Cardionerds: A Cardiology Podcast

CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for this wonderful series, as we journey through the history of cardiology, across 6 extraordinary chapters. We continue with Chapter 5 where Dr. Braunwald discusses his discoveries related to carotid sinus stimulation, limitation of infarct size & the open artery hypothesis. The open artery hypothesis has revolutionized the way we take care of patients with myocardial infarction. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. Audio editing by Pace Wetstein. Dr. Braunwald’s favorite paper: (Please note the very last paragraph)Kjekshus JK. Factors influencing infarct size following coronary artery occlusion. JOslo City Hosp. 1974;24(11-12):155-175. CardioNerds Braunwald Chronicles Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters. We continue with Chapter 4 where Dr. Braunwald discusses his discoveries related to the A “Royal Screw-up” & The Discovery of Hypertrophic Cardiomyopathy. There are hypertrophic cardiomyopathy centers of excellence sprinkled throughout the world. Comprehensive ACC/AHA guidelines for hypertrophic cardiomyopathy that came out in 2020, there’s incredible drug discovery and randomized controlled trials looking at innovations in the management of HCM. We had a whole series on CardioNerds for hypertrophic cardiomyopathy where we taught about the four “Ps” or four preventions of hypertrophic cardiomyopathy management; prevent symptoms, prevent stroke in atrial fibrillation, prevent sudden cardiac death in the patient and prevent sudden cardiac death in the family. How fortunate are we to now hear all about how hypertrophic cardiomyopathy was discovered. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles.Audio editing by Pace Wetstein. CardioNerds Braunwald Chronicles Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters. We continue with Chapter 3 where Dr. Braunwald discusses his discoveries related to the natural history of aortic stenosis, beta-blockers in heart failure and times when seizing the moment led to important contributions to the world of cardiology. Dr. Braunwald also shares insights on mentorship as he speaks fondly of his relationship with the cardiac surgeon, Dr. Andrew “Glenn” Morrow. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. Audio editing by Pace Wetstein. CardioNerds Braunwald Chronicles Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters. We continue with Chapter 2 where Dr. Braunwald discusses his Camelot years, discoveries with regards to myocardial oxygen consumption & how the transseptal approach was developed. We hear about the incredible environment at the NIH during his early days, his delineation of the variables that result in myocardial oxygen demand and the discovery of the transseptal approach, which is so key to so many of our percutaneous interventions today. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. Audio editing by Pace Wetstein. CardioNerds Braunwald Chronicles Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds (Amit Goyal, Daniel Ambinder, Carine Hamo, and Karan Desai) are honored to bring to you the Braunwald Chronicles. These are stories of discovery, innovation, accidents, perseverance, and more…truly these are the stories of cardiology, directly from a father of modern cardiology himself, Dr. Eugene Braunwald. Dr. Braunwald’s life and stories together are the saga which have brought us to this day in modern cardiology. So please join us for the Braunwald Chronicles, as we journey through the history of cardiology, across 6 extraordinary chapters. We begin with Chapter 1: At The Right Place, At The Right Time & With The Right People.  We learn about how serendipitous events in Dr. Braunwald’s early days, paired with his incredible grit & brilliance got him to the NIH where he quickly became the chief of cardiology at the of age 31, the precipice to an illustrious career ahead. We thank Dr. Karan Desai, Editorial APD with the CardioNerds Academy, and fellow at University of Maryland, for all the work he put into designing the Braunwald Chronicles. A very special thanks Dr. Randall Starling, advanced heart failure faculty at the Cleveland Clinic, former President of HFSA, and a dedicated mentor and support to CardioNerds for introducing us to Dr. Eugene Braunwald and for providing the following introduction. Audio editing by Pace Wetstein. CardioNerds Braunwald Chronicles Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds Amit Goya and Daniel Ambinder, cardioobstetrics series co-chair Dr. Natalie Stokes, and episode lead Dr. Priya Kothapalli (University of Texas at Austin, Dell Medical School) discuss pregnancy and coronary artery disease with Dr. Malissa Wood, co-founder and co-director of the Corrigan Woman’s Heart Health center at Massachusetts General Hospital. They discuss the differential diagnosis of chest pain in the pregnant patient, the diagnostic approach and management of acute coronary syndromes in the patient population, and manifestations and management of SCAD in pregnancy. Episode introduction by Dr. Julie Power. Claim free CME for enjoying this episode! Guest Profiles • Production Team CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Guest Profiles – Episode 114. Pregnancy Coronary Disease Dr. Malissa Wood Dr. Malissa Wood is a cardiologist at MGH, where she is one of the founders and co-director of the Corrigan Woman’s Heart Health center at MGH. She has authored two books “Smart at Heart” and “Thinfluence” and she’s made substantial contributions globally in promoting awareness of gender disparities in cardiovascular disease. She is the incoming chair elect for the ACC board of governors and current Governor of the Massachusetts ACC chapter, and is one of the leading experts in the world of Spontaneous Coronary Artery Dissection, or SCAD. Dr. Priya Kothapalli Dr. Priya Kothapalli is a second-year cardiology fellow at The University of Texas at Austin, Dell Medical School. Her clinical interests include endothelial dysfunction and vulnerable plaque. She looks forward to advanced training in interventional cardiology. CardioNerds Cardioobstetrics Production Team Natalie Stokes, MD Sonia Shah, MD Amit Goyal, MD Daniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder), cardioobstetrics series co-chair Dr. Natalie Stokes, Northwestern University CardioNerds Ambassador Dr. Loie Farina, and episode lead fellow, Dr. Agnes Koczo (University of Pittsburgh) join Dr. Julie Damp of Vanderbilt University Associate Director of the VUMC Cardiovascular Disease Fellowship for a discussion about pregnancy, heart failure, and peripartum cardiomyopathy. Episode introduction by Dr. Luis Calderon. Audio editing by Pace Wetstein. Claim free CME for enjoying this episode! Abstract • Pearls • Quotables • Notes • References • Guest Profiles • Production Team CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Episode Abstract In this episode we discuss the presentation of peripartum cardiomyopathy (PPCM), tips for examining a late antepartum patient, and review management of pregnancy complicated by cardiogenic shock.  Weaved throughout the case, we discuss important concepts including the role of prolactin in PPCM which factors into both treatment decisions like prescribing bromocriptine (what!) as well as counseling on breastfeeding. Be sure to tune in to hear Dr. Damp’s review of the latest evidence regarding the diagnosis and management of PPCM, as well as her personal experience counseling patients on heart failure therapies and ICD placement in the context of important factors like breastfeeding status, contraception and future pregnancies. Pearls 1) PPCM most typically presents in the early postpartum period and is defined as an LVEF <45% (with or without LV dilatation and RV involvement) and no other explanation for the cardiomyopathy. 2) Patients with PPCM  can present with classic heart failure symptoms, which may be challenging to distinguish from the typical symptoms and signs of pregnancy. To help differentiate pathology from normal physiology, consider the constellation of exam findings (e.g., isolated peripheral edema versus peripheral edema, +S3, elevated JVD and rales), the severity of the findings, and comparison of symptoms/findings to prior pregnancies.. There are no specific serum markers for PPCM yet. 3) Prolactin and a vascular etiology have been implicated in the  pathogenesis of PPCM. There are ongoing trials to evaluate treatment with bromocriptine, which blocks prolactin (look out for upcoming the REBIRTH RCT examining this!). Importantly, there is no clear evidence that breastfeeding is prohibitive to myocardial recovery and should not be discouraged given benefits to both mom and baby. 4) Many of these patients recover, but those at highest risk are those with severely depressed LV systolic function, dilated LVs, RV involvement, and of African descent. 5) Goal directed medical therapy with beta-blockers in both ante- and postpartum period is a cornerstone of therapy. ACEi/ARB/MRA/ARNI are contraindicated in pregnancy but may be added postpartum and with breastfeeding. Quotables 1.  “It can be so challenging to distinguish symptoms (in a pregnant patient) from cardiac disease! One thing to keep in mind is severity – the more pronounced a finding or symptoms, the more concerning.” – Dr. Julie Damp 2. ”We often have more options than we think in medical management for heart failure through pregnancy and breastfeeding, but they do need some adjustments from our usual therapies.” -Dr. Julie Damp 3. “Start discussions about prognosis, monitoring, future pregnancies, and contraception early!” -Dr. Julie Damp Show notes 1. How do you distinguish findings of normal pregnancy from signs and symptoms of heart failure? Pregnant patients may normally have basal rales that typically clear with coughing, laterally shifted PMI, bounding PMI and pulse, JVD, S3, systolic murmur, edema/tense soft tissue, and heart rate elevation.  Patients may feel short of breath, exertional fatigue, orthopnea, and palpitations. Think about the combination and severity of signs/symptoms to distinguish normal from abnormal (CHF) in your exam. For instance, isolated mild lower extremity edema in a patient who is otherwise relatively asymptomatic with no other concerning findings on exam will be approached differently than a patient with LE edema along with rales, S3 and significant dyspnea. Asking patients who have had a prior pregnancy to compare their symptoms with the prior pregnancy can be helpful as well. Timing of symptoms is also an important thing to consider.  For patients with underlying cardiac disease, they may start to develop symptoms earlier in pregnancy as hemodynamic changes evolve. 2. Given the prolactin hypothesis, should I use bromocriptine for treatment of PPCM and counsel my patients against breastfeeding? Various etiologies regarding the pathogenesis of PPCM have been proposed including myocarditis-like process, autoimmune causes, dietary deficiencies of selenium, as well as remodeling from a maladaptive response to hemodynamic changes in pregnancy. More recently, a vascular-hormonal hypothesis has been proposed where potent anti-angiogenic hormones are released creating a vasculotoxic environment. Specifically, a 16-kda fragment of prolactin, named vasohibin, has been implicated in the pathogenesis. This has led to several RCTs in Germany and Burkina Faso evaluating bromocriptine (a dopamine receptor agonist which inhibits prolactin secretion) for the treatment of PPCM. As more data emerges, the role of bromocriptine will be better defined. For now, patients with more severe PPCM or risk factors that suggest a worse prognosis may benefit from its use. This certainly must be a shared decision as there are risks to bromocriptine including inhibiting lactation and thromboembolism. Use of bromocriptine should be paired with anticoagulation. In the Investigations in Pregnancy Associated Cardiomyopathy (IPAC) study, 100 women were followed prospectively (15 of whom were breastfeeding at entry). While it was a small study, there was no difference in mean change in LVEF from entry to 12 months. While it is a small study, there was not even a signal towards an adverse effect with breastfeeding on myocardial recovery (graphic abstract below). 3. How should we approach patients with PPCM presenting with cardiogenic shock? Note, our usual inotropic agents can still be used in pregnant patients. There have been case series of successful use of mechanical support as a bridge to recovery or durable VAD for PPCM patients. In one review, pregnant patient on VA-ECMO tended to have better outcomes than other patients who require this form of support. This difference is more pronounced if you look at pregnant patients with cardiac cause for decompensation. Their survival approaches 80% with fetal survival of 65%.  Complications of cardiogenic shock are similar those in nonpregnant patients. However with shock in a pregnant patient, we also need to factor in timing and mode of delivery as well as anticipated bleeding with delivery. It is important that management is a discussion across a multi-disciplinary Cardio-Ob team caring for the patient. 4. What are the cornerstones of management for PPCM patients? GDMT: most heart failure medications are considered safe in breastfeeding patients and beta blockers are a cornerstone of therapy (except atenolol). There is no data on ARNI in breastfeeding women yet. ACEi/ARB/MRA/Sacubitril-Valsartan/Ivabradine should not be used during pregnancy. You may use hydralazine/nitrates for afterload reduction in pregnancy. Anticoagulation should be considered postpartum with LVEF < 35%. For patients with PPCM who would typically qualify for an ICD, the general expert consensus experts is to wait longer before placing a device, as there is a high rate of myocardial recovery in the first 6-12 months after diagnosis. An option for these patients is a wearable defibrillator, however, keep in mind that there are logistical challenges with breastfeeding while wearing a defibrillator. Davis, M et al. Peripartum Cardiomyopathy. J Am Coll Cardiol. 2020 Jan 21;75(2):207 221. 5. What are predictors for recovery and what’s important to remember in follow-up for these patients? Low LVEF at diagnosis (particularly LVEF <30%), LV dilatation, and RV involvement are associated with poor prognosis. PPCM disproportionately affects African American women in the US who also have lower rates of recovery and higher morbidity and mortality. In the IPAC study, 70% of patients achieved myocardial recovery (LVEF >50%) by 1 year following diagnosis. However, none of the patients with both LVEF < 30% and LV > 6 cm at presentation recovered to normal LVEF. For those who do not recover normal cardiac function, studies show nearly 50% will go on to further deterioration with a subsequent pregnancy and are at the highest WHO classification risk for pregnancy. Progesterone-releasing subcutaneous implants are first line for contraception, but likely all contraceptive methods have a benefit which outweighs potential risks of a subsequent pregnancy with abnormal baseline cardiac function. References Davis, M et al. Peripartum Cardiomyopathy. J Am Coll Cardiol. 2020 Jan 21;75(2):207 221. Koczo A, Marino A, Jeyabalan A, Elkayam U, Cooper LT, Fett J, Briller J, Hsich E, Blauwet L, McTiernan C, Morel PA, Hanley-Yanez K, McNamara DM; IPAC Investigators. Breastfeeding, Cellular Immune Activation, and Myocardial Recovery in Peripartum Cardiomyopathy. JACC Basic Transl Sci. 2019 Jun 24;4(3):291-300. Elkayam U, Schäfer A, Chieffo A, Lansky A, Hall S, Arany Z, Grines C. Use of Impella heart pump for management of women with peripartum cardiogenic shock. Clin Cardiol. 2019 Oct;42(10):974-981. Olson TL, O’Neil ER, Ramanathan K, Lorusso R, MacLaren G, Anders MM. Extracorporeal membrane oxygenation in peripartum cardiomyopathy: A review of the ELSO Registry. Int Cardiol. 2020 Jul 15;311:71-76. Goland S, Modi K, Bitar F, Janmohamed M, Mirocha JM, Czer LS, Illum S, Hatamizadeh P, Elkayam U. Clinical profile and predictors of complications in peripartum cardiomyopathy. J Card Fail. 2009;15:645–650. doi: 10.1016/j.cardfail.2009.03.008 Elkayam U. Risk of subsequent pregnancy in women with a history of peripartum cardiomyopathy. J Am Coll Cardiol. 2014;64:1629–1636. doi: 10.1016/j.jacc.2014.07.961 Guest Profiles Dr. Julie Damp Dr. Julie Damp is program director of the cardiology fellowship at Vanderbilt University. She was part of the multicenter Peripartum Cardiomyopathy Network for the Investigations in Pregnancy-Associated Cardiomyopathy (IPAC) Study. In addition to her clinical and research work in cardio-obstetrics, her expertise include medical education, critical care cardiology, and noninvasive cardiac imaging. Dr. Agnes Koczo Dr. Agnes Koczo is a second year cardiology fellow at the University of Pittsburgh Medical Center. She is interested in cardio-obstetrics and adult congenital heart disease. She plans to pursue a T32 postdoctoral research fellowship studying immune dysregulation in patients with cardiac complications in pregnancy. Dr. Loie Farina Dr. Loie Farina @loiefarina is a cardiology fellow at Northwestern University. After venturing down south for undergrad at Duke (go Blue Devils!), she returned home to Chicago and has since completed both medical school and residency at Northwestern. She hopes to pursue a career in advanced heart failure and transplantation and is passionate about medical education and heart disease in women. Outside the hospital, she enjoys running along Chicago’s Lakefront Trail, cooking, and exploring new restaurants. CardioNerds Cardioobstetrics Production Team Natalie Stokes, MD Sonia Shah, MD Amit Goyal, MD Daniel Ambinder, MD

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Gina Lundberg (Associate Professor of Medicine at Emory University School of Medicine, Clinical Director of the Emory Women’s Heart Center, and Chair Elect for the ACC WIC Section) and Dr. Zarina Sharalaya (interventional cardiology fellow at CCF, CardioNerds Narratives FIT Council Member) for a Narratives in Cardiology episode. Dr. Lundberg highlights the disparities that exists with representation of women in cardiology and cardiology subspecialties, and how to navigate the challenges that exist for women in cardiology. Dr. Lundberg takes us through her career journey and gives several pearls for fellows-in-training regarding achieving career goals, networking, mentorship, and the use of social media to further your career. Special message from Dr. Annabelle Volgman. Audio editing and episode introduction by Gurleen Kaur. Quotables • Show notes • Guest profiles • About Narratives in Cardiology • Production team Claim free CME just for enjoying this episode! Cardionerds Narratives in Cardiology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll Subscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Quotables “Improving the work environment for women is going to be really important for job retention and for encouraging more women to go into EP, interventional cardiology, and heart failure…” “One of the words of wisdom I say to a lot of early career women is slow down. You don’t have to drink the whole thing in your first 10 years. You can just slowly ease into it- there’s a time and a place for everything, a season for everything.” “So start building your network. Build your ‘otter raft’ and by otter, I mean that group of people, men or women who really support you and lift you up, who might recommend you for a position or a lecture that might share opportunities with you” Show notes What are some strategies to improve female representation in cardiology? Practicing cardiologists, both men and women, need to mentor and sponsor trainees to attract more female into the field. Improving the work environment is key to retention of women in cardiology (allowing for more flexibility to meet needs such as child-care etc.). We need to build the pipleline to start recruiting females early on, even in high school. 2. What are some strategies to network as a fellow-in-training? Start building your network early – attend ACC and AHA meetings. The ACC Legislative Conference is great because it’s a bit smaller and allows for more opportunities to meet leaders in the ACC. Share your story with other people (example your old high school or sorority/fraternity) as an opportunity to mentor and inspire others. Build your “otter raft”… that group of people who really support you and lift you up, who might recommend you for a position or a lecture that might share opportunities with you. 3. What is the role or value of social media for professional development? Social medial democratizes the landscape, giving everyone a voice regardless of level of training, background, or beliefs. It is invaluable for connecting and networking, on a global scale. It empowers individuals to share – be it powerful stories, their thoughts, and of course education. We of course need to be responsible with protecting our patient’s privacy, be discerning consumers, and be professional in our interactions. CardioNerds Narratives in Cardiology The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field. Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc. Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc). Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on: 1) Faculty’s content area of expertise2) Faculty’s personal and professional narrative As part of their narrative, faculty  will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning. To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert. The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez. Guest Profiles Dr. Gina Lundberg Gina Price Lundberg MD FACC FAHA is an Associate Professor of Medicine at Emory University School of Medicine and has served as the Clinical Director of the Emory Women’s Heart Center since it was founded in 2013. She is a Preventive Cardiologist and specializes in heart disease in women, lipid abnormalities and cardiovascular risk reduction. She founded the first women’s heart prevention program in the state of Georgia in 1998. Dr Lundberg’s service at Emory University includes improving outcomes for women with cardiovascular disease but also improving gender equity for women in cardiology and encouraging more women to choose cardiology for their careers. She attended the Medical College of Georgia at Augusta University and trained in Internal Medicine at Atlanta Medical Center. Her cardiology fellowship was at Rush University in Chicago. She is active with the ACC, AHA, and NLA. She is the Chair-elect for the ACC Women in Cardiology Leadership Council and is the co-chair for the WIC Communications and Social Media Committee. She is the Co-chair for the NLA Social Media and Communications committee and the co-Chair for NLA DE&I Committee. She serves on the AHA Clinical Cardiology Communications and Social Media committee and the AHA Familial Hypercholesterolemia and Hyperlipidemia working group. And she serves as the Social Media Supervisor for JACC Case Reports. Dr. Zarina Sharalaya Dr. Zarina Sharalaya is an interventional cardiology fellow at the Cleveland Clinic. She completed medical school at The Ohio State University and then completed her residency at The University of North Carolina Chapel Hill. She moved back to her home state of Ohio to do general cardiology fellowship at The Cleveland Clinic. Zarina has been very involved with the Ohio ACC and this year has served as co-chair of the FIT Council. She is passionate about the Women in Cardiology initiative has been able to help formulate the first WIC chapter for Ohio ACC. She enjoys traveling, music, and spending time with her husband and new puppy Zuma. Narratives in Cardiology Production Team Gurleen Kaur Amit Goyal, MD Daniel Ambinder, MD

CardioNerd Amit Goyal, cardioobstetrics series co-chair Dr. Natalie Stokes, and episode lead Dr. Daniela Crousillat discuss normal cardiovascular physiology in pregnancy with Dr. Garima Sharma, Director of the Cardio-Obstetrics Program and the Ciccarone Center ‘s Associate Director of Preventive Cardiology Education in the Division of Cardiology. They discuss physiology from conception to post-partum, including the key hemodynamic, hormonal, and structural changes associated with normal pregnancy in the absence of pre-existing cardiovascular disease. Series introduction by Dr. Sharonne N. Hayes. Claim free CME for enjoying this episode! Abstract • Pearls • Quotables • Notes • References • Guest Profiles • Production Team CardioNerds Cardio-Obstetrics Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Episode Abstract Join us for a thrilling ride with our expert as we dive into the normal cardiovascular physiology of women through pregnancy. We discuss physiology from conception to post-partum, including the key hemodynamic, hormonal, and structural changes associated with normal pregnancy in the absence of pre-existing cardiovascular disease. We discuss how these physiologic changes manifest the history, physical exam, and key diagnostic testing (ECG, laboratory markers, and echocardiogram). Armed with these basic principles, we join Dr. Garima Sharma on patient consults to learn about potential signs and symptoms of cardiovascular disease in pregnancy and appropriate ways to risk stratify women with pre-existing or acquired cardiovascular disease in pregnancy. Importantly, we delve deeper into the importance of the growing field of cardio-obstetrics in the context of rising maternal mortality and staggering racial disparities in the care and outcomes of women in pregnancy. Pearls In normal pregnancy, plasma volume increases by up to 50% resulting in an adaptive decrease in systemic vascular resistance (SVR) by 25% and an increase in cardiac output (CO) by ~50% by the 2nd trimester. Brisk carotid upstrokes, an S3 gallop, soft systolic ejection murmurs, pedal edema, and a mildly elevated jugular venous pressure (JVP) can all be normal physiologic findings in pregnancy in the context of no other signs/symptoms to suggest heart failure. A normal NT-proBNP among pregnant patients with pre-existing cardiovascular disease has a high negative predictive value for predicting adverse maternal cardiac outcomes. Pregnancy risk predictor tools (mWHO, CARPREG II, ZAHARA) are a crucial component of pre-conception counseling to help predict which women with existing cardiovascular disease are at highest risk for adverse maternal outcomes. The U.S. ranks 1st in the world for maternal mortality among developed nations and cardiovascular disease is the leading cause of pregnancy-associated mortality in the U.S. Non-Hispanic Black are 3.5 times more likely to die from pregnancy as compared to White women. Quotables “You don’t know where you are going until you know where you have been” – Dr. Garima Sharma on the importance of holding on to hope when encountering difficult situations in our training and career pathways. “Do not fear the pregnant patient! The pregnant patient is going through a normal physiologic process in her life, and the more we are familiar with it, the less we fear it” – Dr. Garima Sharma on taking care of pregnant patients. “If you are going to move the needle on maternal mortality and in making a long-term sustainable change in the lives of these women, you have to focus on prevention” – Dr. Garima Sharma on the importance of prevention in reducing maternal mortality. “Be empathetic. For most women, pregnancy is a normal state.  These women need your help!” – Dr. Garima Sharma on the importance of taking care of women in pregnancy. Show notes What are the normal hemodynamic changes that occur in pregnancy? Let’s talk physiology! Pregnancy, nature’s most grueling stress test, is a dynamic process associated with significant hemodynamic and physiological adaptations in the cardiovascular system which have evolved to support the needs of a developing fetus. Predictable and expected hemodynamic changes occur during pregnancy for all women. Healthy women can adapt without significant consequences, whereas in women with underlying cardiac conditions, these changes may unmask a previously unknown condition or exacerbate existing abnormal hemodynamics. Adaptive Physiologic Changes of the Cardiovascular System (1) Source:  Me Mehta LS, Warnes CA, Bradley E et al. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation 2020;141:e884-e903. Supplemental Table 1: Physiologic Changes Throughout Normal Pregnancy Compared to Pre Pregnancy State (2) Plasma volume Increases by about 50-75% by the 2nd trimester of pregnancy to meet greater circulatory needs of placenta and maternal organs Erythropoietin causes an increase in red cell mass by 20-30% leading to relative dilution and “physiologic” anemia of pregnancy Systemic vascular resistance (SVR) To accommodate the increase in plasma volume, vasodilatation and vascular remodeling occur with a reduction in SVR SVR decreases starting early in the 1st trimester and falls by 25-30% in the 2nd trimester potentiated by progesterone and estrogen-induced vasodilatation Decreased SVR results in activation of the renal angiotensin-aldosterone system (RAAS) to maintain blood pressure and salt/water balance Cardiac output (CO) Increases by ~ 50% during pregnancy (up to 75% for a twin gestation!), starting at 5 weeks of gestation, and peaks at about 18-24 weeks in the 2nd trimester CO (stroke volume (SV) x heart rate (HR)) increases predominantly via an increase in SV, but also an increase in HR by about 10-15 bpm by the 3rd trimester due to activation of the sympathetic system There are a multitude of other physiological changes that allow our cardiovascular systems to adapt to the normal hemodynamics of pregnancy. Respiratory:  Increase in metabolic rate & O2 consumption, minute ventilation and tidal volume resulting in a mild compensatory respiratory alkalosis. Renal: Systemic vasodilation results in 50% increase in renal plasma flow and glomerular filtration rate (GFR), activation of RAAS to maintain fluid and electrolyte balance. Hematologic: “Physiologic” anemia of pregnancy due to increase in plasma volume > red blood cell mass, increased production of coagulation factors with promotion of a pro-thrombotic state. Endocrine: Increase in total cholesterol, triglycerides, LDL (by 50%) and decrease in HDL; mild insulin resistance. Labor & Delivery and Post-Partum Period: Labor:  The maximum CO associated with pregnancy occurs during labor and immediately post-partum. Repeated Valsalva maneuvers with a doubling of CO (up to 10L!) in active labor Each uterine contraction displaces about 300-500 mL of blood back into the maternal systemic circulation Post-partum: Immediate: Caval decompression from evacuation of gravid uterus leads to marked increase in venous return (“auto transfusion”) back into the maternal systemic circulation Two weeks post-partum: Maternal hemodynamics largely return to the pre-pregnancy state! 2. How are the normal physiological changes of pregnancy reflected in the physical exam and diagnostic cardiac testing? When should we worry? Physical Exam (2) Heart rate: Increases by 10-15 bpm by 3rd trimester, mild sinus tachycardia Blood pressure: Decrease of 10-15 mm Hg in both SBP and DBP, nadiring in 2nd trimester, improving to pre-pregnancy state in 3rd trimester Weight: 25-35 lbs considered normal total gestational weight gain in patients who are normal weight pre-partum Cardiac exam: Mildly elevated jugular venous pressure with more prominent x and y descents, brisk carotid upstrokes, soft, systolic ejection murmur (flow murmur), S3 gallop, mild pedal edema, varicose veins, mammary flow murmur ECG: Mild sinus tachycardia Infrequent premature atrial and ventricular atrial contractions Leftward axis deviation Q waves in inferior (II, III, aVF) and/or lateral (V4-V6) leads due to heart’s spatial shift left, anterior, and in the transverse plane to accommodate the gravid uterus Cardiac Biomarkers NT-proBNP Increase up to two-fold in pregnancy but should remain within normal range Important clinical utility in patients with pre-existing cardiac disease to serially assess changes throughout pregnancy BNP <100 pg/nL among women with cardiovascular disease has a 100% negative predictive value for identifying cardiac events during pregnancy (3) NT pro BNP <128 at 20 weeks has 97% NPV for maternal complications (4) Echocardiography: (5) Increase in LV volumes (but remaining within normal limits) and 50% increase in LV and RV mass as response to increased blood volume and CO “Physiologic” left ventricular hypertrophy Left ventricular ejection fraction remains unchanged Mild increase in aortic root diameter Trivial MR, TR, and PR (not typically AR!) Trace, physiologic pericardial effusion (can be normal in up to 40%) When should we worry? Diastolic murmurs Signs of congestive heart failure (crackles, elevated JVP/Kussmaul’s sign, marked lower extremity edema or weight gain) Loud P2 or RV heave which could signal elevated pulmonary pressures/pulmonary HTN Elevated NT-proBNP Large pericardial effusion or symptoms of pericarditis 3. What are the available pregnancy risk predictor scores for the risk stratification of women with pre-existing cardiovascular disease who are interested in achieving pregnancy? Modified World Health Organization (mWHO) Classification (6) Most commonly used risk prediction tool to estimate individual maternal cardiovascular risk in women with pre-existing CVD based on known cardiac pathology Classification ranges from simple lesions in Class I (mitral valve prolapse, repaired ASDs) to Class IV (pulmonary arterial hypertension, severe MS/AS, peripartum cardiomyopathy) in which pregnancy is typically advised against due to high (20-25%) maternal risk of adverse events CARPREG (CArdiac Disease in PREGnancy Study) II Risk Score (7) Developed from the prospective Canadian Cardiac Disease in Pregnancy Study in women with pre-existing cardiac disease, the score includes 10 predictors of a cardiac event,  including a prior history of cardiac events, baseline NYHA functional class, and late access to prenatal care to better determine overall risk (different than the mWHO classification which is based on just the cardiac lesion) Weight-based point system: 5% risk of complications in lowest risk group (0 to 1 points) versus >40% risk with > 4 points Source: Silversides CK, Grewal J, Mason J et al. Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study. J Am Coll Cardiol 2018;71:2419-2430. (7) ZAHARA Risk Score Weighted scoring system based on retrospective cohort of patients with pre-existing congenital heart disease only Least commonly used risk tool as based on limited patient population (ACHD) 4. What are the most common cardiac complications which can occur in women with pre-existing cardiovascular disease in pregnancy and when do they occur? Arrythmias: Atrial fibrillation is the most common arrythmia in women with underlying structural heart disease. PACs/PVCs can be common in normal pregnancy. If they occur, arrythmias are most common in the 2nd trimester. Heart failure: Worsening/decompensation of left ventricular function, particularly in women with personal or family history of cardiomyopathy and history of peripartum cardiomyopathy. The development of heart failure and pulmonary edema are most common in the 3rd trimester or immediately (<1 week) post-partum. (7) Don’t forget about other adverse pregnancy outcomes (APOs) which are associated with long term cardiovascular complications! (8) Maternal Complications: Hypertensive disorders of pregnancy (i.e. pre-eclampsia), gestational diabetes Obstetrical/Fetal Complications: Preterm birth, small for gestational age infant Review Ep #18 with Dr. Martha Gulati and Ep #41 with Dr. Leslie Cho for more! 5. What is the state of maternal mortality in the U.S. compared to the rest of the world, and what is this rise in maternal mortality attributed to? The United States ranks 1st among developed nations in maternal mortality (9) Cardiovascular disease is the leading cause of pregnancy-associated mortality in the United States and has gradually increased over time (7 to 17 deaths per 100,000 live births from 1989-2017) Maternal mortality is attributed to 1) rising maternal age, 2) comorbid pre-existing conditions (HTN, diabetes, obesity), and 3) the growing number of women with congenital heart disease achieving childbearing age Increase in obesity (41% of U.S. population) and chronic hypertension are two of the most important preventable risk factors! Pre-pregnancy HTN has doubled among women in past decade and disproportionately affects rural communities and racial groups (10) Over 700 women a year die of complications related to pregnancy each year in the United States, and it is thought that about two-thirds of those deaths are preventable. Non-Hispanic Blacks and American Indian/Alaskan Native women are 3-4x more likely to die from a pregnancy-related cause compared to White women (11). Source: 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;68:762–765. (11 References Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation 2014;130:1003-8. Mehta LS, Warnes CA, Bradley E et al. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation 2020;141:e884-e903. Tanous D, Siu SC, Mason J et al. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll Cardiol 2010;56:1247-53. Kampman MA, Balci A, van Veldhuisen DJ et al. N-terminal pro-B-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease. Eur Heart J 2014;35:708-15. Liu S, Elkayam U, Naqvi TZ. Echocardiography in Pregnancy: Part 1. Current cardiology reports 2016;18:92. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Kardiologia polska 2019;77:245-326. Silversides CK, Grewal J, Mason J et al. Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study. J Am Coll Cardiol 2018;71:2419-2430. Søndergaard MM, Hlatky MA, Stefanick ML et al. Association of Adverse Pregnancy Outcomes With Risk of Atherosclerotic Cardiovascular Disease in Postmenopausal Women. JAMA cardiology 2020;5:1390-8. Pregnancy Mortality Surveillance System.       https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillancesystem.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpmss.html. Accessed January 18th, 2021. Cameron NA, Molsberry R, Pierce JB et al. Pre-Pregnancy Hypertension Among Women in Rural and Urban Areas of the United States. J Am Coll Cardiol 2020;76:2611-2619. Petersen EE, Davis NL, Goodman D et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths – United States, 2007-2016. MMWR Morbidity and mortality weekly report 2019;68:762-765. Guest Profiles Garima Sharma M.B.B.S. Dr. Garima Sharma is an Assistant Professor of Medicine in the Division of Cardiology and Department of Medicine at Johns Hopkins University. She serves as Director of the Cardio-Obstetrics Program and the Ciccarone Center ‘s Associate Director of Preventive Cardiology Education in the Division of Cardiology. Her clinical and research interests are in CVD in pregnancy specifically adverse pregnancy outcomes and CV risks, hypertensive disorders of pregnancy, and gender equity. Daniella Crousillat, MD Dr. Daniella Crousillat is an advanced echocardiography fellow at Massachusetts General Hospital in Boston, MA. She is interested in sex differences in valvular heart disease and pregnancy-associated CVD with a special focus on health disparities and the care of vulnerable patient populations. CardioNerds Cardioobstetrics Production Team Natalie Stokes, MD Sonia Shah, MD Amit Goyal, MD Daniel Ambinder, MD

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