Dear Cardiologist: Think You Don’t Belong in Cardio-Reproductive Conversations? You’re Dead Wrong

As I stood on the “Heart2Heart” stage at the annual American College of Cardiology (ACC) conference in New Orleans, LA, last spring, I couldn’t help but feel the weight of my topic at this moment in history. I was invited as a panelist to discuss cardio-reproductive health and the recent legal overturning of the constitutionally protected right to access abortion in the Dobbs v Jackson Women’s Health ruling, and how that may impact the lives of countless people hoping to start a family, or facing an unplanned or unwanted pregnancy. This all comes at a time when the United States is already facing a crisis in maternal health: as pregnancy deaths decline around the world, the US is bucking the trend by seeing maternal mortality tick upwards.

Then, during the panel discussion, a member of the audience raised a hand, asking: “Why should cardiologists even be involved in these conversations?”

Embedded in that question is the stark disconnect between cardiologists and maternal health specialists, calling attention to the urgent need to bridge that gap: no mother should ever go into childbirth fearful that the cost of bringing in a life will be the loss of her own.

So why should cardiologists be involved?

At its foundation, maternal morbidity and mortality is a cardiovascular problem—this should be the fundamental thought when approaching this crisis. Maternal health and cardiovascular health are intricately linked. According to the US Centers for Disease Control and Prevention, cardiac and coronary conditions are among the leading causes of pregnancy-related deaths, despite being largely preventable. In fact, it’s the leading cause for non-Hispanic Black women, going back decades. This should come as no surprise since many of these women live in maternity care deserts, which oftentimes are also contraceptive deserts and cardiology deserts, a situation that highlights more than ever that one’s zip code truly dictates not just maternal choice, but health outcomes. 

Indeed, when we think about maternal health, we often focus on the immediate concerns of pregnancy and childbirth; however, the journey to motherhood starts long before conception. With a scarce number of patients actually undergoing the strongly recommended preconception counseling, many women may have preexisting congenital or acquired cardiovascular conditions, or more commonly cardiometabolic risk factors that go undetected until they become pregnant.

First and foremost, cardiologists play a crucial role in identifying these risks. After all, this is what we traditionally do on nearly every patient we encounter. Unfortunately, we tend to consult with patients later in life, oftentimes not having the opportunity to see, think about, or assess patients of reproductive age. If more of us worked with patients earlier in their life course, or better yet were trained about the full spectrum of factors that influence an individual’s health through all stages of their life, then the processes engrained in us would more easily and effectively be routine for these young, at-risk women.

Secondly, the effects of pregnancy on the cardiovascular system can be profound. The increased demands on the heart and circulatory system of pregnancy are often referred to as nature’s first cardiac stress test. Who better to deal with a cardiac stress test than a cardiologist?

Additionally, with pregnancy also a window to future health and disease where any increased risk identified in pregnancy and the immediate postpartum may be carried and exacerbated even decades later, cardiologist can play a vital role. As an example, if a patient were to present to my clinic and upon my probing relays to me that 20 years earlier they had an adverse pregnancy outcome (APO), including a hypertensive disorder of pregnancy, gestational diabetes, preterm labor, placental abruption, and/or small for gestational age infant, I’d have to tell them this places them at a twofold greater lifetime risk for heart attack, stroke, and death. I’d thereafter after have to screen for any additional cardiometabolic risk factors, while counseling about risk prevention. Obtaining such a history of APOs is most valuable in reproductive age women prior to the development of the more conventional risk factors.

Unfortunately, more times than not, cardiologists overlook the importance of incorporating such detailed pregnancy history in routine encounters due to the limited emphasis on this aspect during their training and an underappreciation of its significance in common clinical practice. For similar reasons, it’s extraordinarily rare for patients, unless asked, to ever reveal such information. Despite several awareness campaigns, this information is currently not public knowledge, chiefly as it’s not regularly emphasized by their obstetrician/gynecologist (OBGYN), leaving patients unaware of this critical health link.

Given all that, truly how best can we as cardiologists be incorporated into maternal healthcare? Perhaps the first step is by simply acknowledging we are an important part of the multidisciplinary, maternal health team. The cardio-obstetric models that have proven to be the ideal, thus far, and have included a team of maternal fetal medicine specialists, OB-GYNs, cardiologists, primary care clinicians, nurse care coordinators, and at times doulas and/or midwives working together.

I’m not naive to the practical constraints and challenges of implementing such cardio-obstetric models, but we must at least understand the value of working in partnership within a reliable network of physicians in each of these various subspecialties to allow easy communication and collaboration on mutual patients. By doing something as rudimentary as that, we can ensure that every pregnant person has access to the care and support they need for a healthy and fulfilling life, not just during pregnancy but throughout their journey into motherhood and beyond, even in settings where dedicated multidisciplinary teams may not be readily accessible.

For me, the audience member’s question at the ACC conference was an eye-opener. Still, my answer to their question is simple: we are more important now than ever.

We can be the catalyst that recognizes risk early and therefore can mitigate these risks over time. We are the ones who can help the patients with preexisting acquired or congenital cardiovascular conditions—either by counseling them about what’s at stake or fixing the problems that would be putting them at risk. We are the ones who can best risk stratify patients with APOs prior to their development of conventional risk factors, and potentially eventual cardiovascular disease.

If done correctly, cardiology involvement in maternal health has the potential to be one of the most high-yield interventions we have thus far to improve these astounding outcomes and ultimately combat this crisis. As cardiologists we have to support the education and infrastructure of women’s cardiovascular programs, which are both cost-effective and highly beneficial. Even more importantly, as individuals we have to understand that maternal health profoundly affects everyone by encompassing not only the well-being of expectant mothers, but also impacting families, communities, and the healthcare system as a whole.

Active involvement in addressing this crisis and implementing strategies to mitigate it start with the basics of asking the right questions and seeing ourselves as active players in often times uncharted territory. In the end, it’s getting more comfortable with the sometimes-uncomfortable conversations centered on reproductive and maternal health, as to provide more comprehensive and patient-centered care. By enhancing our understanding of our patients’ unique cardiovascular challenges and experiences during varying life stages, we can truly become better cardiologists and strong guardians for our women, families, and communities. 

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.