Latest / 20-Minute Health Talk / Keeping moms and babies safe: Improved heart care during and after pregnancy

Transcript

Keeping moms and babies safe: Improved heart care during and after pregnancy · 20-Minute Health Talk

• 0:00
  Music.
• 0:09
  Hello, and welcome to 20-Minute Health Talk. I'm Sandra Lindsay.
• 0:14
  February is Heart Month, and today we revisit a conversation we had with women's
• 0:21
  heart health expert, Dr. Evelina Graver.
• 0:25
  She's director of Northwell Health's Women's Heart Program for the Central Region
• 0:32
  and oversees its Cardio-Obstetrics Program. We spoke with Dr.
• 0:38
  Graver in 2023 about this program, which she calls Her Baby,
• 0:43
  and how it's helping detect and prevent heart issues in women before,
• 0:50
  during, and after pregnancy.
• 0:53
  We know that heart disease remains the number one killer of women in America.
• 0:59
  But what many women don't realize is that symptoms commonly associated with
• 1:05
  pregnancy, like shortness of breath,
• 1:08
  swollen hands and feet, could also be indications of a serious underlying heart condition.
• 1:17
  In this episode, Dr. Graver explains who is at risk, what symptoms to look out
• 1:24
  for, and when to seek help.
• 1:27
  Music.
• 1:36
  On a personal note, I was so happy to meet Dr.
• 1:40
  Graver, whose passion and work I greatly admire.
• 1:44
  We also have some shared experience, which is where our conversation began.
• 1:51
  We share a little bit in common. From as long as I can remember,
• 1:55
  I always wanted to be a nurse. Really?
• 1:57
  And I know you said since the age of five, you knew you wanted to become a doctor.
• 2:03
  A hundred percent. I didn't know that there's actually another profession that's actually out there.
• 2:07
  And I don't know why, because I don't have anybody, because a physician, like none of them.
• 2:12
  You know, coming from an old school immigrant family from Ukraine, right?
• 2:19
  As a girl, you end up doing what your mother does. And my mom is a pianist,
• 2:22
  just, or a teacher, right? And all the men are like engineers.
• 2:27
  So I have no idea where this whole obsession with being a physician came from.
• 2:31
  Well, we're happy that you're in the field, but why cardiology?
• 2:36
  I want to make a difference in reference to number one, the paternal mortality,
• 2:41
  which is really horrible in the United States.
• 2:44
  And since cardiovascular disease is the number one reason why the mortality
• 2:50
  of pregnant women or postpartum women is the highest,
• 2:55
  I really take it incredibly personally for me to make a little bit of amend
• 2:59
  in that atrocious number.
• 3:06
  Adding to what Dr. Graver said there, cardiovascular disease plays a role in
• 3:13
  more than a third of American pregnancy-related deaths.
• 3:17
  And just as important, two-thirds of those deaths are preventable.
• 3:23
  So the question then becomes, what can we do?
• 3:29
  Dr. Graver shares her take on that and much more.
• 3:34
  Here is our conversation with Dr. Evelina Graver.
• 3:41
  All right. Well, such a pleasure again to meet you and thanks for joining us
• 3:47
  today on 20-Minute Health Talk. Thank you.
• 3:49
  I had Dr. Stacey Rosen on the podcast.
• 3:53
  And as you know, Dr. Graver, she's the president of the CATS Institute for Women's
• 3:59
  Health here at Northwell.
• 4:00
  And one of the things that fascinated me
• 4:04
  that she mentioned and I wanted to delve deeper into
• 4:07
  it is heart disease and pregnancy
• 4:11
  right how one affects the other
• 4:14
  vice versa I know it's very interesting right
• 4:17
  so we're not used to recognizing the fact that heart disease can be in women
• 4:23
  we're not used to the thing the fact that heart disease can affect the young
• 4:27
  and now you're taking a combination of a young woman who's not even thinking
• 4:32
  of having any cardiac issues at all,
• 4:34
  who is either thinking of getting pregnant or is pregnant and develops cardiac complications.
• 4:41
  Pregnancy really is like a stress test on the body, on a woman's body,
• 4:45
  based upon all of the hemodynamics that take place, right?
• 4:48
  Your heart rate significantly increases because of the fact that your heart
• 4:52
  goes from pumping usually four to five liters of blood per minute to about eight
• 4:58
  to to 10 liters of blood per minute.
• 5:00
  So that's a significant strain on the heart, right?
• 5:04
  So in med school, we were taught a lot of really sort of clear-cut evaluation
• 5:09
  in reference to a woman that does have congenital heart disease and gets to
• 5:13
  the point where she's in her reproductive years and wants to become a mom. And...
• 5:18
  Subsequently we know the fact that there is a potential risk of maintaining
• 5:22
  a pregnancy with certain of that congenital component.
• 5:26
  However, the one thing, so we kind of knew it as a sort of a one-way street
• 5:29
  relationship, but we never understood the fact that it's actually a two-way
• 5:33
  relationship, meaning because of that component of a stress on the body and
• 5:38
  on the heart during the time of the pregnancy.
• 5:40
  A lot of women develop what's called adverse pregnancy outcomes.
• 5:43
  And adverse pregnancy outcomes are known as sort of preeclampsia,
• 5:48
  which is high blood pressure during the time of the actual delivery and other
• 5:53
  complications of it, or spontaneous preterm delivery before the week of 32,
• 5:59
  or intrauterine growth restriction, where the baby is definitely smaller than its expected size.
• 6:04
  The old school mentality was that it happens, the woman delivers,
• 6:09
  the baby's good, the mom is good, you know, we maintain the blood pressure well
• 6:13
  controlled within the first week or so, and then it's forgotten.
• 6:16
  We now know that that's not the case. We now know the fact that those women
• 6:20
  that have those adverse pregnancy outcomes, the preeclampsia,
• 6:23
  the spontaneous preterm delivery, the intrauterine growth restriction,
• 6:27
  they are at significant risk for lifelong cardiovascular disease.
• 6:32
  So whereas we know the fact that there are certain classical risk factors, right?
• 6:36
  There's the diabetes, there's the hypertension, which is the high blood pressure,
• 6:39
  high cholesterol, you know, smoking, obesity.
• 6:42
  We know those are sort of the classic risk factors for the heart,
• 6:45
  but now these adverse pregnancy outcomes have finally made it into what's called
• 6:51
  novel gender-specific cardiovascular risk factors,
• 6:55
  where we know the fact that these women have to be clearly monitored very closely
• 7:00
  during the first six to 12 months months after delivery,
• 7:03
  because that's when we see the most complications.
• 7:06
  That's when we see certain heart attacks. That's when we see strokes for a lot of those young women.
• 7:11
  So really, who is at risk? Everyone. Everyone.
• 7:16
  So there's certain women that are at higher risk, certain races,
• 7:21
  such as African-American women, such as women of Hispanic descent.
• 7:26
  They are at higher risk.
• 7:28
  Women that have predisposing conditions, such as baseline hypertension,
• 7:32
  baseline diabetes, those that have other risk factors that I mentioned that
• 7:37
  are considered classic risk factors.
• 7:38
  So obviously those women that are going into the pregnancy with those risk factors
• 7:43
  are at higher risk of developing the adverse pregnancy outcomes.
• 7:47
  And we see a lot more of them now because a lot of women tend to get pregnant
• 7:52
  a little bit later in life.
• 7:54
  Women prioritize career at a certain period of time.
• 7:57
  But even those that do not, even the younger ones that are in their early 20s,
• 8:01
  mid 20s, are still at risk.
• 8:04
  And we don't know why. And this is where the research in the field is so,
• 8:08
  so important at this period of time, because we don't know what happens.
• 8:11
  Is it the fact that, you know, what comes first, the chicken or the egg, as they say, right?
• 8:16
  So is it the fact that the pregnancy, because of its being sort of like a stress
• 8:20
  test on the body, unveils certain things?
• 8:23
  Or is it that the actual placenta releases something and there's issues with
• 8:31
  the actual vasculature of the placenta that increases the woman's risk?
• 8:35
  This is where the research is. This is why this is such a highly rapidly developing field right now.
• 8:40
  And because we don't know enough and we need the research.
• 8:46
  Oftentimes, you know, women believe that you deliver and you're good.
• 8:50
  And a lot of the symptoms that you mentioned, you know, could be justified by other things, right?
• 8:57
  Very much so. And to be honest with you, a lot of it is very cultural and there's
• 9:01
  a little bit of a bias, right? right?
• 9:03
  Even before delivering, during the time of the pregnancy, right?
• 9:07
  For some reason, it appears the fact that when a woman is pregnant,
• 9:11
  being short of breath has become a normal.
• 9:15
  Right? Having significantly swollen feet is a norm.
• 9:19
  And, you know, when they come to me with those swollen feet and the swollen
• 9:24
  hands and the significant shortness of breath, I always tell them we have to
• 9:29
  rule out all other possibilities,
• 9:31
  including cardiomyopathies, including gestational hypertension,
• 9:35
  including everything else that can actually fall into before we actually say
• 9:39
  that this is pregnancy related, right?
• 9:41
  And unfortunately, I do end up catching anywhere between five to 10% of those
• 9:47
  women that do come in with pregnancy, normal short of breath,
• 9:51
  that's actually just not pregnancy induced.
• 9:53
  So I just want to clarify for our listeners. Yes.
• 9:56
  Soil and hands, soil and feet, shortness of breath.
• 10:00
  Yes. When you're pregnant, it's not pregnancy symptom that you should be comfortable
• 10:07
  with. Correct. Correct.
• 10:09
  Again, Again, there are certain normals that come across.
• 10:12
  However, those symptoms have to be evaluated.
• 10:16
  And it's not even to be stricken in panic of any kind,
• 10:21
  but to be able to see a cardiologist, to get a baseline EKG,
• 10:25
  to get a baseline echocardiogram and an ultrasound of your heart,
• 10:28
  to assess to make sure the fact that you don't have any significant cardiomyopathy
• 10:33
  or weakening in the heart muscle or valvular disease.
• 10:36
  Because unfortunately, one of the things that pregnancy does unveil as well, is valvular disease,
• 10:42
  disease of the valves that potentially a young woman would never really know
• 10:46
  about because they may not have seen a physician besides there may be their
• 10:51
  pediatrician or something of that nature.
• 10:52
  And maybe someone sometime mentioned that they might have had a murmur,
• 10:56
  but they didn't pay attention much to it. But it's sometimes very hard, right?
• 11:00
  Because you have a young mom who just gave birth or is about to give birth,
• 11:06
  and she's in the height of her happiness, as they say, she's about to become
• 11:11
  a mom, and she's going to have a lot of responsibility on her hands.
• 11:14
  And this is where a lot of women get into trouble because they will prioritize that baby.
• 11:21
  And unfortunately, they will not prioritize themselves and all of their ailments.
• 11:27
  So we know, Dr. Graver, that about 80% of cardiac disease is preventable.
• 11:33
  How can we prevent heart-related problems during pregnancy?
• 11:38
  So the first thing is to make sure that you are in the best cardiovascular shape
• 11:43
  before getting pregnant.
• 11:45
  And how do we do that? That is with constant.
• 11:49
  I don't like to say diet because people think when people diet,
• 11:54
  it's like a two to four week sentence.
• 11:57
  I'm talking about more of a lifestyle modification and being able to maintain a healthy diet,
• 12:03
  which you and I can discuss for hours as to what that actually means and continuous
• 12:08
  exercise where you're exercising at least 30 minutes a day, at least five days out of the week. Okay.
• 12:13
  And maintaining your ideal weight. That's number one.
• 12:17
  I think the other component is never be concerned about getting what's called
• 12:22
  preconception counseling.
• 12:24
  Okay. Meaning if someone ever told you the fact that there is a genetic predisposition
• 12:30
  for heart disease in your family,
• 12:32
  if somebody has ever told you the fact that maybe you did have an abnormal EKG
• 12:36
  or an abnormal physical exam consistent with a murmur before getting pregnant, go see a cardiologist.
• 12:42
  I think that's also quite important to do.
• 12:44
  We want to make sure the fact that all of those classic risk factors that we
• 12:48
  spoke about for heart disease, such as the diabetes, the cholesterol, the hypertension,
• 12:52
  the smoking, the obesity, all of it is controlled, that you don't smoke or vape,
• 12:57
  because vaping right now is even more prevalent within the young than smoking.
• 13:01
  And then if you do have genetic predisposition, because that's the other 20%, right?
• 13:06
  So 80% is is preventable, 20% is genetic, and we cannot run away from our genetics,
• 13:11
  we cannot run away from our age,
• 13:12
  even though I try every day, but, and we cannot run away from sort of our genetic
• 13:19
  cultural background, right?
• 13:22
  But if you know that, if you know that, then getting that early preventative evaluation is key.
• 13:29
  So there is a lot of women that come to see me with preconception counseling,
• 13:34
  women that have congenital disease, that are on certain medications that are
• 13:39
  not, as I like to call them, pregnancy friendly, right? right?
• 13:43
  So we do have to change the management in reference to those medications, right?
• 13:48
  That are more consistent with medications that are safe for both the mom and the baby.
• 13:53
  And thank God we have plenty of options at this period of time.
• 13:57
  For those women that actually develop any of one of those adverse pregnancy
• 14:00
  outcomes, such as preeclampsia or anything else,
• 14:03
  we have options that are, again, safe for the mommy and safe for the baby during
• 14:07
  the time of the pregnancy and then and during the time of lactation,
• 14:11
  breastfeeding, that are safe for both.
• 14:13
  Awesome. So we have here at Northwell a cardio obstetrics program.
• 14:20
  Yes. Can you tell us a little bit more about that?
• 14:22
  So cardio obstetrics program, and I know it's going to sound funny,
• 14:25
  but that really is kind of my baby, really.
• 14:28
  Yes. The point of the program is for there to be a seamless,
• 14:33
  efficient way way that OB-GYN can immediately refer their patients post-delivery
• 14:42
  with preeclampsia or any other adverse pregnancy outcomes,
• 14:45
  or if those OB-GYN feel that their patient actually needs to have preconception
• 14:52
  counseling because of the fact that they've had either cardiac surgery in the
• 14:56
  past as a child because they were born with congenital heart disease or developed
• 15:00
  something something within their teenage years or their early 20s, and they need to be seen.
• 15:03
  So that is sort of a very seamless, efficient way for patients to kind of cross
• 15:09
  over easily without OBGYN having to scramble which cardiologist are they going to see or not.
• 15:14
  And the other component of it is the fact that we have now chosen cardiologists
• 15:19
  that are sort of became experts in the field, meaning that they've shown so much interest in it.
• 15:26
  They've done extra legwork really to kind of understand the pathology,
• 15:31
  pathophysiology as to what happens during the time of the pregnancy,
• 15:34
  how do certain drugs affect,
• 15:36
  that we've created a certain group of cardiologists and a certain group of OB-GYN
• 15:41
  that really have that seamless transaction between their patients.
• 15:45
  It's a very, very unique program. It's one of the few in the nation,
• 15:49
  but one of the most rapidly growing. When did the program begin,
• 15:54
  the Cardio Obstetrics Program, and what are your goals for the program?
• 15:59
  So Cardio Obstetrics Program officially started in September of 2021.
• 16:06
  2020. September of 2020.
• 16:09
  And so was that after which wave of the pandemic? It was after one of the original waves.
• 16:16
  So what happened was that my interest in women's heart program started to grow.
• 16:22
  Early on in my fellowship.
• 16:24
  And that's when Dr. Rosen took me on as a mentee.
• 16:27
  And I realized then subsequently when I was in charge of the cardiac intensive
• 16:32
  care unit, the CCU, there were were too many women in my unit that did not carry
• 16:38
  the typical risk factors that I was taught in regarding to cardiovascular disease.
• 16:42
  And that's where Dr. Rosen and I started really thinking about the importance
• 16:45
  of the Women's Heart Program.
• 16:47
  And after the original wave of COVID, when I served and I ran the COVID unit,
• 16:54
  I came out of the COVID land realizing the fact that I really really wanted
• 16:58
  to do something more for longevity.
• 17:02
  And that's where Cardio OB was born. It's for the entire health system.
• 17:06
  I'm in charge of the central region, which is the North Shore Allergy and Cat's Women's Institute.
• 17:10
  On the east end, we have Dr. Kachibaro and Dr.
• 17:14
  Eugenia Giannos on the western end. And it's a full thickness program,
• 17:19
  meaning the fact that we're not only seeing patients as an outpatient,
• 17:22
  but we also see inpatient consultations as well when those those women come
• 17:26
  in or other cardiac complications occur that needs to be urgently evaluated
• 17:31
  and potentially even monitored in the cardiac intensive care unit.
• 17:35
  And I want to make a difference in reference to number one, the paternal mortality,
• 17:40
  which is really horrible in the United States.
• 17:44
  And since cardiovascular disease is the number one reason why the mortality
• 17:49
  of pregnant women or postpartum women is the highest.
• 17:53
  I really take it incredibly personally for me to make a little bit of amend
• 17:57
  in that atrocious number.
• 18:00
  Wow. Your passion is just palpable. And I thank you for your service.
• 18:05
  The one thing that has gotten me personally through that post-COVID burnout
• 18:12
  is finding that passion,
• 18:14
  is finding the fact that I'm actually able to find something that I genuinely
• 18:20
  enjoy and bring in as much as possible of these women that I know,
• 18:28
  if I can implement all of the necessary changes,
• 18:33
  will make a much better life. monsters changing their life.
• 18:36
  For cardiac disease in general, women, black women, are three to four times
• 18:44
  more likely to develop cardiovascular disease than other ethnicities.
• 18:51
  Yes. Is that the same for... Cardiobstetrics?
• 18:55
  Cardiobstetrics? Yes. Yes.
• 18:57
  African-American women are anywhere between actually 4% to 6% higher to actually
• 19:02
  develop adverse pregnancy outcomes and preeclampsia and gestational hypertension
• 19:07
  and gestational diabetes being the highest ones.
• 19:11
  And these are women that, again, did not have or did not know that they had
• 19:15
  any predisposing conditions.
• 19:17
  And it's not women that are, you know, at a higher BMI level or greater obesity, not at all.
• 19:25
  It's a matter that, again, part of research that we definitely need to do,
• 19:29
  understanding understanding the vasculature, the vasculature difference between
• 19:33
  an African-American woman and other ethnicities.
• 19:37
  Very well. Well, this has been an interesting conversation, Dr.
• 19:41
  Graver. Thanks so much for joining me.
• 19:43
  Thank you. It's great to be able to share it.
• 19:46
  Music.
• 19:53
  Get more expert insight from the leading voices in healthcare today you can
• 20:00
  subscribe to 20-minute health talk wherever podcasts are available.