Dr Kathryn Lindley on Pregnancy-Related Cardiovascular Care Gaps and Training Initiatives

Kathryn Lindley, MD, FACC –

Vanderbilt University Medical Center

In the second part of this 2-part interview, Kathryn Lindley, MD, FACC, associate professor of medicine and associate professor of obstetrics and gynecology at Vanderbilt University Medical Center, explained to The American Journal of Managed Care® (AJMC®) how cardiologists need skills in risk assessment, contraception counseling, and hypertension management for pregnant patients. Lindley also noted that fellowship training should cover these, and that there are ongoing efforts for center-based accreditation.

AJMC: What are some specific skills or knowledge areas that are particularly important for cardiologists to have when caring for pregnant patients with cardiovascular disease, especially when caring for a diverse array of patients?

Lindley: There are several things that really all cardiologists should be competent in. We should all be competent in being able to understand what the risk is of any given patient for having cardiovascular complications in pregnancy so that we can recognize if someone is low risk and they can safely proceed with pregnancy, or if someone is high risk and they either need to be referred to a specialist or they need to consider a pregnancy termination. It's important that this risk stratification occurs early so that patients can be promptly plugged in with the right providers in a really timely manner.

It's also really important that all cardiologists know how to talk to their patients about contraception. I think a lot of times we think about our role being talking to our patients about beta blockers and cholesterol medications, but many of our patients may not have a primary care provider or they may not be seeing an OBGYN routinely, and it's really important that we counsel them on the safety and efficacy of the different available methods of contraception so we can help them effectively plan their pregnancies. The last thing I would say is, it's really important for cardiologists to understand how to manage high blood pressure in pregnancy. We take a very different approach to high blood pressure and pregnancy in the early postpartum period, it's really a major driver of adverse cardiovascular outcomes in pregnant patients, and so I think it's really valuable for cardiologists to understand how and why we manage high blood pressure differently so that we can really think about that through a little bit of a different lens.

AJMC: How can the skills that you talked about be incorporated into fellowship training programs? Are there any initiatives that you're particularly proud of where you are training these specialists on these topics?

Lindley: We actually just recently published a manuscript in the Journal of the American College of Cardiology where we sort of outlined our recommendations for training for cardiologists, and we think about this in several levels of expertise. We recommend that all cardiologists have sort of level 1 expertise, meaning that all cardiologists should know the basics. That can be obtained by didactic lectures, by spending a little bit of time in inpatient outpatient services and cardio obstetrics, and I having some interactions with interdisciplinary team members such as high risk obstetricians and obstetric anesthesiologist. And this should probably be incorporated at least several weeks throughout the course of the 3-year fellowship. Now, for people who are interested in having more of a subspecialty of cardio-obstetrics, those people can think about spending more time taking care of pregnant and reproductive age patients under the supervision of a cardio-obstetrics expert. These trainees will see a large number of patients, they'll preferably do an academic research project in this space, and they'll come out highly competent to develop very complex delivery care plans and will have a lot of experience in recognizing and treating cardiovascular complications in pregnancy.

AJMC: Are there any ongoing efforts to develop accreditation requirements for cardio-obstetrics training, and if so, what are some of the key components of these requirements?

Lindley: Yes, there are some ongoing efforts. I think we're still a little ways from seeing this come to fruition, but there certainly are higher level discussions happening for this right now. There's been a lot of discussion about whether this should be a board certification for individual practitioners vs something that we should look at at a medical center and accredit the center itself. It seems like we're leaning more towards center-based accreditation rather than individual-based accreditation, which in some ways makes a lot of sense because it really is a team effort. It's not really about 1 OBGYN or 1 cardiologist who's really good at caring for these patients, it's really about organizing a whole team of coordinated care for these patients.

AJMC: Is there anything else you would like to mention?

Lindley: We did recently perform a survey of the members of the American College of Cardiology, and we identified that there are really significant knowledge and comfort gaps amongst members across the spectrum—practicing cardiologists, fellows in training, and cardiovascular team members—when it comes to managing cardiovascular problems, providing counseling, and managing medications in pregnant and lactating patients. It indicates to us, kind of as we suspected, that there really is a pretty significant knowledge gap out there among those of us who are practicing in cardiology, which really supports the need both for more education and training for the general cardiology community as well as to increase the number of experts that are out there.