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Role of CMQCC TK CVD Screening AWHONN2020

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Role of CMQCC TK CVD Screening AWHONN2020 CARDIOVASCULAR DISEASE SCREENING IN PREGNANCY- ROLE OF THE CMQCC TOOLKIT AFSHAN HAMEED, MD, FACOG, FACC HS Professor, Maternal Fetal Medicine & Cardiology University of California, Irvine AWHONN California Section Conference, February 21st 2020, Long Beach CA WHY? Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit Maternal Mortality Child Health USA 2013 Maternal Mortality Ratios in Selected Countries over the Past 30 Years 25 1980 1990 20 15 2000 2008 10 (per 100,000 births) 100,000 (per 5 Maternal Mortality Ratio Mortality Maternal 0 Hogan et al, Lancet 2010; 375: 1609–23 July 17, 2015 The US has the highest Maternal Mortality rate of any high resource country and the only country outside of Afghanistan and Sudan where the rate is rising 3-4 X July 17, 2015 Significant reductions in maternal mortality and morbidity can not be accomplished without addressing the gaps in maternity care for black women 1.6% 2X cdc.gov 8 Maternal Morbidity andMortality: CVD 13 Cardiovascular Related Mortalities/2007 in CA Severe Maternal Morbidity - ICU 13 15-20x Serious 350-400x Morbidity: (prolonged length of stay) LESSONS LEARNED FROM MATERNAL MORTALITY REVIEWS Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit Cardiovascular Disease is the leading cause of maternal mortality in CA and U.S. under-recognized in pregnant or postpartum women higher among African-American women ▪ 25% of deaths attributed to cardiovascular disease may have been prevented if the woman’s heart disease had been diagnosed earlier ▪ Pregnancy is a period of frequent interaction with health care providers and offers an opportunity to detect and treat heart disease, improve pregnancy outcomes, and affect future cardiovascular health. Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings Identification and Confirmation of CVD Pregnancy-Related Deaths 2002-2006 California Birth Cohort, 2002-2006 N=2,741,220 Pregnancy-Associated Cohort N=864 Pregnancy-Related Deaths N=257 Cardiovascular Pregnancy-Related Deaths N=64 Cardiomyopathy Other Cardiovascular N=42 N=22 Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 Top 5 Causes of Death 2002-2005 Pregnancy-Related Grouped Cause of Death, Deaths per CA-PAMR Committee N (%) Cardiovascular disease 49 (24) Cardiomyopathy 30 (15) Other cardiovascular 19 (9) Preeclampsia/eclampsia 36 (17) Obstetric hemorrhage 10 (10) DVT/ PE 20 (10) AFE 18 (9) All other causes 64 (31) TOTAL 207 CVD Pregnancy-Related Mortality Rate: 2.3 deaths /100,000 live births Proportions for Each of the Leading 5 Causes of California Pregnancy-related Mortality 25 23.7 20 17.4 15 related related Mortality - 9.7 9.7 10 8.7 5 % of Pregnancy % 0 CVD PreE/E OB Hem VTE AFE 5 Leading Causes of Pregnancy-related Deaths Note: approx 30% of pregnancy-related deaths were from a variety of “other” causes (each below 8% including sepsis, ICH, other hemorrhages) Main et al. Pregnancy-Related Mortality in California. Obstet Gynecol April 2015 CA-PAMR Findings 2002-2006 Timing of Diagnosis and Death ▪ Timing of CVD Diagnosis (n=64) 3% 8% 6% 34% 48% Preexisting (prior to pregnancy) Prenatal period At labor and delivery Postpartum period Postmortem ▪ Timing of Death ▪ 30% of all CVD deaths were >42 days from birth/fetal demise vs. 7.3% of non CVD pregnancy-related deaths ▪ Driven by Cardiomyopathy deaths, with 42.9% deaths >42 days Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings 2002-2006 Presentation of Women with CVD ▪ Abnormal physical exam findings ▪ HTN >140/90 (64%) ▪ HR >120 (59%) ▪ Crackles, S3 or gallop rhythm etc. (44%) ▪ O2 <90% (39%) Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings Contributing Factors & Quality Improvement Opportunities (2002-2006) for CVD HEALTH CARE PROVIDER RELATED • Contributing Factors: (69% of all cases) ▪ Delayed or inadequate response to clinical warning signs (61%) ▪ Ineffective or inappropriate treatment (39%) ▪ Misdiagnosis (37.5%) ▪ Failure to refer or consult (30%) ▪ Quality Improvement Opportunities ▪ Better recognition of signs and symptoms of CVD in pregnancy ▪ Shortness of breath, fatigue ▪ Tachycardia, blood pressure change, or low oxygen saturation ▪ Improved management of hypertension Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 CA-PAMR Findings Contributing Factors & Quality Improvement Opportunities (2002-2006) for CVD PATIENT RELATED ▪ Contributing factors: (70% of all cases) ▪ Presence of underlying medical conditions (64%) ▪ Obesity (31%) ▪ Delays in seeking care (31%) ▪ Lack of recognition of CVD symptoms (22%) ▪ Quality improvement opportunities ▪ Education around when to seek care for worrisome symptoms ▪ Support for improving modifiable risk factors, such as attaining healthier weight and discontinuing drug use Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008 PREGNANCY SYMPTOMS VS. CARDIOVASCULAR Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit Pregnancy Mimics SYMPTOMS SIGNS • Reduction of exercise • Edema tolerance • JVD • Hyperventilation - shortness of breath • Murmurs • Orthopnea • Palpitations • AUSCULTATION • 96% have a “functional murmur” • Light headedness • Mid-systolic and low intensity • Dizziness/Syncope • Third heart sound is common Plasma Volume in Pregnancy Pitkin RM Clin Obstet Gyn 1976;19:489 Physiologic changes Signs and Symptoms of Pregnancy that mimic heart disease Affect diagnostic tests •Heart failure •Arrhythmia DEATH History Physical Symptoms Examination CMQCC CARDIOVASCULAR DISEASE TOOLKIT Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit California Pregnancy-Associated Mortality Review (CA-PAMR) Quality Improvement Review Cycle 1. Identification of cases 5. Evaluation and Toolkits 2. Information collection, Implementation of QI CVD review by multidisciplinary strategies and tools Venous committee Thromboembolism Hemorrhage Preeclampsia 4. Strategies to 3. Cause of Death, improve care and Contributing Factors and reduce morbidity and Quality Improvement (QI) mortality Opportunities identified IMPROVING HEALTH CARE RESPONSE TO CARDIOVASCULAR DISEASE IN PREGNANCY AND POSTPARTUM: A CALIFORNIA QUALITY IMPROVEMENT TOOLKIT The CVD Toolkit was developed by CMQCC at Stanford University under contract with CDPH with funding from federal Title V MCH Block grant © California Department of Public Health, 2017 Cardiovascular Disease in Pregnancy and Postpartum Task Force Chair: Afshan Hameed MD—UC Irvine Co-Chair: Christine H. Morton PhD—CMQCC WRITING GROUP REVIEWER GROUP ◼ Deirdre Anglin MD, MPH—USC ◼ Kathleen Belzer, CNM, NP—East Bay Perinatal ◼ Julie Arafeh MSN, RN—Stanford ◼ Chloe Bird, PhD—RAND ◼ Alisa Becket—WomenHeart ◼ Susan Bogar, MSN, CNM—UCLA ◼ Leona Dang-Kilduff, RN, MS, CDE—RPPC ◼ Elisabeth Chicoine, MS, RN, PNP—Sonoma County Department of ◼ Elyse Foster, MD—UC San Francisco Health Services ◼ Abha Khandelwal, MD—Stanford ◼ Karen Clemmer, MN, PHN—Sonoma County Department of Health Services ◼ Elizabeth Lawton, MHS—CDPH/MCAH ◼ Uri Elkayam, MD—USC ◼ Elliott Main, MD—CMQCC ◼ William (Bill) Gilbert, MD—Sutter Health System Sacramento ◼ Barbara Murphy, MSN, RN—CMQCC ◼ Tipu Khan, MD—California Academy of Family Physicians ◼ Monica Sood, MD—Kaiser Walnut Creek ◼ Nathana Lurvey, MD—ACOG IX ◼ Maryam Tarsa MD, MAS—UC San Diego ◼ Karen Ramstrom, DO, MSPH—CDPH/ Center for Family Health ◼ Lisa Townsend—Sister to Sister ◼ Mari-Paule Thiet, MD—UCSF ◼ Jan Trial, EdD, RN, CNM—Memorial Care ◼ Julie Vasher, DNP, MSN, RNC-OB, CNS-BC—CMQCC CVD Case Presentation ▪ 25 year old obese (BMI 38) African-American G2P2 presents 10 days after an uncomplicated vaginal delivery with fatigue and persistent cough since delivery. ▪ BP 110/80, HR 110, RR 28, afebrile, with O2 sat 94% on room air. ▪ She gets diagnosed with respiratory infection and is prescribed an antibiotic. Fatigue is attributed to lack of sleep. CVD Case Presentation (CONTINUED) ▪ One week later, she presents again with continued symptoms. Antibiotics are switched and beta-agonists are added for presumptive “new-onset asthma.” ▪ Two days later, the patient experiences cardiac arrest at home and resuscitation attempts are unsuccessful. ▪ Autopsy findings were indicative of cardiomyopathy. CVD Assessment Algorithm for Pregnant and Postpartum Women SYMPTOMS VITAL SIGNS RISK FACTORS ABNORMAL PHYSICAL *NYHA class > II EXAMINATION • Resting HR ≥110 bpm • Age ≥40 years Suggestive of Heart Failure: • Systolic BP ≥140 mm Hg • African American Heart: Loud murmur or • Dyspnea • RR ≥24 • Pre-pregnancy obesity • Mild orthopnea Lung: Basilar crackles • Tachypnea • Oxygen sat
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