really think outside the box. I hope that they um support novel strategies as to like how do we reach these patients? Telehealth was amazing. That's like the one good thing that came out of COVID, right? Like that, we realize that some of the care we provide doesn't have to be in person. And that's important. Telehealth has been shown to maybe decrease some of the disparities, particularly in rural um America. But like I see it as like a golden opportunity postpartum when these women just like, can't get out of the house, don't have transportation, there's childcare issues. Um And it's a way to at least get them on the phone and continue that relationship. Knowing that at that juncture in time, it may be hard for them to see you. But if you become sort of their advocate um and go on that journey with them, I think they're more likely um to come back and remain engaged. But I think that's really like the how do we keep them engaged and how do we keep them on their meds? I think we need to figure out a better health care delivery system. So let me give that up. So, no, I think that's powerful. I think the, the emphatic uh exclamation point of termination of this excellent grand rounds is just that point outreach. Um You can get on on the avenue here and drive over the bridge and in about seven minutes, you can uh be in a neighborhood where these events are happening uh continuously on a daily basis. And until we find out how to breach these walls, where we have a nice view of set in cha, set in channel or an air conditioned room, this isn't gonna be solved. Uh And I reflect back to our uh va affiliate meeting last Friday uh where it was um um we were all educated that in the VA system, about 68% of the, the no shows were due to transportation problems. So they collaborated in this public private partnership with Uber to go get them and they cut it by 80%. So somehow our Colleges of Pharmacy, our Colleges of Public Health, our College of Medicine and our uh academic center at Tampa General Hospital. And this is the clarion call of leadership. We have to find a way to outreach, not expect them to come to the Ivory Tower. It's very difficult to navigate. It's a foreign environment. We have to go into their uh domains uh and understand uh where they're living, how they're living and how we can best integrate care for them. So I think Dr Cust really sat satisfied the power of three, professionalism, uh, pedigree and potential and, and she's, as I said. Published Created by
