California Cardiovascular Screening Tool: Findings from Initial Implementation

Abstract

Objective American College of Obstetricians and Gynecologists (ACOG) recently published the California (CA) cardiovascular disease (CVD) screening algorithm for pregnant and postpartum women. We aim to prospectively determine screen-positive and true-positive rates of CVD among women across two populations.

Study Design This is a prospective cohort study of obstetrical patients from April 2018 to July 2019 at academic medical centers in CA and New York (NY). We attempted to screen all patients at least once during their pregnancy care (prenatal or postpartum). Women who screened positive (“Red Flags,” >3–4 moderate risk factors, abnormal physical examination, and persistent symptoms) underwent further testing. The primary outcome was the screen-positive rate. Secondary outcomes included the true-positive rate and the strength of each moderate factor in predicting a positive CVD screen.

Results We screened 846 women. The overall screen-positive rate was 8% (5% in CA vs. 19% in NY). The sites differed in ethnicity, that is, African American women (2.7% in CA vs. 35% in NY, p < 0.01) and substance use (2.7 vs. 5.6%, p < 0.04). The true-positive rate was 1.5% at both sites. The percentage of screen-positive patients who did not complete follow-up studies was higher in NY (70%) than in CA (27%). CVD was confirmed in 30% with positive screens with complete follow-up. Combinations of moderate factors were the main driver of screen-positive rates in both populations.

Conclusion This is the first data describing the performance of the CVD screening algorithm in a general obstetric population. Factors, such as proportion of African American women affect the likelihood of a positive screen. The screening algorithm highlights patients at higher lifetime risk of CVD and may identify a group that could be targeted for more direct care transitions postpartum. Data may be used to design a larger validation study.

Keywords

cardiovascular disease in pregnancy - cardiovascular screening in pregnancy - cardiovascular disease prediction in pregnancy - maternal mortality

Note

The work was presented at the Society for Maternal Fetal Medicine's 40th Annual Pregnancy Meeting February 6, 2020 in Grapevine, Texas.

Publikationsverlauf

Eingereicht: 20. Februar 2020

Angenommen: 13. Mai 2020

Artikel online veröffentlicht:
16. November 2020

• References

• 1 American College of Obstetricians and Gynecologists' Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 212: pregnancy and heart disease. Obstet Gynecol 2019; 133 (05) e320-e356
• 2 Petersen EE, Davis NL, Goodman D. et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
• 3 Hameed AB, Lawton ES, McCain CL. et al. Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. Am J Obstet Gynecol 2015; 213 (03) 379.e1-379.e10
• 4 Mehta PK, Minissian M, Bairey Merz CN. Adverse pregnancy outcomes and cardiovascular risk factor management. Semin Perinatol 2015; 39 (04) 268-275
• 5 CDC. Accessed June 8, 2019 at: https://www.cdc.gov/women/lcod/2015/race-ethnicity/index.htm
• 6 Petersen EE, Davis NL, Goodman D. et al. Racial/ethnic disparities in pregnancy-related deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2019; 68 (35) 762-765
• 7 California Maternal Quality Care Collaborative. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum. Available at: https://www.cmqcc.org/resources-toolkits/toolkits/improving-health-care-response-cardiovascular-disease-pregnancy-and . Accessed August 30, 2020
• 8 Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med 1990; 322 (22) 1561-1566
• 9 Lieb W, Gona P, Larson MG. et al. The natural history of left ventricular geometry in the community: clinical correlates and prognostic significance of change in LV geometric pattern. JACC Cardiovasc Imaging 2014; 7 (09) 870-878
• 10 Lane-Cordova AD, Khan SS, Grobman WA, Greenland P, Shah SJ. Long-term cardiovascular risks associated with adverse pregnancy outcomes: JACC review topic of the week. J Am Coll Cardiol 2019; 73 (16) 2106-2116
• 11 Wu P, Mamas MA, Gulati M. Pregnancy as a predictor of maternal cardiovascular disease: the era of cardioobstetrics. J Womens Health (Larchmt) 2019; 28 (08) 1037-1050
• 12 Smith GN, Louis JM, Saade GR. Pregnancy and the postpartum period as an opportunity for cardiovascular risk identification and management. Obstet Gynecol 2019; 134 (04) 851-862
• 13 Gladstone RA, Pudwell J, Nerenberg KA, Grover SA, Smith GN. Cardiovascular risk assessment and follow-up of women after hypertensive disorders of pregnancy:a prospective cohort study. J Obstet Gynaecol Can 2019; 41 (08) 1157-1167.e1
• 14 Grandi SM, Filion KB, Yoon S. et al. Cardiovascular disease-related morbidity and mortality in women with a history of pregnancy complications. Circulation 2019; 139 (08) 1069-1079
• 15 Gladstone RA, Pudwell J, Pal RS, Smith GN. Referral to cardiology following postpartum cardiovascular risk screening at the maternal health clinic in Kingston, Ontario. Can J Cardiol 2019; 35 (06) 761-769
• 16 Scholten RR, Thijssen DJ, Lotgering FK, Hopman MT, Spaanderman ME. Cardiovascular effects of aerobic exercise training in formerly preeclamptic women and healthy parous control subjects. Am J Obstet Gynecol 2014; 211 (05) 516.e1-516.e11