What women need to know about pregnancy complications and heart disease

 by Carolyn Thomas   ♥  @HeartSisters

“I’d love to speak about the patient’s perspective at your Toronto conference in June,” I said last winter in response to an invitation from Dr. Graeme Smith, a Canadian obstetrician who teaches at Queen’s University in Kingston and specializes in high-risk pregnancies. “But traveling halfway across the country is just too hard on me these days.”

As the unofficial poster child for the well-documented link between pregnancy complications and premature cardiovascular disease, I was already very familiar with Dr. Smith’s work.  See also: “Pregnancy complications strongly linked to heart disease“

Shortly after I turned down his kind invitation to speak, he invited me again (hey, he’s persistent!) – but this time he offered the irresistible option of speaking to the Toronto audience via teleconference:

“Does this mean I can stay in my jammies, drink coffee at my kitchen table, and just speak to your group over the phone?!”

That’s exactly what it meant, and that’s how it came to pass that I happened to be a virtual speaker at this Toronto gathering of physicians, as I told my Twitter followers below:

While waiting for my presentation time slot, I also had the opportunity to go online and listen to a few other conference speakers that morning. As Dr. Jennifer Blake, the CEO of The Society of Obstetricians and Gynaecologists of Canada, posted on Twitter:

Meanwhile, here’s how Dr. Smith likes to describe this under-appreciated risk:

“Pregnancy is the ultimate cardiac stress test.”

He mentioned in his opening remarks at the conference that his own research has found that women diagnosed with pregnancy complications like preeclampsia also tended to have these known risk factors for heart disease(1):

• higher blood pressure

• higher LDL (bad) cholesterol

• higher blood sugar

In fact, he warns, preeclampsia increases the risk of heart disease by 2- to 3-fold compared to those women who don’t have preeclampsia. 

Cardiologist Dr. Martha Gulati from Ohio State University was also in Toronto that day as an invited speaker. Her presentation included several stats that would no doubt surprise most women (even those who are regular Heart Sisters readers!)

For example, a 2014 study (Howlader et al) reported that in the year 2010, over 400,000 women in the U.S. died from cardiovascular disease, compared to 40,000 from breast cancer.

Yet if we asked women what they believe to be their biggest health threat, how many would mistakenly answer “breast cancer”?

Dr. Gulati quoted the venerable Dr. Nanette Wenger, Chief of Cardiology at Emory University’s Grady Hospital, who once said:

“The medical community has viewed women’s health with a ‘bikini’ approach, looking essentially at the breasts and reproductive system, and almost ignoring the rest of the woman as part of women’s health.”

As a result of this ignorance, women have much poorer outcomes following a cardiac event, said Dr. Gulati, who reminded her colleagues in the audience:

“Women are NOT small men!”

Yet she also reminded them that heart disease is largely preventable.

“It’s NOT an inevitable part of life. 

“We have effective means to reduce heart disease, but we don’t use them enough or effectively – especially in women and minorities.“

Also on the conference speaking agenda was obstetrician Dr. Eric Steegers from the Netherlands who spoke about his interdisciplinary team’s work in postpartum lifestyle modification for women considered at high-risk for future cardiac events because of pregnancy complications(2).  These complications include:

• preeclampsia
• gestational diabetes
• polycystic ovary syndrome (PCOS)
• premature ovarian insufficiency
• recurrent miscarriages
• intrauterine growth restriction (IUGR: a low birth weight/full term baby)
• premature delivery

Dr. Steegers described reproductive disorders as a short-term problem for the OB-GYN, but a longterm problem for the cardiologist.

But because most women with the conditions listed above have rarely been  considered at high risk for cardiovascular disease, current cardiac treatment guidelines are not tailored to this group of young women.

Worse, he said, many doctors aren’t even aware of this link.

He told us of a study (unlikely to surprise any exhausted, sleep-deprived and overwhelmed new parent) in which researchers looked at potential barriers to making heart-healthy lifestyle decisions after the birth of a new baby.(3) Researchers found that although women expressed an intention to live a healthy lifestyle after their new baby arrived, this generally did not happen. As Dr. Steegers explained:

“Motivators included improving their own current health condition as well as modelling a healthy lifestyle for their children.

“But important barriers were reported to be a lack of knowledge, poor recovery, and lack of professional support after delivery.”

But when these barriers were addressed, as another Dutch study reported (3), planned intervention after a complicated pregnancy resulted in heart-healthy outcomes for new mothers like:

• doing more exercise
• healthier diet
  
• lower weight/BMI
• lower waist-to-hip ratio

Then it was my turn to share the patient’s perspective with the Toronto audience.

Here’s that story: shortly before the due date of my first baby, I was one of the approximately five per cent of pregnant women who develop the serious pregnancy complication of preeclampsia (previously known, by the way, as toxemia of pregnancy – a term that originated in the mistaken belief that the condition was caused by toxins. A vintage medical text called Manual of Obstetrics actually recommended “amputation of one or both breasts” to treat toxemia). 

Not one of my doctors or nurses – both before and after that delivery –  mentioned to me at the time that my diagnosis meant I was now at a significantly higher risk of having a heart attack compared to women who have never experienced preeclampsia. Few if any experts had any idea back then, of course, that these two health issues were even related.

Fast forward several years to the day I survived what doctors call the “widowmaker” heart attack. 

In an effort to narrow down a possible cause for my myocardial infarction, each of the cardiologists, nurses, residents and cardiology fellows who met me during my stay in the Coronary Care Unit of Victoria’s Royal Jubilee Hospital asked me very similar questions:

• “Do you smoke?”
• “Have you ever had a prior cardiac event?”
• “Do you have a family history of heart disease?”

Yet not one of them asked me the question Dr. Graeme Smith wishes all health care providers would ask all female heart patients:

“Have you ever been diagnosed with a pregnancy complication?”

Although it’s difficult to point to one single risk factor as the clear culprit, cardiologists now know that most cardiac events are 20-30 years in the making. My timing seemed alarmingly on track to help confirm the known link between my heart attack and a pregnancy complication that had happened decades earlier.

And when I reminded that Toronto audience that I’d started running during my post-natal exercise classes after that first baby, and that I was a distance runner over the next two decades, the overall consensus among the physicians in my audience was that running and its associated level of increased cardiovascular fitness may very well have helped to postpone my cardiac event by several years.

In Kingston, Dr. Graeme Smith and his team at Queen’s have started an innovative project called the MotHERS Program (Mother’s Health Education, Research and Screening) – a resource for pregnancy, delivery and postpartum – along with a Maternal Health Program where women whose pregnancy complications put them at higher risk for heart disease will receive ongoing cardiac screening and follow-up.

Dr. Smith recommends that screening for cardiovascular risks should be undertaken in the first year after delivery in these high-risk women, preferably starting at around six months postpartum.

This unique screening project is an important and pro-active initiative, as Dr. Smith describes his Maternal Health Program:

“Too much of health care is spent reacting to disease after it’s happened, and not enough is spent on prevention. This is a place to start.”

Despite the shared enthusiasm for this topic of those attending the Toronto event, sometimes I wonder how well we’re doing in spreading the word throughout the medical profession about the significant link between pregnancy complications like preeclampsia and heart disease.

Aside from Dr. Smith’s team in Kingston, the very keen physicians who took the time to attend/present in Toronto, and a handful of international researchers working hard on this issue, are most family physicians or obstetricians even aware of this link?

And if they are, what resources are they recommending to at-risk patients to help lower the likelihood of a future cardiac event?

As Dr. Smith once told The New York Times about the link between preeclampsia and cardiovascular disease:

“Increased awareness about the two conditions might allow physicians to identify a woman’s heart disease risk sooner. The earlier you diagnose them, the more likely you are to prevent cardiovascular disease. This is an opportunity where people can change their future.

“But if you ask a cardiologist, they say: ‘I never heard of it.’ 

“It’s not just cardiologists who are not aware of the link between pregnancy complications and cardiovascular disease. We did a survey study among doctors in Ontario: most general practitioners and obstetricians don’t know of this link or at least don’t make any recommendations for follow-up.

“Our goal is to change all that!”

If you’ve been diagnosed with preeclampsia, please visit The Preeclampsia Foundation’s website, and participate in their Preeclampsia Registry, a research tool that will help investigators track women like me who have ever had preeclampsia.

♥

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(1)  Graeme Smith et al. “Smith, G.N. (2009) Development of Preeclampsia provides a window of opportunity for early cardiovascular risk screening and intervention. Expert Rev Obstet Gynecol 4(4), 355-357.

(2) Motivators and Barriers to a Healthy Postpartum Lifestyle in Women at Increased Cardiovascular and Metabolic Risk. Meeke Hoedjes et al.  Hypertension in Pregnancy. 31: 147-55. 2012.

(3) Preliminary results of the Postpartum Rotterdam Appraisal of Cardiovascular Health and Tailored Intervention Study (ProActive-study). ZonMw Programma Preventie, deelprogramma Innovat

See also:

Pregnancy: the ultimate cardiac stress test

Pregnancy complications strongly linked to heart disease

The ‘bikini approach’ to women’s health research

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 Q: How familiar are you with the link between pregnancy complications and heart disease?

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