Episode Transcript
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Kanny (00:09):
So welcome back to the
Cardio Ohio podcast.
This is Canny Gral here inColumbus as usual, and I'd like
to welcome my co-host as wellfrom Cleveland, Dr.
Ellen Seic.
Ellen (00:21):
Thank you.
Can I.
As you all might remember, wepreviously had a session on a
cardio obstetric topic before.
However, that was really lookingat patients who had cardiac
pathology prior to theirpregnancy, trying to figure out
what their risk for goingthrough pregnancy would be and
how we were going to managethem.
And today we're gonna betackling an issue that's.
(00:44):
Probably gonna be more commonthan that.
We're gonna be talking about howto manage patients with
peripartum hypertension, and I'mactually very privileged today
to introduce to you Dr.
Deidre Martina, who is themedical Director of Cardio
Obstetrics at HillcrestHospital, which is part of
Cleveland Clinic.
She is boarded in cardiology,nuclear cardiology, and
(01:04):
echocardiography, as well asbeing a fellow of the American
College of Cardiology.
But Deidra, before we getstarted.
We do have a lot of trainees wholisten to our podcast.
So I would love it if you couldtell us a little bit about your
professional journey and how yougot interested in cardio ob.
Dierdre (01:22):
Yeah.
Well thank you Ellen, for havingme and so honored to be here to
speak to all of your listenerstoday.
You know, I think cardio,obstetrics, it has been around
for a while and it's kind oftaking off a little bit more
steam now, but you know, thereisn't a great pathway to get
this.
I think people that practicecardio obstetrics were kind of
thrown into this somewhatwillingly because there was just
(01:44):
nobody else that wanted to takecare of these pregnant patients.
A lot of it born out of.
Sort of in urban areas wherethere weren't a lot of contacts
that could manage some of thesepatients.
And then just in general, Ithink as both of you probably
know, we kind of develop thesespecialty clinics out of a need
for the patients, where someonehas a particular interest in
something and they start tofocus their practice on that.
(02:07):
So we're still in the infancystages of creating sort of
practice guidelines and centersof excellence for cardio
obstetrics.
And really it is kind of a learnon the fly still subspecialty of
cardiology.
And I think for me, a lot ofthis was going to conferences
like a CC and a HA with topicsof interest that were related to
(02:29):
cardio, obstetrics.
And I'm happy to chair, I am thevice chair of the a CC Cardio
Obstetrics Essentials Course,which happens every year in
October this year it'll be atthe Heart House again in
Washington DC and that's reallywhere we take a deep dive into
different aspects of cardioobstetrics, including valvular
heart disease, arrhythmia, adultcongenital heart disease.
(02:51):
There's not yet a sort of aboard certification or even sort
of A-C-G-M-E criteria withinfellowship that must be
fulfilled.
But we are working on that andmeeting with a CC leadership now
to kind of standardize some ofthe things that we think are
important and need to be done byevery general cardiology fellow
and then people that are sort ofpracticing for centers of
(03:11):
excellence or to considerthemself a cardio obstetric
center.
Traditionally, a lot of it wasborn out of adult congenital
heart disease practitioners thatwere dealing with these patients
because they were.
Patients that already hadestablished heart disease and
now because they're livinglonger with some of the
therapies we have, bothmedications and interventions,
they're now living to that agewhere they're having children of
(03:34):
their own.
So it was kind of born out ofthis you know, us doing a good
job at keeping these young womenalive.
And so I think traditionally hasbeen a lot of adult congenital
specialist, but now the, the.
Spectrum has kind of changed forthese women, and we start to
see, as you had mentioned in thepreview today, is that a lot of
this is not necessarilyestablished heart disease before
(03:54):
pregnancy, but chroniccomorbidities like diabetes and
hypertension and obesity.
So we tend to be a little bitolder getting pregnant now and
have accrued some of thesecomorbidities.
So this is the space now wheregeneral cardiologists can come
in and really still kind ofmanage some of these things that
are happening peripartum tominimize risk and make pregnancy
(04:16):
safer throughout.
Kanny (04:18):
Uh, Thanks Dere.
As you just alluded to, I thinkin a lot of practice settings,
it is general cardiology who isoften the first, cardiac
practitioner, maybe the onlycardiac practitioner.
Who is evaluating some of thesepatients before we get into like
the risk factors for peripartum,hypertension, and obviously
eventually treatment andimplications, can we just kind
(04:38):
of start with the generaldefinition or like what the
current concept is as of how wedefine, how we define it, as
well as some of the conditionsthat complicated, such as
preeclampsia?
Dierdre (04:49):
Sure.
So I think one of the thingsthat we have sort of established
recently that hypertension ishypertension, sort of across the
board.
We're really just defininghypertension in pregnancy as any
blood pressure greater than one40 over 90.
Currently by ACOG guidelines.
That just has to be two readingsat least four hours apart.
(05:10):
And then the timing of when thathypertension starts is how we
kind of define either chronichypertension, which is before 20
weeks of gestation.
So that's usually saying thatthe woman had sort of
preexisting conditions alreadyand not necessarily to the
pregnancy physiology.
So chronic hypertension before20 weeks and then we call
(05:30):
gestational hypertension is theonset of hypertension after 20
weeks of gestation.
This may be isolated to thepregnancy and some of the
pregnancy physiology that'shappening.
And gestational hypertensionresolves within three months of
the pregnancy.
So they may or may not have totake anti-hypertensives for a
short course but usuallyresolves after them.
(05:51):
If they do develop gestationalhypertension and still require
medications greater than threemonths postpartum, they then
sort of move into the chronichypertension realm again.
We do define severe hypertensionin pregnancy as a blood pressure
greater than one 60 over one 10.
And we sort of treat that aspreeclampsia, even if they don't
(06:12):
have proteinuria, just becauseit's severe range.
And I think some of yourlisteners remember the CHAP
trial, which came out now, Idon't know, five or so years
ago.
We used to wait until pregnantwomen were in this severe range
of blood pressure before westarted to treat, but the CHAP
trial really showed us thattargeting a goal less than one
40 over 90 is best for baby andmom.
(06:34):
And there were no adverse eventsof intrauterine growth
restriction or preterm delivery.
And so the target really shouldbe less than one 40 over 90 in
all patients, including pregnantpatients.
So then we move on to thosestandard sort of hypertensive
disorders in pregnancy.
Now, if we look at other endorgan damage, we start to think
(06:54):
about eclampsia andpreeclampsia.
So traditionally preeclampsiawas thought to have, involvement
of the kidneys where you wouldhave urine leaking in the or
protein leaking in the urine,and that would be measured by a
24 hour urine collection or spotproteins.
We also can have other signs ofend organ damage.
(07:14):
What we can have fluid in thelungs causing pulmonary edema,
even swelling in the brain,which leads to seizures or
eclampsia.
We start to see elevated liverenzymes, a rise in creatinine,
and a decrease in our plateletcount.
So you don't need to haveproteinuria necessarily to
diagnose preeclampsia, but youhave to have hypertension and at
(07:36):
least one of these otherabnormalities in the labs to
diagnose preeclampsia.
So these are, you know, justbasic labs that people would get
coming in a CBC or a chem seven,and then thinking about an x-ray
or looking for lower extremityedema, shortness of breath on
exam there.
So essentially we're, there's aspectrum of these hypertensive
(07:57):
disorders starting with.
Chronic hypertension,gestational hypertension.
Then moving into preeclampsia,eclampsia.
And then also within thatspectrum is the help syndrome,
which is a, another sort of formof preeclampsia where we have
other liver enzyme disorders andarrays from there, but treated
very similarly to preeclampsia.
Ellen (08:18):
Wonderful.
So Deidra, are there particularpatients who are at highest risk
for developing preeclampsia oreclampsia?
Dierdre (08:27):
Sure.
Well, I think anyone that haschronic hypertension, so if you
have hypertension prior togetting pregnant, the risk of
preeclampsia is about 25%.
So those are the pretty highrisk patients that we're gonna
follow very closely.
And usually we're targeting totry to get to at least 37 weeks
using aspirin for preeclampsiaprophylaxis and making sure they
(08:47):
have a good plan for bloodpressure control and monitoring
at home.
Otherwise, here in the US blackwomen are three to four times
more likely to have hypertensivedisorders in pregnancy.
So we're also really targetingto make sure that they have all
the resources that are neededand following directly from
there.
So that's definitely part of thethings that we're targeting.
(09:08):
I think it's important to saythat, you know, in pregnancy,
this is one of the only timeswhere we, we are able to give
women blood pressure cuffs forprevention.
But even still at institutionslike mine, a lot of this is not
covered by insurance, which manyof you may be familiar with this
sort of bundled payment thathappens in pregnancy.
So there are some institutionsthat do.
(09:30):
Provide blood pressure cuffs,but even here in my institution,
this is done by grant funding,so the resource resources are
limited and still, it may besort of tricky to do remote
monitoring or have patients sortof monitor at home and keep
blood pressure tabs whilethey're taking medications.
So these are all the things thatwe kind of work out when we're
developing programs and plansfor peripartum hypertension or
(09:54):
postpartum hypertension clinics.
And I think really, you know, Ithink the long and short answer
is that a lot of Americans areat risk for hypertensive
disorders or pregnancy.
We are definitely not thehealthiest females getting
pregnant in the world.
And I think when we look at thea HA study that was done in 2020
of very young women gettingpregnant.
(10:14):
There's only about 5% of womenthat are in ideal cardiovascular
health before they get pregnant.
So those that are meetingactivity guidelines have their
blood pressure at goal, theircholesterol at goal, their sugar
at goal, and not smoking only 5%of women.
So obviously that can createproblems within pregnancy when
you're not at your peak healthgetting pregnant to start with.
Ellen (10:38):
Mm-hmm.
As far as the timeframe, what,what is the timeframe of when
you expect to first start seeingthese problems?
Obviously, if people chronicallygo into a pregnancy with
hypertension, that's one thing,but for someone who has not had
high blood pressure prior topregnancy, when do you start
seeing the blood pressure go up?
Dierdre (11:00):
Yeah.
You know, Ellen, so differentfor every patient.
I think.
I think commonly we see theblood pressure start to rise at
the end of the pregnancy, andthis will usually be 35, 36, 37
weeks.
It's very common that women havehad a perfectly normal
pregnancy.
They're going for their prenatalcheck and they're saying, oh,
your blood pressure's high.
(11:21):
We're gonna have to bring you into monitor.
And then.
They decide to deliver ifthey're close to term, because
they're either afraid thatpreeclampsia is starting or
they're already in earlypreeclampsia from there.
So that's a very common.
Way that it presents, but it canpresent earlier for people
sometimes.
And so I think really educatingwomen on the signs and symptoms
(11:44):
of preeclampsia is one of themajor things that we try to say.
If you're having any swelling,visual changes, shortness of
breath, and granted.
These could be things that arepart of n normal pregnancy
physiology.
So we're trying to sort of notfreak women out during the
pregnancy as well, but also keepthem educated to look for things
that may be more severe thannormal.
(12:05):
And I think it's important foryour listeners to know too, that
you know, just like you wouldfor any patient that came in
with hypertension or evenconcerns for heart failure.
The same kind of workup appliesfor these pregnant women.
You know, the BNP, the B typenatriuretic protein should stay
pretty stable even in pregnancy.
And so if there's a concernabout is this normal pregnancy
(12:27):
physiology or not, we can do labmarkers.
I.
You know, troponin should benormal in a pregnant patient.
You know, obviously we haverisks for blood clots and
pulmonary embolism and it's notuncommon that we can screen for
those things as well if they'representing to an urgent or
emergent care.
But we can do that same workupof chest x-ray looking for
(12:48):
pulmonary edema with lowradiation.
We can send labs like A BNP lookfor thyroid dysfunction that can
be contributing.
So, you know, I think it'simportant to really.
Not forget our sort of ABCs ofhow we sort of start the
differential first, and notalways just chalk everything up
to Oh, that's normal inpregnancy for you.
Kanny (13:09):
So Deirdre, you alluded
to kind of the, the basic workup
that many of us who are, spendour time on cardiology consult
services are kind of used to,and I, I think.
Obviously, the, the issue withhypertension is common enough in
pregnancy that many of the, kindof milder cases or more routine
ones are managed pretty well bythe either the OB team or the
(13:31):
high risk OB team.
And usually the cardiologist inmy experience, seems to get
involved if there's, concernsabout heart failure or another,
challenging medication dosing.
Is there any other pearls youhave for like the, the
consulting cardiologist in termsof what things might stand out
that would, suggest a higherrisk situation or a patient that
needs more intensive monitoringor therapy?
Dierdre (13:53):
Yes.
So as I mentioned before, Ithink, the BNP level should be
an indicator for most women thatshould be pretty stable and
normal, even in pregnancy.
So if we have an elevated BNP, Iwould probably just go ahead and
do a quick echo to make surethat there's no major valve
problems or stretch of thechambers, either atrial or
(14:16):
ventricular.
And granted that.
You know, most women this agedon't have chronic disease, and
so you're very rarely gonna seeany abnormal diastolic
parameters in the acute setting.
'cause you know, really diastalis really meant to be for kind
of middle aged patients withchronic disease.
So it's not uncommon that yourdiastolic parameters be
(14:37):
completely normal, but yet womencan still experience acute
diastolic heart failure afterpregnancy, right?
If they're.
Swollen, having edema, evenafter C-section or a vaginal
delivery, they sometimes need afew days of Lasix to kind of get
things moving in the rightdirection.
So I think not to be afraid toimage, and it seems like we
image all the time for everyother thing in cardiology that
(15:00):
we shouldn't be stingy with ourimaging if we're not sure if
this is normal pregnancyphysiology.
And then I think the main thingis, there's no wrong answer on
how to treat blood pressure andpregnancy except to avoid,
obviously, teratogenicmedications.
So knowing that if you'repregnant and you're going to
(15:20):
start a medication, our firstgo-to medications in general are
Labbe Law and Nifedipine, bothof which can be used in
pregnancy and in breastfeedingvery safely.
We can also use diuretics inpregnancy.
The only caution is we justwanna make sure that we're not
causing dehydration, obviously,during pregnancy.
(15:41):
And so just monitoring fordehydration and kidney function,
and even afterwards inbreastfeeding to make sure that
they're getting enough volume tosupport their breastfeeding
needs as well.
So we can start with those otherforms of beta blockers are also
okay to use.
The only one I tend to avoid isatenolol.
That was one of the earliermedication study that did show
(16:03):
some association withintrauterine growth restriction.
And it is our only beta blockerthat's excreted renally, so I
usually tend to avoid that one.
And obviously we're gonna avoidace inhibitors and ARBs and the
Nies Andras in pregnancy becausethey have not been studied in
pregnancy.
So if we just stay away from thebad players, you really can use
(16:24):
what is needed, depending on howthe patient is responding.
And it can be, you know,multiple times a day, once a day
dosing.
If they have a fast heart rateor other arrhythmia, you may
favor beta blocker or overNifedipine.
And just kind of go from there.
So those are the main things.
I usually just start with thelool and ine, but if you need
hydralazine or diuretics or evenclonidine, those things can be
(16:47):
added.
We're just avoiding the Ace arb,RNA and MRA class.
Then just like everything, aslong as we have a way to monitor
the response, you know, the, themain thing is in pregnancy, we
don't want too high bloodpressure, but we certainly also
don't want hypotension, right?
So if we're monitoring at home,either remote monitoring or if
(17:07):
they're coming in to check theirblood pressure, just to make
sure that we're keeping them inan even range, not to have those
extremes, high or lows.
Ellen (17:15):
Wonderful.
So once we're successful atmanaging their blood pressure
through the pregnancy, I guessthere are two aspects of my next
question.
One is, what would be theimplication for the mother and
how do you counsel themregarding future pregnancies?
And then the second part is.
What are the long-termimplications for future
(17:37):
cardiovascular risk in someonewho developed high blood
pressure during pregnancy?
Dierdre (17:43):
Sure.
You know what?
I kind of treat all hypertensivedisorders in pregnancy the same
when I'm kind of talking aboutrisk for future pregnancies.
'cause I think once you've hadhypertension in one pregnancy,
we should monitor you closely.
And I think you're either atrisk for chronic hypertension or
at least having gestationalhypertension again.
And I think, you know, thosethings kind of increase our risk
(18:05):
for preeclampsia going forward.
So.
In my view, the two types I'mlooking at are women who either
they had this pregnancycomplication and they're not
having any more children, so I'mgonna focus on the long-term
cardiovascular risk reduction,or if a woman is still
childbearing and planning morepregnancies, my main focus to
say, how can we make the thenext pregnancy more safe for
(18:28):
you?
For the most part, for both ofthose types of patients, we're
really talking about lifestyleintervention.
We have to start early withgetting a healthy diet, low
sodium, getting them on aMediterranean diet.
'cause we know that hasdecreased rates of intrauterine
growth restriction and pretermdelivery.
And a 28% reduction inpreeclampsia the more tightly
(18:49):
that you follow a Mediterraneandiet.
So I'm really focusing oneducating them about those
things.
And so, you know.
In general, ACOG guidelines sayany woman that has had
hypertension in pregnancy needsa reassessment of her blood
pressure control within 72 hoursof delivery.
So a, you know, we're checkingto make sure that blood pressure
is staying well controlled andthat we don't develop postpartum
(19:12):
preeclampsia as well, which isnot uncommon.
And so we have that within 72hours.
And then there's severaldifferent models of how you can
follow blood pressure in thattwo to six weeks postpartum.
When they still may, may needsome medications to manage the
blood pressure that can be doneremotely with text messaging,
video calls.
(19:33):
Here at Cleveland Clinic we havea shared medical appointment
where we see groups of patientstogether and sort of make
decisions about their bloodpressure management if they need
to and go over cardiovascularscreening for the future as
well.
I, I will point your readers toa CC released a, a postpartum
hypertension toolkit last year,which is available free to
(19:55):
download on the a CC website.
And it goes through manydifferent clinic models and how
you can bill, how you code,gives you sort of templates for
notes and for talking about howto counsel patients.
So I think it's a very usefulresource for your listeners as
well.
I think talking about those twosort of courses, the immediate
(20:17):
risk for next pregnancies, andthen the longer term, we're
talking about 15 to 20 yearsreally about cardiovascular risk
and usually how I start thatconversation with women too is
to say, you know, even when I'mtalking 15 to 20 years, if
you're 30 something or latetwenties, getting pregnant.
We're still talking aboutpremature onset of
cardiovascular disease in womensince this would be happening
(20:39):
pre menopause for most of them.
And so really it's thefoundation of prevention is
we're saying we're recognizingthis risk now and we want you to
work now to reduce those riskfactors.
So I spend a lot of timeeducating them about how we can
sort of mitigate those riskfactors for metabolic syndrome,
how to get the cholesterolcontrolled, the blood pressure
(21:00):
controlled, and the sugarscontrolled.
That kind of.
Milieu of know your numbers.
So you should be seeing aprimary care doctor so you know
where your cholesterol numbersare, where your hemoglobin A1C
should be, is your bloodpressure at goal from there and
educate them so they know whatto look for.
'cause I think, you know,especially for young women, it's
kind of, we, we get a lot ofstuff from social media and
(21:22):
you're supposed to takesupplements and do all these.
Things that we can buy and doand shake, you know, to keep
ourselves healthy.
But it's really focusing on whatare the sort of, you know, the,
the, the guideline directed sortof measures of how we consider
ourself in ideal cardiovascularhealth and how you get there may
differ by some people, butknowing what metrics they should
(21:44):
be measuring.
And then as far as thislong-term cardiovascular risk
you know, there's very fewindications I would think for
many of these young women to beon a cholesterol medication.
You know, as you all know, we'renot really starting the
screening for theatherosclerotic disease until
the age of 40, but I do thinkthese phenomenons of
(22:05):
preeclampsia and evengestational diabetes.
This is a microvasculardysfunction and it probably
means that there's some sort ofpredisposition for microvascular
disease in sort of all of ourorgan beds later on.
And I think the coronary calciumscore is a great way to kind of
restratify these women startingearly.
(22:25):
So I usually will start doingthat in the early forties to
kind of have a baseline, becausethere is some data showing,
especially even with gestationaldiabetes, that women have
elevated coronary calciumscores.
Despite where they are aftertheir delivery, if they have U
glycemia or if they're stillpre-diabetic or they turn into
chronic diabetes, their coronarycalcium scores can remain
(22:48):
elevated over time.
So I think there's tools we canuse about, it's not all just
about the numbers and the labs,but we can risk stratify with
high sensitivity CRPS forinflammation.
We can use coronary calciumscores and obviously we still
use stress testing for symptommanagement.
If we're saying we're short ofbreath or have decreased
(23:09):
exercise tolerance and reallyintroducing them to that way of
how we can maintain a healthylifestyle from a very young age
throughout.
Ellen (23:19):
That's wonderful.
I think we could also maybethrow in not only a fasting
lipid panel, but alsolipoprotein little A, which as
we all know is a, is a heritablerisk factor, which although we
aren't treating it directly now,we certainly would be more
aggressive at other risk factormodification, sort of a more
holistic approach.
Dierdre (23:41):
Agreed.
That is my sort of only, youknow, we've all moved kind of
away from primary prevention,aspirin.
But in my sort of own practice,you know, I do use aspirin in
these events when we getcoronary calcium scores greater
than a hundred, or if I havethese lipoprotein little as
greater than a hundred.
This is my sort of like, okay,you win.
(24:01):
I'm gonna give you aspirinmoments for these patients.
I still tend to hedge a littlebit, even for young patients.
Sometimes I'll do intermittentdosing for aspirin just to kind
of minimize bleeding risks forthere.
But I do think that is one ofthose areas where aspirin's not
completely dead to us forprimary prevention and has some
benefit.
Kanny (24:21):
So I think what you're
saying really Deidre, is that
basically once you know theacute period of the pregnancies
passed that.
Our approach should really bethe same way we would approach
anyone that we kind of considera more high risk kind of primary
prevention category in terms ofusing, lifestyle, using,
selective use of screening andright, and, and the selective
(24:41):
application of preventivemeasures.
I am curious though, obviouslythey'll, I'm sure there's plenty
of women who have what you wouldconsider mild, gestational
hypertension, maybe, maybe theyrespond to lifestyle changes in
the end of pregnancy or maybeeven a low dose of one of the
medications you mentioned.
I assume most of them never seea cardiologist during the
pregnancy or the delivery.
(25:03):
Do you feel like the OBcommunity's pretty educated now,
that someone like that shouldstill, benefit from closer
monitoring?
Or do you still see somepatients who kind of fall
through the cracks for a whileeven when, there was kind of a
red flag in pregnancy that they,may have needed to be followed
more closely?
Dierdre (25:21):
Well, I think the short
answer is there's definitely a
lot of people falling throughthe cracks.
I mean, I can speak from my ownexperience with the postpartum
hypertension clinic.
I mean, right now my requirementto be referred is any
hypertensive disorder inpregnancy, so it can just be
gestational hypertension, itcould be chronic hypertension,
preeclampsia, eclampsia, healthsyndrome, any of those qualify.
(25:43):
I also see patients withgestational diabetes and so.
That can be thousands ofpatients.
If we think about the incidencesof gestational diabetes is on
the realm of five to 14%, and wehave similar incidents of that
for hypertension and pregnancyas well.
So thousands of patients yet.
You know, when I fill thesespots and sometimes they are
(26:05):
filled, there tends to be a veryhigh no-show rate.
So I have like 35 to 45% no-showrate for these women that are
even scheduled.
And these are the women thatwe've identified and asked to
come not, and there's a wholeother slew of patients that you
know, have not been identifiedand not referred from there.
So I think.
I have worked very closely withthe OB community and my maternal
(26:27):
fetal medicine colleagues to tryto educate them.
We've made flyers to kind of gothrough the basic, this is what
preeclampsia is, and these arethe risk factors in the future,
and you need to follow up withus so that we can make sure X,
Y, and Z.
And really, you need a primarycare doctor who's going to
follow long term.
We do the same for gestationaldiabetes.
(26:48):
I just think part of it is inthe nature of what it is.
You know, you're catching womenat this very eventful time in
their life.
They have a newborn.
There's a million things tolearn, especially if they're a
first time mom.
I think many women can identifyyour health is not always the
priority if you're leading ahousehold.
And now if you just have a newbaby, you may have other babies
(27:10):
at home too.
And so trying to make themprioritize this when for the
most part they feel relativelyfine, especially if it was
something that resolved quickly.
I think that part is a littlehard, and that's where we rely
on our OB GYN colleagues to kindof.
Even if it's at the six weekmark postpartum going forward to
say, Hey, you know, now thatthings have settled down, we
(27:31):
wanna remind you that you havethis appointment with the
cardiologist so that you can,you know, think about screening
or if there's other pregnanciesfrom there.
So it is a group effort.
I then when I see them in mypostpartum cardiology clinic, I
really am referring them to aprimary care.
'cause many of these women don'thave a primary care provider.
They have their OB, GYN, thatthey either had been using for
(27:54):
birth control, pap smears, andthen pregnancy care, but not
necessarily a primary carethat's doing all their screening
exams and things like that.
So I think we're like a steppingstone to trying to get primary
care and our hope that is thatthen this screening will
continue long term.
Ellen (28:12):
So Deidre, thank you.
You have taught us so much aboutthis topic already, and you've
alluded to your postpartumcardiology clinic.
I was wondering if you couldjust fill in a little bit more
about how you've set that up.
Dierdre (28:26):
Yeah, again, I'll say
the a CC, postpartum
hypertension toolkit is a greatresource because there are many
different ways that you can dothis, and it really kind of
depends on your localenvironment.
For me, because I was trying tomaximize the amount of people
that I could see, and alsobecause I.
In my particular postpartumheart clinic, we do do a lot of
education, and as I'm sure a lotof your listeners know, a lot of
(28:49):
this education and preventionyou can't really bill for,
right?
In a general cardiology sense,so.
The way we do is a sharedmedical appointment.
So we have 10 to 20 patientsscheduled at a time.
We do this in a conference roomthat has some cordon off areas
where we can do private exams.
So a patient will come in and Iwill see them and I have a nurse
(29:12):
practitioner that also works inour clinic and one ma.
So we are a three woman showessentially, and we are seeing
all these patients at one time.
The shared medical appointmentis a 90 minute visit.
We spend about an hour gettingall the people checked in, they
get EKGs, vitals, weights, andphysical exam.
And then about 30 to 40 minutesis a didactic session talking
(29:36):
about hypertension cholesterol,diabetes, and how to minimize
metabolic syndrome, risk factorsin the future.
And so essentially how this isbilled to insurance is just
individual office visits foreach patient, because in a
shared visit, as long as you'redoing an exam, you're taking an
HMPA, you're still reviewing themedications, and I am actually
(29:57):
adjusting medications for manyof them.
The ideal timing that I see themis two to six weeks postpartum.
Some of them stretch out alittle bit, two to three months,
just depending on when they canget scheduled.
But we're still managingmedications for them too and
getting them connected tochronic care.
So in that sense, it's justbilled as a regular office visit
to their insurance and based onyour level of care.
(30:20):
And then essentially they'regetting this education piece bet
from me and my nursepractitioner just thrown into
the visit.
So.
We say a lot of the same things,but this is helpful.
We, we have like a PowerPointpresentation.
They can see images.
We say, this is what, you know,coronary artery disease is, and
this is how it relates to yourcholesterol.
So they're sort of putting thoseconnections together earlier and
(30:43):
hopefully that keeps them moreinformed going forward.
Kanny (30:46):
Well, Deirdre, that,
that's a fantastic summary.
We're kind of up against ourtime, I think.
Mm-hmm.
I was hoping we could put somelinks to the course you alluded
to, as well as that toolkit inour s Sure.
So we're happy to do that.
Just to quickly wrap up though,are there any, you know, what
you would consider like newerfrontiers?
And cardio ob in some of themeetings and stuff.
(31:08):
What, what do you think are someof the areas that as
cardiologists will start youknow, potentially incorporating
into practice in this area inthe next few years?
Dierdre (31:17):
Well, I'm not sure
newer frontiers, but I think
that, you know, like most thingsin cardiology, we see higher and
higher risk patients doing thesethings that we wouldn't think
possible, you know, 10, 20, 30years ago.
So, you know, do we seetransplant patients having
babies?
Do we see LVAD patients havingbabies?
Occasionally, a lot of adultcongenital.
(31:39):
Patients having babies.
So I think that intersection ofheart failure, adult congenital,
and cardiology is ever growingand how those links and sort of
figuring out better ways.
I do think there is a lot ofspace for, you know, in general
maternal mortality and how we'regonna move that needle and
maternal mortality.
And I think as a call to.
(31:59):
Some of your listeners here isthat one of the things is that
every state has a maternalmortality review committee to
that face, and many of thesestates don't have a
cardiologist.
In fact, the grand majority ofthese maternal mortality review
committees don't have acardiologist on the, the review
committee.
And as you know, heart diseasesnow becoming the.
Leading cause of pregnancyrelated mortality.
(32:21):
So I think there's a call for usto get more involved in this
space so that we can reducematernal mortality.
'cause a lot of this is due tohypertension, heart failure,
things like that, that we are,you know, obviously experts at
managing.
So I think that's one of thethings going forward.
Then I think as I alluded tobefore, we'll start to see that
we actually have, you know,practice guidelines, centers of
(32:43):
excellence on how you do this.
And you know, as cardiologistswe love a checklist and a
guideline that we can follow andsay we did X, Y, and Z.
And so hopefully we'll get thatwithin the next 10 to 15 years
as well.
Kanny (32:56):
Well, we look forward to
that.
And we just wanna thank youagain for helping educate our,
our colleagues here in Ohio notjust on the podcast today, but
also with your excellent recentlecture at our spring summit.
And we look forward to hearingabout your clinic and future
endeavors as well.
Dierdre (33:11):
Great.
Thank you guys so much.
I'll definitely send out thelinks to the a CC cardio BCME
and then a call for the fellows.
Ellen (33:18):
Wonderful.
Thank you so much, Deidre, forspending time and sharing your
expertise with us.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,