University Health System is addressing a gap in health care for women who have or are at risk for heart disease.
Ildiko Agoston, MD, FACC, FASE, examines a patient’s echocardiogram at University Hospital.
“For many decades, women have been underdiagnosed, undertreated and underserved when it comes to heart disease,” says Ildiko Agoston, MD, FACC, FASE, a University Health System cardiologist, Medical Director of the Cardiology Clinic at UT Health Medical Arts and Research Center, Director of the Women’s Comprehensive Health Institute and Charles Conrad Brown and Anna Sahm Brown Distinguished Professor in Cardiovascular Disease at UT Health San Antonio, which is the academic partner of University Health System. “If women aren’t aware of their risk for heart disease, they can’t take action to change it.”
Indeed, heart disease is the leading cause of death for women, accounting for more than 10 times as many deaths as breast cancer annually. Although heart disease is also the leading cause of death for men, more women than men die from heart disease every year.
“The challenge for us is that we typically think of heart disease as a man’s condition,” says Patrick S. Ramsey, MD, MSPH, FACOG, a University Health System maternal-fetal medicine specialist and Director, Maternal Transport and Outreach at University Hospital and Clinical Professor, Department of Obstetrics and Gynecology at UT Health San Antonio. “It’s not.”
Serious and Subtle Differences
Dr. Agoston, a University Health System cardiologist, sees patients at the Women’s Comprehensive Health Clinic at UT Health San Antonio.
Certain types of heart disease are more prevalent in women than men. These include coronary microvascular disease, which affects the smaller vessels of the heart, and takotsubo cardiomyopathy, or broken-heart syndrome, which is a weakening of the left ventricle that is usually caused by emotional or physical stress.
In addition, heart disease may present different symptoms or require different treatments depending on whether the affected patient is a man or a woman. For example, men with coronary artery disease (CAD) are commonly treated with stents and balloons to open congested arteries, while the same approach may be more difficult to perform on women with CAD.
“Due to the size of women’s hearts and the smaller size of their arteries, it has been harder to apply the same treatments for CAD,” Dr. Agoston says.
CAD symptoms may be more subtle or nonexistent in women compared with men with the condition. In some cases, women may not exhibit symptoms until they have a heart attack.
Even then, women’s heart attack symptoms tend to be atypical and include heartburn, diaphoresis and nausea. If a woman has diabetes and experiences a heart attack, she may experience shortness of breath, rather than crushing chest pain, as an initial heart attack symptom, making it even more difficult to seek timely treatment.
“A common thing we’ve seen in Texas and other states is that sometimes providers don’t pay attention, or they don’t take signs and symptoms seriously,” Dr. Ramsey says. “All of us as women’s health providers need to be better versed in these warning signs so that patients can get in earlier for care.”
“We need to educate our community if we want to make a significant impact on maternal mortality. The High Risk Pregnancy and Heart Disease Conference brings together local specialists who are interested in taking care of women with heart disease who are pregnant or planning their pregnancies.”
— Ildiko Agoston, MD, FACC, FASE, a University Health System cardiologist, Medical Director of the Cardiology Clinic at UT Health Medical Arts & Research Center, Director of the Women’s Comprehensive Health Institute and Charles Conrad Brown and Anna Sahm Brown Distinguished Professor in Cardiovascular Disease at UT Health San Antonio
Tailored Multidisciplinary Treatment
As part of this effort, University Health System’s academic partner, UT Health San Antonio, established the Women’s Comprehensive Health Institute at the UT Health Medical Arts & Research Center in 2012. This multidisciplinary clinic is a one-stop shop for women where they can receive multiple screenings and exams during a single visit.
“Women fill out a questionnaire and meet with a healthcare coordinator to determine what screenings they need based on evidence-backed guidelines,” Dr. Agoston says. “They can meet with a board-certified OB/GYN, dermatologist and internist all in one day, which helps keep them healthy and maximize the benefits of their appointment time.”
The healthcare coordinator at the Women’s Comprehensive Health Institute tailors screenings based on medical history, family background, age and risk factors. For instance, if a woman has a family history of heart disease, she may be scheduled for a cardiac stress test or electrocardiogram in addition to her other exams. These screenings help doctors detect the presence or development of heart disease early, allowing for more effective and simple treatment and preventive measures such as lifestyle changes, medication and other therapies.
If women require treatment for heart disease, the specialists at University Health System work together to ensure all aspects of care are covered.
“We have highly specialized cardiologists who are board-certified in interventional cardiology, vascular medicine, echocardiography, nuclear medicine and electrophysiology,” Dr. Agoston says. “Our collaboration with the cardiothoracic and vascular surgery team enables us to do complex coronary, valvular and peripheral interventions with excellent outcomes.”
Pregnancy and Heart Disease
Although heart disease affects both men and women, men do not have to contend with pregnancy complications that can worsen heart disease symptoms and vice-versa. The team works together to address the specific needs of pregnant women with heart disease.
Patrick S. Ramsey, MD, MSPH, FACOG, is Director of Maternal Transport and Outreach at University Health System.
“Pregnancy can be a major stress test for women, particularly for those with cardiovascular disease,” Dr. Ramsey says. “As early as the first trimester, cardiovascular function increases dramatically and continues throughout pregnancy and into the delivery period.”
Certain cardiovascular conditions can also affect the pregnancy itself. Heart disease can cause preeclampsia and pre-term births and impair growth. Women with congenital heart disease are also at risk of giving birth to children with the same congenital condition they have — a risk that has grown over time.
“Many women with complex congenital heart disease survive to motherhood thanks to surgical procedures available today,” Dr. Agoston says. “These women are prone to high-risk pregnancies.”
In addition, modern lifestyles cause many women to postpone family planning until later in life, when risk for cardiovascular disease and other comorbidities, such as hypertension and diabetes, is higher. All of these factors can affect women’s peripartum outcome and require special treatment.
“We have a multidisciplinary clinic for patients with high-risk pregnancies and heart disease, where we collaborate closely with maternal fetal medicine, cardiology, cardiothoracic surgery, pulmonary, neonatology and anesthesiology specialists,” Dr. Agoston says. “We hold regular patient conferences where we discuss our cases and make very specific delivery plans with our multidisciplinary team.”
“More women are getting pregnant at an older age, more are obese when they get pregnant and others have related comorbidities, such as hypertension and diabetes. All of these factors are contributing to increased cardiovascular mortality in pregnant women.”
— Patrick S. Ramsey, MD, MSPH, FACOG, a University Health System maternal-fetal medicine specialist and Director, Maternal Transport and Outreach at University Hospital and Clinical Professor, Department of Obstetrics and Gynecology at UT Health San Antonio
Patrick S. Ramsey, MD, MSPH, FACOG, Director of Maternal Transport and Outreach at University Health System, handles high-risk pregnancies and deliveries at University Hospital and is a maternal-fetal medicine specialist at UT Health San Antonio.
For especially complex or high-risk cases, a patient navigator can help coordinate care between patients and providers. Having a single contact point for care helps ensure that important information is communicated clearly between different specialists while giving patients a place to turn if they have questions. The patient navigator can also provide an additional layer of comfort and familiarity as expectant mothers navigate high-risk pregnancies.
“Our patient navigator is the person’s point of care up until the time of delivery,” Dr. Ramsey says. “We even have a maternal transport program where the navigator will actually ride with patients in the ambulance or helicopter if they need to be transported or transferred to another location.”
Should an emergency arise, University Hospital is equipped with a Level I pediatric trauma center, a Level IV NICU and will soon complete construction on the new Women and Children’s Tower. University Hospital is seeking state designation as a Level IV maternal care program.
“We have immediate access to critical care specialists in the event of a heart attack or cardiac arrest,” Dr. Ramsey says. “These specialists can be present and perform invasive cardiac procedures within minutes, if needed.”