Women's Heart Health Program Aims to Reduce Disparities

A pioneering program at Massachusetts General Hospital focuses specifically on cardiovascular conditions in women, with specific aims to reduce enormous disparities in outcomes for women compared to men.

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"Historically, women have been treated like small men. But the biology of menses, menopause, and pregnancy have huge impacts on women's cardiovascular systems. Women can actually present differently and have unique cardiovascular conditions," says Nandita Scott, MD, co-director of the Elizabeth Anne and Karen Barlow Corrigan Women's Heart Health Program at the Mass General Corrigan Minehan Heart Center. "For decades, the healthcare system has been neglecting sex-specific issues. We are aiming to address those disparities to improve care."

Dr. Scott says that when the program started in 2007, the concept of a dedicated women's heart health program was entirely novel, and Mass General has remained at the forefront of advancing the field of cardiovascular disease in women.

Clinical Care for Cardiovascular Disease in Women

Women's Heart Health Program clinicians treat patients and serve as a resource for other healthcare professionals. They conduct research to improve the knowledge base regarding particular cardiovascular conditions that affect women predominately and educate current and future cardiologists as well as patients.

"This is about much more than pairing a female cardiologist with a female: it's not just about seeing women," says Amy Sarma, MD, co-director of the Cardiovascular Disease and Pregnancy Program at Mass General. "There are many diseases affecting the cardiovascular system that are more prevalent in women, and we have less of an evidence base to treat them, which has led to a huge disparity in care."

The program's clinicians have particular clinical and research expertise in cardiovascular conditions that affect women, including:

• Spontaneous coronary artery dissection (SCAD)
• Cardiovascular disease in pregnancy
• Menopause and its effects on cardiovascular health
• Microvascular conditions
• Nontraditional causes of myocardial infarction (MINOCA)
• Heart health of transgender patients

Spontaneous Coronary Artery Dissection

SCAD is a rarer type of heart attack that disproportionately affects women that is often undetected. Pregnant women with coronary artery dissection have more severe presentations and poorer outcomes. It is caused by tears in the wall of the coronary artery rather than plaque buildup and requires a unique treatment paradigm.

Mass General is one of a few centers in the country that offers multidisciplinary SCAD care. As a major referral center for patients with the condition, the Women's Heart Health Program sees a higher volume of women with this rare problem.

In addition to offering medical and inteventional treatment options for SCAD, clinicians in the Women's Heart Health Program also:

• Address the anxiety often associated with SCAD in collaboration with a PhD-trained psychologist who directs our Women's Heart Health Mindful Living Center
• Consultation for pregnant patients (or those wishing to consider pregnancy) and those experiencing menopause with a history of SCAD given unique effects of female hormones on this disease process
• Enroll patients in iSCAD, a national registry to advance SCAD research (Mass General is the most active center for iSCAD enrollment)
• Offer cardiac genetic testing to identify any hereditary gene mutations associated with SCAD when indicated
• Can perform cardiopulmonary testing in highly active patients who have experienced SCAD in conjunction with the Cardiac Performance Program to help inform safe levels of physical activity
• Speak at national events to increase awareness of the unique needs of this patient population
• Engage with students, residents, and fellows to train the next generation of clinicians

"A lot of these patients are understandably anxious or depressed because they are healthy young women who end up with heart attacks. Addressing the problem from the mind-body perspective is a very important part of their healing process and part of their prescription," Dr. Scott explains.

Cardiovascular Disease in Pregnancy

Pregnant women have been traditionally excluded from cardiovascular studies.

"Because of this, there is a lot that is still not well understood about the management of pregnant patients with cardiovascular disease," Dr. Sarma explains. "It is really important to have both clinicians and researchers who are dedicated to, invested in, and passionate about improving cardiovascular health in these women, especially as cardiovascular disease is the leading cause of maternal mortality in the U.S. and globally."

The Cardiovascular Disease and Pregnancy Program provides personalized, multidisciplinary care for people with congenital or acquired cardiac conditions who are pregnant or want to become pregnant. A multidisciplinary team develops care plans for these higher-risk patients before pregnancy, during pregnancy, and in the postpartum period.

Preeclampsia is also a leading cause of maternal morbidity and mortality and increases the risk of cardiovascular disease later in life. The Mass General team is working to improve the evidence base and community knowledge of hypertension in pregnancy.

"There is a lack of knowledge among patients and clinicians of the increased risk of heart disease in women who have had preeclampsia. We have several ongoing research efforts aimed at understanding how best to help patients reduce their risk and are rolling out several novel clinical programs as well," Dr. Sarma says.

Dr. Sarma's research has included developing and testing a novel algorithm and virtual monitoring to help women manage their blood pressure from home postpartum.

In addition, researchers like Michael Honigberg, MD, MPP, within the Women's Heart Health Program, are also exploring genetic factors to identify potential preeclampsia and gestational hypertension therapeutic targets.

Dr. Scott is also a founding investigator for the Heart Outcomes in Pregnancy Expectations (HOPE) Registry of pregnant women with cardiac disease. HOPE is a U.S.-based registry that aims to track clinical characteristics and long-term maternal-fetal outcomes to identify and address gaps in the knowledge base.

Mass General is also part of the REBIRTH study, an effort to explore using bromocriptine in peripartum cardiomyopathy, sponsored by the National Institutes of Health.

Cardiovascular Disease in Women and Transgender Heart Health

The Mass General Women's Heart Health program has many other areas of focus:

• Menopause and its effects on cardiovascular health: Emily Lau, MD, MPH, leads a program that provides patient-specific counseling on the appropriate use of hormones and the associated cardiac risks. Traditionally, women with heart disease have been advised not to take hormones. However, because this decision is very personal and nuanced, the team offers individualized risk stratification and nonhormonal options for patients with cardiovascular disease.
• Microvascular conditions: Diseases in the smaller blood vessels can be disabling, but diagnosis is difficult because they cannot be seen on cardiac computed tomography or catheterization. The program works with the Mass General nuclear lab to investigate microvascular dysfunction using cardiac PET testing. In appropriate cases, the Women's Heart Health Program works closely with interventional cardiology and can offer specialized coronary angiography to identify and learn how to best treat this condition.
• Transgender heart health: While emerging data suggest that there are possible links between gender-affirming hormone therapy and the risk of cardiovascular problems later in life, there are significant gaps in knowledge about these links and a lack of research. Colleen Harrington, MD, along with Drs. Scott and Sarma are working with national leaders in the field and Mass General experts in transgender care to develop a program aimed at improving cardiovascular health among transgender patients. Research consistently demonstrates disparities in the care that transgender individuals receive, and Mass General is highly committed to improving the cardiovascular health of our patients.

Educating Current and Future Cardiologists

"Our ultimate goal is to reduce mortality from cardiovascular disease in women, so Mass General can't be the only place that patients can seek care. We are actively working on disseminating information and training the next generation of leaders. We also strive to make ourselves available as a resource to other clinicians," Dr. Sarma says.

The program is using many channels to disseminate information about women's unique heart health needs:

• Mass General hosts a dedicated women's heart health fellowship, and all cardiology fellows rotate through the women's program for sex-specific training, which has not traditionally been part of the core curriculum and not widely available at other training programs.
• Doreen DeFaria Yeh, MD, and Dr. Harrington have helped develop guidelines for cardio-obstetrics, as most cardiologists are not trained to take care of pregnant patients.
• For over a decade, the program has offered continuing medical education courses for healthcare professionals. The program also advocated to get sex-specific content added to the well-known Mass General Cardiology Update course.
• The program grants frequent requests from national and international institutions to bring healthcare professionals to Mass General to shadow and learn more about women's heart health.
• The program's leaders regularly speak at national meetings to make these topics part of the main discussion at cardiology conferences.
• The EPIC electronic health record is being revised to alert clinicians throughout the enterprise when a patient falls into a high-risk category for pregnancy and the postpartum period.
• The program hosts community events and is planning a SCAD walk and online educational events about cardiovascular disease in pregnancy.

Institutional Support for Women's Heart Health

Drs. Scott and Sarma are optimistic and excited about the program's potential to address care disparities and improve women's outcomes. They believe Mass General is a perfect place to change the paradigm in women's heart health, thanks largely to the Corrigan family's generous financial support.

In addition, the institutional leadership recognizes the program's value and supports its efforts. The program and patients alike benefit from Mass General's multidisciplinary collaboration among specialists, such as maternal-fetal medicine, interventional cardiology, radiology, and obstetric anesthesiology.

To contact the Women's Heart Health Program, call 866-932-2855.

Learn more about the Women's Heart Health Program

Refer a patient to the Corrigan Minehan Heart Center