Park and colleagues highlight the value of screening for female-specific risk factors related to OB-GYN history for assessing risk and stress the importance of developing a system to transition women, such as those with hypertensive disorders during pregnancy, to regular follow-up with a primary care physician or cardiologist. They also suggest using OB-GYN visits to screen women for risk factors, given many women often use their OB-GYN as their primary care provider.

In a separate viewpoint, Victor G. Becerra-Gonzales, MD, and Claudia Martinez, MD, note the increase over the last decade in the availability and use of ART, but explain there is a limited amount of conclusive research on the cardiovascular effects of high doses of hormone therapy in women, especially those of "later age." They stress the need for "increased funding and attention to the design of studies to clarify the cardiovascular effects of ART in women."

The creation of a formal and structured women's cardiovascular health curriculum within fellowship training programs is key to ensuring clinicians understand and gain expertise in sex- and gender-specific cardiovascular care, according to Nosheen Reza, MD; Srinath Adusumalli, MD, MSc, FACC; and Matthew D. Saybolt, MD, FACC, et al., in another viewpoint.

Reza and colleagues provide an inside look at the woMen's CardiovAsCular HeAlth (MUCHACHA) curriculum implemented in 2016 as part of the University of Pennsylvania's cardiovascular disease fellowship training program. "Our hope is that these efforts will improve the education of future generations of trainees; encourage team-based approaches to care, research and quality improvement; and ultimately, reduce disparities in prevention and treatment of cardiovascular diseases in women."

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The authors recommend that cardiologists screen their patients for marijuana use, asking them how often and how much they use. They also should ask about how their patients use marijuana. For patients who wish to continue to use marijuana, or who have other medically indicated reasons for use, the reviewers recommend limiting use as much as possible and for clinicians to inform patients that vaping and certain synthetic forms of cannabinoids are particularly potent and may have greater adverse effects. Some patients, such as those considered for heart transplantation or those who present with early-onset myocardial infarction or heart failure at a young age, should be screened for marijuana use.

The review provides detailed tables of many drugs administered for various cardiovascular conditions, with the anticipated effects of marijuana on each one. These can be used by caregivers to decide whether they need to adjust dosing if the patient continues to use marijuana.

Data on the exact health effects of marijuana on the cardiovascular system are limited, largely because federal laws that classify marijuana as a Schedule I drug have limited the ability of scientists to conduct high-quality research.

"Now that we have seen marijuana use become more popular than tobacco smoking, we need more rigorous research, including randomized clinical trials, to explore the effects of marijuana on cardiovascular health," Vaduganathan says.

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In the year before TMVr, HF hospitalization rates were 479 hospitalizations per 1,000 person-years vs. 370 hospitalizations per 1,000 person-years in the year after TMVr. Cardiovascular-related hospitalizations decreased from 838 hospitalizations pre-TMVr vs. 632 hospitalizations post-TMVr. However, bleeding and noncardiovascular hospitalizations increased in the year after TMVr. In addition, the rates of hospitalized days decreased for HF and cardiovascular causes.

In terms of cost, the odds of having no HF-related Medicare costs was 68.7 percent pre-procedure vs. 78.5 percent post-procedure. Among patients who did have post-TMVr costs, there was a significant increase in the average total Medicare costs per day alive ($49 pre-procedure vs. $131 post-procedure).

According to the researchers, TMVr is associated with a decrease in cardiovascular and HF hospitalizations and number of hospitalized days. While there was increase in the likelihood of having no HF-related Medicare inpatient costs in the year after the procedure, costs did increase for patients who incurred costs post-TMVr. Additional research is needed to "understand how to reduce hospitalizations and inpatient costs after TMVr," the authors conclude.

In an accompanying editorial comment, Harindra C. Wijeysundera, MD, PhD, and Maneesh Sud, MD, write that future research should prioritize "identifying the mechanisms responsible for the increase in noncardiovascular hospitalizations after TMVr and implementing personalized in-hospital or post-discharge strategies targeting those at greatest risk."

Rymer JA, Li Z, Cox M, et al. JACC Cardiovasc Interv 2019;12:2416-26.

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