By Elisabeth Geier
More than 21 percent of deaths, across genders, are attributed to cardiovascular disease (CVD), the leading cause of death in the United States. Yet, despite its prevalence, CVD is frequently misdiagnosed and mistreated in women. Not only do symptoms often present differently in women than men, but critical gender-specific risks have long been overlooked.
In those pregnant, the risks are even higher: heart disease and stroke combined account for over 34 percent of maternal deaths. “We are the only industrialized nation that has a rising maternal mortality rate,” says Dr. Jennifer Haythe, cardiologist and Co-Director of the Women’s Heart Center at NewYork-Presbyterian/Columbia. “Over the last several years, a lot of that has shifted from bleeding and infection to predominantly cardiovascular disease, whether that’s absolute valvular disease, coronary artery disease, cardiomyopathy, or hypertensive disorders like preeclampsia.”
“I think we’re really getting an understanding that these women need dedicated care,” she says. And Dr. Haythe, along with the cardio-obstetrics team at Columbia, is leading the charge to improve pregnancy outcomes and reduce hospital readmission rates for pregnant people with CVD. “A little over 50 percent of all maternal deaths happen after delivery within the first year of what we call the ‘fourth trimester,’” explains Dr. Haythe. “So, part of our goal is providing women with really close follow-up during that time.”
That follow-up is especially important for Black women, as race is the biggest predictor of poor outcomes. “Black women can be three times to sometimes four times more likely to die or have a complication of childbirth,” says Dr. Haythe.
Black adults, in general, are significantly more likely to die from heart disease than their white counterparts. And the deluge of data long overlooked in nearly all areas of disease and treatment has prompted the medical community to finally acknowledge the negative impact racism has on health.
“There’s something going on, and it may be just the pressure of racism itself,” says Dr. Haythe. “Experiencing racism in society has a stress associated with it that’s having a negative outcome” And those outcomes arise quickly. Studies show that within a generation of coming to the United States, Black immigrants have babies with lower birth weight than their mothers' generations, indicating pre-term births and increased risk of death.
In 2020, the cardio-obstetrics team at Columbia published a paper in the Journal of the American College of Cardiology (JACC) that described the experience and outcomes of their team-based approach to maternal healthcare.
“While it was a retrospective study, we found that we had very low readmission rates for pretty complicated people, and very low mortality,” says Dr. Haythe. “Our 30-day readmission rate was lower for our cardiovascular patients than the nationwide 30-day readmission rate for pregnant women in general.” Although the study in JACC didn’t specifically focus on people of color, the data reflected the broad population served at Columbia, which includes a high number of Black and Hispanic patients. The multidisciplinary approach was not only working but proved to be an essential framework.
Statewide, New York has created a maternal mortality review committee modeled after a successful initiative in California that reduced maternal mortality by half. The committee, of which Dr. Haythe is a member, reviews every single maternal death in the state, looking at things like race, access to healthcare, socioeconomic background, neighborhood, and past care to determine and address the social factors that contribute to maternal mortality. “I think we’re very well positioned to help our community and make a big difference,” says Dr. Haythe.
In addition to these data-driven shifts, the conversation about racial and gender disparities in health care is “dramatically different than it used to be,” explains Dr. Haythe. Medical schools have been pushed to offer educational resources on bias, and the language about disease, disease prevalence, and about patients themselves has necessarily evolved. One key factor was patient access to medical records.
Patients can now read what’s been written about them. “It’s making doctors and practitioners think about how they’re expressing their views about a patient,” says Dr. Haythe. “When you realize someone else is reading it…it makes you think twice. Is that exactly what I want to be saying? Is that how I want to be saying it? And I think that’s really important, that's how you become more aware of your own bias whether it’s unconscious or conscious.”
Growing awareness is paramount to lasting change, but today the impact of racial and gender discrimination is highlighted acutely by the COVID-19 pandemic; Black, Hispanic and Asian communities are disproportionately affected across the board. As vaccines became available in 2021, systemic racism and longstanding disparities in medical care created barriers and contributed to vaccine mistrust. Then there’s the impact of the pandemic itself.
“First of all, COVID can cause heart problems,” says Dr. Haythe. “Also, the pandemic has created so much depression, stress, and anxiety. There are those few stories about people who decided to use COVID as their ‘I’m gonna get in shape!’ moment…but I would say the majority of people drank more, ate more, did less exercise, were more sedentary, and so in all those ways, it’s bad for heart health.”
If there’s a silver lining to the pandemic, Dr. Haythe says it’s the rapid growth and efficacy of telemedicine. “While I know that there are a lot of people who say it’s not the same as seeing a doctor in person, the truth is it’s really a good thing to have. It allows for a new connection with our patients and their families.”
Video visits and telemedicine also provide greater context around stress factors that contribute to heart health. “[We get] a sense of how happy they are at home, whether they live with people around them all the time, if they live in poverty,” says Dr. Haythe. “You don’t really see that when someone shows up in your office.”
While challenges surely remain, Dr. Haythe is encouraged by the way women’s heart health and the racial disparities within are now being prioritized. News media continues to promote awareness of CVD in women. Discussions are frequent and flowing between experts, advocacy groups, and patients on social media and in online forums. Studies and initiatives are receiving more and more funding and support. “For so long, most women didn’t even know that heart disease was their number one risk of death,” Dr. Haythe says. “Many still don’t, but it’s getting better. And that’s really great.”