Amanda Wilde (Host): Cardiovascular health plays a crucial role in maternal health. We're talking about heart disease and risk factors in pregnancy with Dr. Hartaj Powell. Dr. Powell is Medical Director of Obstetrics and Gynecology at Holy Cross Health. 

Welcome to Your Best Life Podcast presented by Holy Cross Health. I'm Amanda Wilde. Welcome, Dr. Powell. Thank you for being here.

Hartaj Powell, MD, MPH: Good afternoon. Thank you for having me.

Host: So, to set things up, why is heart health so important for us to talk about?

Hartaj Powell, MD, MPH: Well, as you know, February is cardiac or Heart Health Awareness month. And that is because heart disease is the number one killer of U.S. men and women. And, there are disparities for heart disease with racial and ethnic minorities experiencing higher rates of cardiovascular disease and its complications.

And pregnancy can be and is a wonderful time for most, but it does bring about changes that can put you at higher risk if you have cardiovascular disease. It affects 1 to 4 percent of the almost 4 million pregnancies in the United States each year. It is the leading cause of death in pregnancy and the postpartum period.

It is from the data, 26.5 percent of pregnancy related deaths, with higher mortality rates among women of color and women with lower socioeconomic incomes. There does seem to be a rising trend in maternal deaths related to cardiovascular disease, which appears to be due to acquired heart disease or disease that is present not at birth.

So it develops after birth. So for example, coronary artery disease or cardiomyopathy, which is a disease that affects the heart muscle and causes it to perform less optimally. And peripartum cardiomyopathy is the leading cause of maternal deaths, accounting for almost 23 percent. And it does usually occur in the late postpartum period.

Host: So you're saying that actually cardiovascular disease may develop with pregnancy and or may go up during pregnancy.

Hartaj Powell, MD, MPH: That's correct. We often think that you have to have heart disease prior to, and that's what's going to increase your risk. But, most women are young and healthy, and we found that they can develop cardiac conditions during or after pregnancy.

Host: So what are some of the risk factors for that for maternal cardiac disease?

Hartaj Powell, MD, MPH: So, in general, the risk factors in non pregnant and pregnant patients are very similar. So, as we just shared, race and ethnicity are risk factors because minorities experience higher rates. And in pregnancy, the non Hispanic Black women have a 3.4 times higher risk of dying from cardiovascular disease complications than non Hispanic White women. Another risk factor is high blood pressure or hypertension. And we know that hypertension affects 10 percent of pregnancies and severe and early onset or in the first trimester earlier in the pregnancy with high blood pressure, increases the risk for the birthing person to experience heart complications during or after the delivery.

So they have a 13 fold increased chance of having a heart attack than someone who is pregnant who doesn't have hypertension. It's a really important topic to be discussing today, but other risk factors include your age. So greater than 40 years of age, high cholesterol, obesity, smoking, diabetes, a family history, and of course, lack of exercise or physical inactivity.

Host: So that is quite a list of risk factors. Whether or not you have those risk factors to begin with, what are some of the signs or symptoms pregnant patients might experience that could indicate a heart condition?

Hartaj Powell, MD, MPH: So that's a great question because it can be confusing. Pregnancy is a natural stress test because the cardiovascular system undergoes changes to accommodate the demands of pregnancy. So for example, the body produces more blood, which is needed by the growing baby, but means your heart is working harder than when you are not pregnant. The hormones of pregnancy affect your blood pressure and your blood vessels. You also carry extra weight as you get further along in pregnancy, which puts more work for your whole body in general, including your heart. So there are normal pregnancy and postpartum signs and symptoms that go along with those, and they can overlap with the signs and symptoms of an underlying heart disease condition.

So, for example, shortness of breath. Even myself going up the stairs, I can get short of breath, right? I'm not pregnant. And so when you are, especially further along in the pregnancy, you will experience shortness of breath. So, you know, is that normal or abnormal? That's hard to tell. Chest pain can also be caused by acid reflux, which is very common especially in the third trimester of pregnancy. Having palpitations or feeling like your heart is racing. Because normally in pregnancy, your heart rate does go up, so that's difficult to differentiate if it's normal or not.

Feeling dizzy or lightheaded, feeling tired, swelling in your legs and feet. Again, all very common to have during pregnancy and can be difficult to differentiate if it's normal pregnancy or if there's an underlying cardiac condition. 

Host: How do you determine when cardiovascular disease is present in pregnancy, then?

Hartaj Powell, MD, MPH: So that's why it's really important to see your obstetrician, keep those visits, and tell your obstetrician what you're feeling and what you're seeing and they can help you determine what's normal and what's not normal.

Host: Can you get cardiovascular disease as part of pregnancy in the postpartum period?

Hartaj Powell, MD, MPH: Yes, actually it's more common to present in someone who's never had any cardiac issues, postpartum. It most commonly presents as heart failure, like we said earlier; but it can also present as a heart attack, an abnormal heart rhythm or arrhythmia, and in very rare cases, an aortic dissection.

Host: You mentioned something very concerning earlier on that there are maternal health disparities with different groups of people. What are those challenges and how do you address them?

Hartaj Powell, MD, MPH: So it is very disturbing, as you said. It's unfortunate, but we know that there are patient, physician, and health system level factors that can affect our health outcomes. There's physician implicit and explicit bias. There's overt racism within our health care system, and these can result in misdiagnoses or inappropriate treatment.

So, the health system has barriers to efficient triaging based on your symptoms of severity and how often you're having them. There's language barriers, there's differences in cultural humility, and these are all important factors that are and will continue to be investigated so that we can fully understand the pervasiveness of the disparities that women of color face when encountering the healthcare system. In addition, women of color may have experienced injustice in healthcare processes in the past or their family members, which leads to mistrust in the medical system. So all of these things contribute to a disproportionately higher rate of pregnancy associated complications among women of color, which then in turn places these women not only at a greater risk of cardiovascular disease and events in the postpartum period, but also can increase their lifetime risk of cardiovascular disease.

Host: What can we do to address this greater risk?

Hartaj Powell, MD, MPH: Well, it's really about education and understanding these risk factors, that there are just racial and ethnic disparities, and early detection and treatment of these risk factors can significantly reduce the risk of cardiovascular disease and its complications. It's been shown that just having this as part of your differential diagnosis for the healthcare provider, can decrease cardiovascular complications by 25%.

Host: That's significant. So education and awareness of each individual you're dealing with. If a patient has cardiovascular disease or is at risk of heart disease during pregnancy, what will be different about the care they receive?

Hartaj Powell, MD, MPH: So, most importantly, it's going to be that you might have more appointments, so that we can monitor your blood pressure, also monitor the baby. You might have more ultrasounds, and a consultation with a cardiologist and the high risk maternal fetal medicine physician. So it's more about appointments, the number of them, the frequency, and working with a multidisciplinary team to optimize your health and your baby's health.

Host: Well, Dr. Powell, thank you so much for sharing your invaluable insights and for your work helping keep pregnant women healthy and safe.

Hartaj Powell, MD, MPH: Thank you so much for having me.

Host: For more information on women's health and to follow Dr. Powell's work, visit holycrosshealth.org. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is Your Best Life Podcast presented by Holy Cross Health.