Note to self: tell med students about women’s unique cardiac risk factors!

by Carolyn Thomas   ♥  @HeartSisters

There’s an old saying about public speaking that I like: every planned presentation actually consists of three different talks:

• 1. the talk we plan to give
• 2. the one we actually give
• 3. the perfect one we give in the car on the way home

That’s how I felt as soon as I ended my recent one-hour Zoom session about women and heart disease for New York medical school students. It was only after our recorded session ended that it hit me: “Oh, no!  I didn’t mention pregnancy complications!”    

This is a known cardiac risk factor that’s unique to women – and in my case, was likely the culprit behind my own heart attack.       .   

Regular Heart Sisters readers will already know that pregnancy is often referred to as the “ultimate cardiac stress test”  because pregnancy complications* can double a woman’s risk  of subsequent heart disease – often diagnosed years afterwards. That’s as serious a cardiac risk factor as smoking or high cholesterol – both of which can also take decades before leading to cardiac diagnoses.

Yet when I survived my misdiagnosed “widow maker“ heart attack back in 2008, every doctor and nurse I met in the CCU (the hospital’s intensive care unit for heart patients) asked me the same questions: “Have you ever smoked?”  (No!) or “Do you have a family history of heart disease?”   (No!)  But not one doctor, nurse or hospital janitor ever asked if I’d experienced complications during either of my two pregnancies.

At my first post-hospital discharge follow up appointment, my longtime family doctor told me she was “stunned” when notified about my heart attack news. Although she knew about my preeclampsia diagnosis while I was expecting my first baby, few doctors in 2008 seemed aware of the strong link between that history and subsequent heart attack risk. My cardiologist now suggests that preeclampsia was probably my only identifiable cardiac risk factor.

I’ve heard pregnancy complications described as “a short-term problem for obstetricians but a longterm problem for cardiologists”  – yet I didn’t know about this until one year after my heart attack. That’s when I happened upon an interview in the New York Times with Canadian OB-GYN Dr. Graeme Smith, whose research at Queen’s University on this link between pregnancy complications and cardiovascular disease had been published in medical journals seven years earlier.(1)   He later launched North America’s first Maternal Health Clinic in Kingston for Mums at higher risk of future heart disease due to their history of pregnancy complications.

And it wasn’t until three years after my heart attack that the 2011 update of the American Heart Association’s Scientific Statement on Cardiovascular Disease Prevention Guidelines for Women finally included pregnancy complications in its official list of women’s cardiac risk factors(2).

This update also recommended that healthcare professionals who meet older female patients for the first time should take a careful and detailed history of pregnancy complications “with focused questions about gestational diabetes, preeclampsia, pre-term birth, or birth of a full-term/low birth weight baby.”*

Yet despite my personal preeclampsia experience, and despite the American Heart Association’s official scientific statement on pregnancy complications, and despite the articles I’ve written about this pregnancy complication/heart disease link, I somehow ran out of time to include this important cardiac risk factor during my recent presentation for those New York med students.

Speaking of med students: reaching medical students directly has been a dream of mine since I started doing my original “Heart-Smart Women” presentations after my WomenHeart Science & Leadership patient advocacy training at Mayo Clinic in Rochester, Minnesota.

I loved sharing what I’d just learned at the Mayo Women’s Heart Clinic with audiences of other women. Since then, I’ve spent years speaking to thousands of women (and several men!) about women’s heart disease. And as more speaking invitations to share a patient perspective came in each year from medical conferences and healthcare staff events, I also loved the experience of reaching the physicians and cardiac nurses who care for those women.

But I often feel like I simply can’t bear reading yet another cardiac gender bias study that concludes, in the immortal words of my heart sister Laura Haywood-Cory (who survived a SCAD heart attack at age 40): “Sucks to be female. Better luck next life!”

Every year since my 2008 Mayo training has also brought more published research on the disturbing differences between how male and female heart patients are studied, diagnosed and treated.  How can this still be happening 15 years after my own experience? Distressing study results just keep on coming. And the current cardiac risk calculators that physicians commonly use, for example, don’t even ask about female risk factors like pregnancy complications.

In fact, I’ve come to believe that it’s our future doctors who may represent our most likely chance of finally tackling the cardiology gender gap that current doctors seem unable to close.

And I know I’m not alone in that belief.  Last week, I wrote about nine new education modules on women’s heart disease developed through the Canadian Women’s Heart Health Alliance at the University of Ottawa’s Heart Institute. These education modules address those known gaps in medical education. See also: Nine lessons about women’s heart disease that future doctors will learn in med school

Cardiologist Dr. Beth Abramson, lead author of an article published about the Ottawa project in the Canadian Journal of Cardiology, sums up the challenge:(3)

“Changes in medical training and continuing education programs are needed, so that physicians acquire the up-to-date knowledge about sex and gender differences relevant to the prevention and management of cardiovascular disease in women. Changing physicians’ knowledge and behaviour is a necessary step if we are to improve standards of women’s cardiac care.“

And until both knowledge and behaviour are changed starting in medical schools and beyond through continuing education –  I’ll try to do a better job of including pregnancy complications in my heart presentations for med students!

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1. Smith GC et al. “Pregnancy complications and maternal risk of ischaemic heart disease: a retrospective cohort study of 129,290 births.” Lancet. 2001 Jun 23;357(9273):2002-6.

2. Wenger NK. “What do the American Heart Association guidelines tell us about prevention of cardiovascular disease in women?” Clinical Cardiology,  2011 Sep;34(9):520-3.

3. Abramson, B. “Incorporating a Women’s Cardiovascular Health Curriculum Into Medical Education”. Canadian Journal of Cardiology. Volume 3, ISSUE 12, SUPPLEMENT , S187-S191, December 2021.

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Q:  Have you experienced pregnancy complications that were later linked to a cardiac diagnosis?

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NOTE from CAROLYN:   I wrote more about the disparity in women’s cardiac research, diagnostics, treatments and outcomes compared to men in Chapter 3 of my book, A Woman’s Guide to Living with Heart Disease.  You can ask for it at your local library or bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

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