UCI Health Ob/Gyn, Dr. Afshan Hameed, MD talks about a new of detecting cardiovascular disease in pregnant women as early as possible.
Interview conducted by Ivanhoe Broadcast News in July 2022.
We’re talking about cardiovascular disease in pregnant women, and how prevalent it is.
HAMEED: Absolutely, and that is why we have not been able to address that until recently. The maternal mortality reviews, they started about 15 years ago in the State of California. That was a result of the rising rates of maternal mortality, not only throughout the United States but in California as well. To give you a little background about California, we have a large population. One in nine babies that are being born in the US is in California. We have a large maternity population, and our maternity care in California has big impact on the rest of the country.
Do most women who have cardiovascular disease during pregnancy know they have it?
HAMEED: I think the ones that know that they have cardiovascular disease or they start out knowing that they have heart disease, they actually do relatively well. In the sense that when we review maternal mortality and the cases of cardiovascular-related deaths, these are primarily in women who did not know that they had cardiovascular disease. In general, there are two types of cardiovascular diseases. One, that, like you said, somebody comes in, they have known disease and they come in, they go to the high-risk doctor. They usually have a cardiologist and we know what to do and when to do, and if they develop any complications, we know how to deal with them. Then there is this other big group that is more of a concern is either somebody has cardiovascular disease, but they didn’t know about it, it’s mild, but it gets aggravated in pregnancy because of the changes in pregnancy. As you know, in pregnancy, there’s a hemodynamic stress. It’s similar to you being on the treadmill for nine months and you’re going to have high heart rate, your blood pressure changes, your blood volume goes up. There is a lot of cardiac diseases or lesions that may manifest for the first time in pregnancy.
Can you name some of those?
HAMEED: For example, if somebody has mild-to-moderate valve disease like mitral stenosis, they may have atrial septal defect or ventricular septal defect, those are not necessarily that significant in terms of symptoms or effects on the patient when they’re not pregnant. They may be relatively symptomatic and well compensated, but once they get pregnant is when everything- your blood volume goes up twice as much and your heart rate goes up and you are in that stressful situation hemodynamically, and that’s when they come up with symptoms. They start having more shortness of breath or they may be more tired or start having chest pain and they get diagnosed that way. The most important piece that I wanted to bring up is the De Novo Cardiomyopathy. This is the type of cardiomyopathy where the patient didn’t ever have it before, never knew, was totally fine, heart was functioning normally, but in pregnancy, towards the end of the pregnancy typically or even after they deliver, up to five months after delivery, they may develop heart failure. This is the group of patients that is super high risk and they constitute a large proportion of patients who die or have catastrophic events after delivery, and it’s called peripartum cardiomyopathy. The definition is it’s in towards the end of pregnancy or up to five months after delivery. That’s where the challenge comes in. When we take care of patients during pregnancy, up to two-and-a-half months after delivery, and then they are on their own. Generally, they are young women who don’t have other medical issues, so a prototype case from maternal mortality reviews in various states is a patient who had no risk factor, is doing pretty well, delivered a baby, went home, and then she started having shortness of breath a week later. She comes to the emergency department saying that, “I’m short of breath and I’m tired.” No one puts two and two together, and they feel like, “She just had a baby, she’s tired, she didn’t sleep last night.” So usually, they don’t get the attention that they need.
Is there a demographics specifically that’s more at risk?
HAMEED: Absolutely. In health disparities that we know of outside of pregnancy, it’s way more actually in cardiovascular disease in pregnancy, with black women at four times higher risk of dying from cardiovascular disease in pregnancy. We do know that- and Hispanics have a higher risk than white population. There are disparities amongst patients who die of cardiovascular disease during or after pregnancy.
Do you have a number for Hispanic women?
HAMEED: It is two times higher than the white women, but not as high as the black women.
Is it your now mission to bring awareness to this?
HAMEED: Absolutely. That is the exciting part that I’m super passionate about, and this is what we have done. I’ve been involved with the California Maternal Quality Care Collaborative, Maternal Mortality Review Committee for the last almost 15 years, time goes by. For 15 years, we have worked on various other causes of maternal mortality and then on the cardiovascular disease. We actually put together a toolkit, which is cardiovascular disease risk assessment during pregnancy and postpartum period. Once we determine that cardiovascular disease is the number one cause, then we’re looking at the contributing factors. Why is it- why are women dying of cardiovascular disease? The biggest contributing factors that led to the maternal death were lack of awareness, lack of recognition of symptoms, because as you may know that pregnant women are very likely to be shortness of breath or tired or swelling of their feet, which is very similar to a patient who has heart failure. A lot of time, there is an overlap of pregnancy symptoms and cardiovascular symptoms. Then number 2, they are young woman, you never think about cardiovascular disease. They come to ED, emergency department, nobody thinks of cardiovascular disease in a 28-year-old otherwise healthy patient. Those were the contributing factors and we also found that they were vital sign abnormalities, patient’s heart rate was high or the blood pressure was high, or their oxygen saturations were low, but they were not really addressed.
Those contributing factors then led us to look at the quality improvement opportunities. The quality improvement, again, was the education looking at these vital signs, the risk factors, the overall profile of the patient, and putting all of that together into one is what brought together in form of a toolkit, which is the cardiovascular disease risk assessment toolkit for pregnancy and pregnant and postpartum patients. This toolkit, actually, the gist of this toolkit is in two algorithms that are in there. And those algorithms have four buckets to make it very simple. One, if the patient is complaining of shortness of breath or chest pain, pay attention. If there are vital sign abnormalities like heart rate, blood pressure, oxygen, pay attention. Then if there’s demographics or risk factors such as older age, over age 40, black, obese, hypertensive, diabetic, all of those- any one of those, again, is a high-risk factor. Then the physical examination findings. When we put those four categories together, we came up with a risk scoring system and then we determined that if a patient has four elements from those buckets, she is considered high risk. Once we did that, once this algorithm was formulated, and let me tell you that this work was very extensive. It’s a multidisciplinary group where we had ED physicians, we had cardiologists, obstetricians, midwives, nurses, anesthesia, neonatology, the whole group of people who could ever come in contact in care of pregnant patient. We said, “Okay, we have this algorithm, we know that these are the elements that put the women at high risk for dying from cardiovascular disease. Taking this algorithm and apply it to the 64 cardiovascular deaths that we had at the time and seeing if we would have identified these patients.” One of the biggest piece was that more than 50 percent, actually almost 80 percent were not identified as heart disease before they died.
Eighty percent, we didn’t even know, even though they were presenting with all of those four bucket things but we didn’t think that it was cardio. So this algorithm was applied to those 64 patients who had died and we would have detected 93 percent of them as being high risk for cardiovascular disease. That was the beginning of the work that we are doing now.
What would’ve happened? How would you have treated?
HAMEED: We would have treated them as heart failure. Again, once we had those contributing factors and quality improvement opportunities lined up, then we determine whether there was a good chance to save a life. In that set of patients, we determine that one in three or one in four women would have been alive had we paid attention, had we known that she had cardiovascular disease. Because she had presented to the ED three times before she died. We could have altered that outcome. Now the next question was, yes, the tool did very well in patients who died, but that’s not where we want to get. We want to prevent it way before and we want to be proactive. Then the next step was, how would this algorithm work in all comers? This was a pilot study that we did a few years ago between UCI and Albert Einstein Medical Center in New York. We determined that we actually could screen this for 50 women and we could identify them, and we could accurately assess their cardiac function or determine that these all comers, about 20 percent of them had some sort of cardiovascular issue that required to be addressed. That was the beginning. Then what we did is we got a grant from Betty Moore Foundation to look at the cardiovascular disease risk assessment as a measure. Or in other words, try see if we are able to, is it even feasible that we can screen all women who are pregnant or postpartum using this tool. Then the ones who are positive risk, do the follow up. That was the work we have been doing for the last few years. We have data on that and we have submitted for publication. Along the same parallel, we had applied for the NIH grant that we got, and this is to study the 18 elements in the algorithm to see which one of them are more predictive so that we can make it simplified, make it more user-friendly, and make it such that it could be applied to every single pregnant woman everywhere so that we know what their risk profile is. Fast forward, I think one of the opportunities is if the woman knows that the shortness of breath may be heart disease, they are more likely to go to the hospital. Then if the physician at the other end knows that the shortness of breath in a woman who just delivered two months ago is unusual, so let me think about cardiovascular. That is where we are. We would like to identify the high-risk patients, counsel them, educate them, treat them, and to have the providers be aware of this differential diagnosis as you’re dealing with pregnant women.
There’s a couple of researchers who just want a background, just one question as to that on the sheet of paper that you have to fill out at the doctor’s office anyways.
HAMEED: Absolutely.
And that could save lives?
HAMEED: Absolutely. Along this way, we actually have integrated this algorithm into the electronic medical record system. We use Epoch at UCI, so it’s in the system. For every pregnant patient, once you enter pregnancy, it comes up as a red banner to screen them. It literally takes about 30 seconds to just make a few clicks and you know if the patient is high risk or not. This has been implemented at UCSD and we have many other centers that we are working with: University of Tennessee, University of Kansas, Missouri, Albert Einstein, and many other centers that actually- UPenn. We are co-investigators on that grant. They just got a grant from American Heart Association to study this algorithm not only in the obstetrics setting but now more on the ED side. It’s going to be implemented throughout the state, and they are going to hopefully make an impact there as well.
This is you being able to save women all across the globe just by being aware?
HAMEED: Absolutely. You just have to spend that 30 seconds and educate the patient. Once it gets integrated into the electronic medical record system, you’re more likely to follow that and you’re more likely to identify those high-risk patients who may actually be cardiomyopathy when they’re presenting with shortness of breath.
The signs that you might want to be aware of yourself would be shortness of breath, fatigue, racing heart?
HAMEED: Yes, palpitations. Heart beating fast, weight gain, shortness of- shortness of breath is the biggest one, especially when it comes to cardiomyopathy.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
John Murray
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
