Nashville doctors link heart health to prenatal care

A pair of Nashville doctors are integrating cardiology into prenatal care, as they look to fill a void that leaves many women susceptible to heart disease.

Pregnancy puts stress on a woman's heart, particularly for those with family history, past disease or lifestyle risk factors. But for most pregnant women, the often intensive regimen of prenatal care — and the doctor's visits that follow a birth — seldom address potential long-term heart problems.

Dr. Cornelia Graves and Dr. Stacy Davis, doctors at Saint Thomas Health, are trying to change that by intertwining heart care into pregnancy and working on a model that ensures women receive the ongoing multispecialty care they need.

“We often think about the outcome for the mom being short term, ‘let’s get her through the pregnancy.’ We have to think beyond the pregnancy," said Davis, director of the Comprehensive Heart Failure Center at Saint Thomas Heart-Midtown.

"We have to get the mom doing better for years to come. Then if everything we’re trying to do, if we take the big picture, we sway health care costs. If we can do a good job at a young point then we can prevent these spiraling costs down the road."

Heart disease impacts women of all races and socioeconomic classes.

More women die each year from cardiovascular disease and stroke than from all cancers combined, according to the American Heart Association. For African-American women, the risk is more acute: More than 48 percent of African-American women age 20 and older have cardiovascular disease.

In a state rife with high blood pressure, diabetes and obesity, aligning cardiology and obstetrics, Graves and Davis said, is essential. The two established the Collaborative Perinatal Cardiac Clinic to bring a comprehensive, individualized treatment plan to pregnant women who need cardiac care as well.

Cardiologists are commonly brought in to consult with women who had serious disease as a child.

But Graves and Davis think deeper integration is increasingly important as the state grapples with balancing rising health care costs and people leading unhealthy lifestyles with a focus on preventative care.

"The body doesn’t go, ‘Gee, she’s 25 and pregnant, maybe I should hold off with her heart not working until she’s through with childbearing,' ” said Graves, medical director of Tennessee Maternal Fetal Medicine and director of perinatal services at Saint Thomas.

Close coordination 

The doctors are passionate about the collaboration. Right now they talk on the phone, exchange notes and traipse between different buildings on Saint Thomas' Midtown campus. They finish each other's thoughts and refer to specific patients or experiences with a single word.

Davis' office will be moving into the same building as Graves this fall and is lobbying to be on the same floor. It will make the new venture easier and more integral.

Their patients take many paths to their offices. Some are referrals, through clinics or the emergency room. Davis gets a call from Graves about once a week about a woman who had a heart defect repair as a child and who is now pregnant. Many women think the repair "fixed" the problem, but a birth defect can flare up under the stress of pregnancy.

Brittany Sullivan, a childhood cancer survivor, was referred to Davis when she became pregnant. The echocardiogram shocked Davis and Sullivan: The cancer had recurred for the fifth time — in Sullivan's heart.

"Even in my worst-case scenario I could not have possibly dreamed this scenario up," Sullivan said. "My husband and I did a lot of mourning and grieving."

After consultations with specialists at Vanderbilt University Medical Center and Saint Thomas Health, and some recommendations to end her pregnancy, Sullivan decided to proceed under Graves' care while starting a targeted cancer treatment.

Now Sullivan, 28, is a high school biology teacher and mom to Carley Jean, a vivacious and bright toddler who turns 3 in March.

Sullivan's care team includes Davis and an oncologist at VUMC and is about to expand. She learned this month the tumor, after remaining the same size for some time, has grown. She's set to enroll in a clinical trial in Miami.

The collaboration between Graves and Davis and the willingness to collaborate with another medical center encouraged and surprised Sullivan, who has spent many years being a patient and then training as a physician's assistant.

"They said, 'Our goal here is not to get you through the pregnancy but to get you through your daughter's high school graduation. We have long-term plans for you," recalled Sullivan. "That was the first time I'd heard that. That was one of the only times I'd heard that kind of hope."

Continuing care vital 

Graves and Davis want conditions that arise in pregnancy, such as gestational diabetes and pre-eclampsia, to be treated and tracked as a risk factor as women age. The damage doesn't disappear once a baby is born.

Graves is tracking 15 women who had pre-eclampsia. Of the group, 14 have had abnormalities after pregnancy, including cholesterol and blood pressure that remained elevated and one with a clotting disorder.

“If pre-eclampsia is a failed stress test and these women have a family history of high blood pressure and heart disease, we need to be taking it more seriously. We can’t wait until they are 60 to do so," Graves said.

The doctors are concerned that many women drop out of the health care system after they pass childbearing age when trips to the doctor become more sporadic. The next time a woman gets a treatment plan may be in her 60s when she finds herself in a cardiologist's office.

Consistent care would in many cases improve the quality of life for women later in life and, if the focus switched to prevention, potentially save billions in health care costs, they said.

Heart failure cost an estimated $20.9 billion in 2012, a figure that is projected to rise to $53.1 billion by 2030, according to a 2015 report from Milliman.

"If we do prevention then we can save health care dollars down the road," Davis said.

Graves is working with Rep. Harold Love, D-Nashville, on legislation to track the death rate during pregnancy and for six weeks after labor.

Tennessee ranks 32nd in the country for maternal mortality, with 11.1 deaths per 100,000 live births. In one quarter of 2015 Graves said she was aware of 10 deaths around the state. Tracking the death rate is a step toward understanding the care women need, Graves said.

Bill would allow state to track maternal mortality

Mothers are having children at older ages, which carries greater risks, particularly for African-American women — a group that has a high incidence of heart disease.

The months when women focus on health because there's a "baby on board" is a time when physicians should be blueprinting a woman's care trajectory.

"This is an opportunity to improve access to care, get people into preventative mode sooner, because we don't do that well enough. We don't," Davis said. "We have to get the mom doing better for years to come."

Reach Holly Fletcher at 615-259-8287 and on Twitter @hollyfletcher.