Survey: Many cardiologists not confident safely prescribing to pregnant patients
Click Here to Manage Email Alerts
A survey of U.S. cardiologists, CV team members and fellows in training revealed few ever received cardio-obstetrics didactics during training and many institutions lacked access to dedicated cardio-obstetrics teams, researchers reported.
Although approximately 86% of practicing cardiologists surveyed see patients who are pregnant every year, half were not confident in prescribing CV medications to these patients, according to findings published in the Journal of the American Heart Association.
“Prior to this survey, other than a few institutional-specific reports, we had no data about the current state of cardio-obstetrics knowledge and training or availability of this team-based model of care in the U.S. I’m in the minority of individuals who has been fortunate enough to practice at an institution like Cedars-Sinai where patients have access to excellent cardio-obstetrics team-based care,” Natalie A. Bello, MD, MPH, director of hypertension research in the department of cardiology at the Smidt Heart Institute at Cedars-Sinai, told Healio. “We need more educational opportunities for trainees and practicing clinicians to fill the self-identified gaps in knowledge. This doesn’t mean that everyone needs to be an expert in the field, but the general knowledge base should be augmented to provide better care to all of our patients.
“I was somewhat surprised by the low numbers. I didn’t think we would see exceptionally high rates of training reported by people who have been in practice, but it was especially eye opening to find that 83% of current fellows report no formal training available in their program,” Bello told Healio. “It should be noted that we didn't directly survey program directors, so it is possible that this is an underestimation.”
Design of cardio-obstetrics training survey
To better understand the level of cardio-obstetrics knowledge, practices and services provided in the U.S., researchers conducted a cross-sectional e-mail survey of 5,091 U.S.-based American College of Cardiology member clinicians, including adult and pediatric cardiologists, fellows in training and CV team members, such as nurse practitioners, pharmacists, physician assistants and registered nurses.
The survey included 24 items, covering the topics such as care of patients who are pregnant/postpartum; personal competency in managing CVD in patients who are pregnant and nonpregnant; presence and composition at the respondent’s institution of a dedicated cardio-obstetrics team; prior training/education in cardio-obstetrics; and desired educational needs and resources.
Gaps identified in cardio-obstetrics knowledge
Approximately 10% of the selected cohort submitted responses to the e-mail survey, of whom 311 were cardiologists (26% women), 51 were CV team members (84% women) and 139 were fellows in training (37% women).
Based on survey responses, 56% of cardiologists were confident in prescribing a CV medication to a patient who is pregnant and 52% were confident prescribing to a patient who is lactating. Fellows in training and CV team members were less confident compared with cardiologists.
Researchers reported that the widest knowledge gaps on the care of patients who were pregnant compared with nonpregnant were around medication safety (42%), ACS (39%), aortopathies (40%) and valvular heart disease (30%).
In addition, 76% of respondents reported a lack of access to a dedicated cardio-obstetrics team at their respective institutions, and just 29% of cardiologists reported receiving cardio-obstetrics didactics during training, according to the study.
Bello and colleagues found that one-third of fellows in training reported seeing a patient who is pregnant zero to one time per year. Moreover, only 12% of fellows in training reported receiving formal training in cardio-obstetrics. Among CV team members, 94% reported receiving no formal cardio-obstetrics training.
Ninety-two percent of respondents responded positively to the idea of the inclusion of cardio-obstetrics among ACC educational products.
“Comprehensive training depends somewhat on what type of cardiology an individual plans on practicing, and where they will be practicing. For example, someone at a large academic center with a robust cardio-obstetrics program doesn't necessarily need the same skill set as someone in a rural area where they may be the only cardiologist within a several hour drive for patients,” Bello told Healio. “However, at a bare minimum, all cardiologists should be familiar with the care of pregnant individuals in important areas including but not limited to the evaluation and management of a pregnant individual with chest pain or valvular heart disease, the treatment of hypertension in pregnant individuals as well as those with hypertension who are thinking about becoming pregnant and those with aortopathies.
“The ACC is in the process of organizing a CME event focused on addressing the gaps in knowledge identified in this survey,” Bello said. “In addition, the Cardio-Obstetrics Work Group within the ACC has been providing quarterly journal clubs on cardio-obstetrics that are free, 1-hour sessions highlighting important topics in the field and providing expert opinions on the best ways of treating specific conditions in pregnant patients. It's also really important that general cardiology and subspecialty groups add sessions related to cardio-obstetrics didactics at annual meetings and other CME events. We’ve started to see this more over the past several years, but a more seamless integration into all aspects of cardiology training and CME is needed.
Perspective
Back to Top
Martha Gulati, MD, MS, FACC, FAHA, FASPC
We are now finally talking more about cardio-obstetrics and its importance in the cardiology community. Although less than one-third of people report having some form of specialized care for the cardio-obstetric patients, this is far better than a decade ago. We are making progress. We have a cardio-obstetric community within cardiology and the work that is clearly apparent via this survey emphasizes the need for this to be a focus within all training programs and also a subspecialty.
If we intend to contribute to closing the gap in maternal mortality in the U.S., it is going to take an extraordinary effort. But this will require cardio-obstetrics to be a core component of training for all cardiologists, and a specialty at tertiary birth centers to provide expertise in the highest risk birthing persons.
We also need to train more than just cardiologists. The entire CV team needs to have some training and understanding of these high-risk, complicated patients. It is time for us to take ownership of these patients and not think of them as a problem for our OB-GYN colleagues. This will require a team approach, that is well-trained, well-equipped and prepared for cardio-obstetrical urgencies and emergencies, in addition to preventive CV care in those who survive childbirth but are identified to be at future risk for atherosclerotic CVD.
We are at the earliest stages of a significant body of data related to cardio-obstetric issues. We have a way to go from the evidence to implementation into training and clinical practice. But surveys and papers like this are necessary to create the energy for change.
In my hospital, I was really the only cardiologist with any "expertise" in this area. Most cardiologists ran from obstetrics patients. Similarly, CV team members, but this is because most people are not trained in this area. Was I trained? No. I just learned as I went because of necessity and because these patients were always sent to me, or I was asked to consult on them.
At one point, we had so limited literature available even to guide us. Now it is changing. If we implement standardized training, this too will change. Patients should be assured that it is changing. There are new programs opening everywhere. Today, I read a tweet from Kardie Tobb, DO, in North Carolina who announced the opening of a new cardio-obstetrics clinic that she is running. How exciting for people in Greensboro, North Carolina, and I expect to see many more. We are training the next generation, and this is an important area that many trainees are interested in.
Collapse
Click Here to Manage Email Alerts