Feb 14, 2022
This week's episode is special: Circulation is proud to present the 6th annual Go Red for Women issue podcast. Please join Sana Al-Khatib and James de Lemos as they welcome authors Michelle Albert and Sadiya Khan as they discuss their articles "Shining a Light on the Superwoman Schema and Maternal Health" and "Geographic Differences in Prepregnancy Cardiometabolic Health in the United States, 2016 Through 2019." Then Sana presents an overview of the other exciting articles in this important issue.
Dr. Sana Al-Khatib:
Hello, and welcome to this special Circulation on the Run podcast, focused on the sixth Go Red For Women issue of the journal. I am Dr. Sana Al-Khatib. I'm an electrophysiologist at Duke University Medical Center and a senior associate editor for Circulation. I have the pleasure of co-leading the sixth Go Red for Women issue with, my friend and colleague Dr. Biykem Bozkurt. Very excited to introduce Dr. James de Lemos, the executive editor for Circulation, who will co-host this part of the podcast with me. Welcome, James.
Dr. James de Lemos:
Well, Thanks. I'm delighted to be here.
Dr. Sana Al-Khatib:
The theme of our podcast today is social determinants of health. We will discuss a perspective article in the issue, titled The Interplay of Sex with Social Determinants of Health in Cardiovascular Diseases, led by Dr. Michelle Albert, who is a cardiologist at the University of California in San Francisco. We will also discuss a research letter on geographic disparities in pre-pregnancy cardiometabolic health in the United States from 2016 to 2019, led by Dr. Sadiya Khan, a cardiologist at Northwestern Medicine in Chicago. Welcome, Doctors Albert and Khan.
Dr. Michelle Albert:
So pleased to be here. An honor to be part of the Go Red issue.
Dr. Sadiya Khan:
Thank you for having us.
Dr. Sana Al-Khatib:
Wonderful. So we'll start with the discussion and turn it over to you, Dr. de Lemos, to ask the first question.
Dr. James de Lemos:
Well, thanks, Sana. Michelle, let's start with you. I love the title of your essay. I'd like you to sort of orient our listeners as to why this title, why the topic and what you write about in your piece.
Dr. Michelle Albert:
Thank you, James. The title of the essay or Perspective is “Shining a Light on the Superwoman Schema and Maternal Health.” We felt, along my coauthors, Dr. Rachel Bond and Dr. Annette Ansong--Dr. Ansong is a pediatrician, actually. Dr. Bond is also a cardiologist. We felt that it was really important to put forward the psychological parts of the maternal health crisis as a major social determinant of health. Most often, the focus is only on the other risk factors that we know of, like hypertension, diabetes and obesity. And while those are also extremely important, it is actually the interplay between those risk factors and social factors, including racism, including access to care, that actually drive the maternal health crisis for women of color. Particularly for black women, who have about three to four times the mortality and pregnancy complications, compared to white women.
Dr. James de Lemos:
Michelle, one thing that you've really defined your career by is moving to the biology of adversity. I thought the figure in your paper was striking. Can you expand a little bit on what you mean by this, and how these social determinants and the pernicious effects of things like racism and psychological stress, translate into the biology that I think Sadiya will tell us about, even in her research letter?
Dr. Michelle Albert:
Yes, James. As you know, I've had a longstanding research history and portfolio, looking at the interplay between biology and social factors, coined the biology of adversity. The adversity part of this is something, we often think about the ACEs, adverse childhood experiences, and think about how those relate to health outcomes, including cardiometabolic and cardiovascular health outcomes. But as we think about adults, actually, it's the adult environment that actually defines adversity for children. Certainly, as it pertains to black women and other women of color, there are certain special circumstances that get embedded into the whole framework of the biology of adversity, that lead to poor overall cardiovascular outcomes, but also maternal and non-maternal health outcomes. So conceptually speaking, the framework of the biology of adversity is the incorporation of stressors into the brain. That then results in a hyper inflammatory milieu, combined with dysregulation of the hypothalamic pituitary access, as well as the flight or fright hormones or the up-regulation of the sympathetic nervous system. And actually importantly, the down-regulation of the parasympathetic nervous system, which is an area that is actively under research currently, that then results in the downstream cascade of health effects. For black women, this is characterized by, in part, the Superwoman Schema, which includes several major themes. The first major theme is the history of oppression and racism and sexism. Also, a history of disappointment, the influences of spiritual values and form other influences, interplayed. These are stressors that incorporate with other stressors. And then there's an interplay with subscales, that focus on the ability to succeed, despite limited resources. Putting others ahead of yourself. So less self-care for yourself, but putting self-care of others ahead of your self-care, the lack of showing vulnerability, as well as suppressing one's emotions. So, all of these things interact with behavior and genetics, as well as epigenetics, to flow into that cascade of the biology of adversity. For me, I gave this presentation four years ago now, at American Heart Association, where I sort of reformatted this whole biology of adversity to incorporate the Superwoman Schema, which was first defined or characterized by Cheryl Woods-Giscombé, who is a PhD scientist in the United States.
Dr. Sana Al-Khatib:
Now, that was very helpful and insightful, Michelle. Could you tell us about, what are the main next steps that need to be done in this area, that you think are going to be important to move this line of research forward, so that we can actually change this situation and really improve healthcare for these women?
Dr. Michelle Albert:
Well, I like to think of the answers to that question on several levels. So, I think one of the first levels is ensuring that women, especially women of color and specifically black women, are aware of the fact that hypertension, preeclampsia and eclampsia are risk factors, not only for their pregnancy, but also for cardiovascular disease later on, and for their children developing hypertension and cardiovascular disease later on. So, I think education is really important, on one level. On the next level is, actually having a continuum of care, where women are asked to get early prenatal care, even when they're contemplating pregnancy. So that they can be screened for hypertension, diabetes and their stressors, assessed and put in contact with resources. Having doulas, midwives involved in this process, as well as cardiologists who are involved in the pregnancy setting, as well as post-pregnancy for these women. Then, there's an advocacy initiative that has to take place, that focuses on getting aid. Kamala Harris has put forward a bill to actually do just that for maternal health, focusing on racism and bias in healthcare, because black women across the spectrum of socioeconomic status, experience poor maternal health outcomes. So, this is not only an access to care issue. It's not only a socioeconomic status issue. It is an issue that pertains to the women not being listened to, with racism and other stressors. I can't stress those first two things more, the whole discrimination part of it, and dumbing down the concerns of black women. Then, I think on a research perspective, certainly the American Heart Association has got now this HERN Network, which is a network that's going to focus on research around maternal health. So in that context, figuring out the best care models for women. Understanding the biology and how it interplays with poor outcomes later on, is also very important. One point around the biology that I want to point out for, let's say, African American women and actually Asian women as well, is that there's a higher prevalence of fibroids. There's very little research focusing on fibroids and its importance on maternal health outcomes and even the care for those women. Frankly, in my mind, a lot of that has to do with bias and how we value the healthcare of certain groups of women over other groups of women. So, those are some of the things, in terms of the solutions.
Dr. Sana Al-Khatib:
Absolutely. Before we move on to the presentation by Dr. Khan, are there any final words Michelle, that you'd like to share with the group, in terms of any final wisdom, so to speak, that you want to leave the listeners with?
Dr. Michelle Albert:
Yeah. I would just say that the maternal health crisis is preventable and it is tied into... Much of our audience are going to be healthcare providers. To the healthcare providers, I'm going to say, you really, really need to listen to these women when they tell you that they're experiencing certain symptoms. You also need to dig deeper to find out about their concerns, especially their stressors, in addition to making sure their blood pressure is controlled and that their weight is managed.
Dr. James de Lemos:
Well, thank you, Michelle. We'll turn to Sadiya now, and her team's research letter on geographic differences in pre-pregnancy cardiometabolic health in the US. For our listeners, I think what you'll see, if you read this paper, is how remarkable the research letter format is, and how much information Dr. Kahn and her team have conveyed in this really, really powerful letter, that I think has major public health implications. Sadiya, do you mind orienting our listeners to what you studied and how you did it?
Dr. Sadiya Khan:
Thanks, James. And again, thank you for the opportunity to join you guys in this podcast. I think Michelle very eloquently set up the preface for this research letter, which was understanding that health in pregnancy begins before conception. That was really the reason we wanted to focus on health factors, particularly cardiometabolic health factors, like body mass index, diabetes status and hypertension status in the pregnant individual, prior to pregnancy. The second piece of this that we were really interested in, is that we had observed that there are significant differences across the United States, in maternal morbidity and mortality outcomes. There are much higher rates of pregnancy-related deaths occurring in the South and Midwest, compared with other states in the US. That led us to ask this question, if we're able to better describe or define health prior to pregnancy, will we see similar patterns? We used the Centers for Disease Control Natality database, which includes all live births in the United States. So, the strength of this dataset, is that this is a surveillance system employed by the CDC, to monitor and record health outcomes of the pregnant individual and the newborn in the United States. Using this dataset, we were able to display maps for pre-pregnancy cardiometabolic health and look at changes from 2016 to 2019. Unfortunately, there's not much positive news, in that we've seen continued declines in favorable or optimal pre-pregnancy cardiometabolic health, which we defined as having a normal BMI and the absence of diabetes or hypertension. In addition, we saw that the levels of favorable pre-pregnancy cardiometabolic health were lower in the South and Midwest. It starts to set up some questions about upstream social determinants of health, that may be playing an important role as we start to address this problem at the individual level, but also at the societal and population level.
Dr. Sana Al-Khatib:
Very interesting and important findings there, Sadiya. Are you planning to work on additional research, to build on the research that you were publishing in this issue?
Dr. Sadiya Khan:
One of the most important questions that came from this are, what are the potential ways to start to address and support care for pregnant individuals, or as I think is Michelle really nicely put it, is for preconception care. So, thinking more about the reproductive life course before pregnancy, as well as during and after pregnancy. For that, one of the things that seems to be potentially really important, could be how Medicaid expansion has helped in states that have expanded, and differences between states that have or have not expanded Medicaid. Knowing that, that probably isn't sufficient, but it has that been helpful.
Dr. James de Lemos:
Yeah. I was struck, Sadiya. I mean, Michelle's essay and your research project really shine a bright and distressing light on maternal health in the US, I think and the crisis that we're under, that many of us don't even maybe recognize is happening. The time trends you showed were, to me, striking, giving over such a short period of time, how much maternal cardiovascular health has declined. It seems, indirectly at least maybe, that declining at a higher rate than overall cardiovascular health. I first applaud you for writing on this topic because I think it brings this issue to light, in terms of a public health crisis, frankly. But I wonder if you have any thoughts on why specifically, things are declining at such a higher rate for pregnant women or pre-pregnant women, maybe relative to national trends? Maybe they're not. Maybe this is what's happening across all age and gender demographics.
Dr. Sadiya Khan:
It's a really important observation. I agree with you. It seems like it's much more striking in this concentrated and focused group of individuals, that are pregnant and giving birth. It's possible because of the age range that we focus on, the 20 to 44 year old age range, that there are potentially more significant declines happening during this time period. We know cardiovascular health in general, appears to have some age-dependent dips, generally around adolescence. That early adulthood, college age period seems to be where a lot of cardiovascular health decline happens. So, I think that's what we're observing, as we're seeing these more striking trends in this age group. But it would be interesting to know, compared to non-pregnant individuals and across the life course, if that is in fact, the case.
Dr. Sana Al-Khatib:
Then I'll ask you what I asked Michelle, Sadiya. Any final words of wisdom that you'd like to share with our listeners?
Dr. Sadiya Khan:
I don't know if I'll be able to speak as eloquently as Michelle did. I think her responses really capture both of these papers and thinking about ways forward, about how we can dress the maternal health crisis. But I think that the word that she used, that really sticks with me and is one of the reasons that I'm so passionate about this work, is that this is preventable. That there are so many different things that could be in place, whether it's at the individual clinician and patient level, at the individual health system level, at the state level, as we looked at here, but really at the national level as well. I think we have a lot of work to do, but there's a lot of things that we know can help.
Dr. Sana Al-Khatib:
Great. Wonderful. James, any final words from you before we wrap up this part of the podcast?
Dr. James de Lemos:
First, Sana and the rest of the Circulation team, I congratulate you on another spectacular Go Red issue, that really is such an important endeavor. You and Biykem have done an incredible job leading this. I thank Michelle and Sadiya for coming on today, but also for their work. I think raises the stakes here, that we've got a public health crisis affecting women, and disproportionately affecting black women in the United States. It's underappreciated. I think you both point out that it's preventable. So, I think it's a call to action. It's a really well stated and an important topic.
Dr. Sana Al-Khatib:
Wonderful. Well, thank you so much, James and Sadiya and Michelle. Thank you so much for submitting your excellent work to us. Thank you for being with us today. This concludes this part of the podcast. Thank you. Next, I'm excited to provide you with a brief overview of the issue. We have two original articles. One is on genes that escape X-chromosome inactivation, modulate sex differences in valve myofibroblasts. This one was submitted to us by Dr. Kristi Anseth and her team. The study elucidated sex dependencies in myofibroblasts activation pathways and transcriptome analyses and small molecule interventions, implicating genes that escape X-chromosome inactivation, in regulating sex differences in the progression of aortic valve stenosis. The authors highlight the importance of considering sex as a biological variable, to understand molecular mechanisms underlying aortic valve stenosis and help guide sex-based precision therapies. The second original article is by Dr. Elena Aikawa and her team. It is on Prothymosin Alpha, a novel contributor to estradiol receptor alpha-mediated CD8+ T-cell activation and recognition of collagen cross-reactive epitopes in rheumatic heart valve disease. This paper provides novel findings that will likely have clinical impact down the road. As the authors pointed out, understanding the Prothymosin Alpha and estrogen sensitivity mechanisms to control the CD8 T-cell function may indeed provide insights into treatment for rheumatic heart valve disease. In this issue, we have three research letters. One letter was on the geographic disparities in pre-pregnancy cardiometabolic health in the US. You just heard about this paper in the first part of the podcast. Another letter, by Dr. Pradeep Natarajan and his team, offers information on the microvascular outcomes in women with a history of hypertension in pregnancy. It highlights that hypertensive disorders of pregnancy, especially preeclampsia, are independently associated with reduced microvascular indices. The investigators called for further research, to translate these findings into cardiovascular risk reduction strategies for women with these conditions. The third research letter, by Dr. Androulakis and his team, provides insights from cardiac magnetic resonance and angiography screening on spontaneous coronary artery dissection, also known SCAD. Theirs was the largest cohort of SCAD patients screened for peripheral vascular pathology by magnetic resonance and geography, to date and one of the largest to assess the SCAD-related impact size and relevant associations. They concluded that cardiac magnetic resonance has valuable contribution to the investigation of SCAD patients. In this issue, we have six perspective papers. In addition to the Perspective paper that you heard about from Dr. Michelle Albert, there are five perspective articles that span topics of great clinical and research relevance and importance. One perspective article, led by Dr. Carolyn Lam, tackles incorporating sex and gender into the design of cardiovascular clinical trials, a very important topic. Dr. Lam highlights the importance of sex and gender to the optimal interpretation, validation and generalizability of cardiovascular clinical trial results. Another perspective by Dr. Kathryn Lindley presents a call for action to address increasing maternal cardiovascular mortality in the US. This actually ties in with the initial part of the podcast. Dr. Lindley offers insightful suggestions, regarding strategies that could improve maternal cardiovascular care. Another perspective by Dr. Anne Curtis, addresses sex differences in response to rhythm management devices. Dr. Curtis reminds us that the conclusion that should be drawn from the many studies that have been conducted on cardiac rhythm management devices, is that these devices are indeed effective in both men and women, but they're still significantly underutilized in women eligible for those therapies. Dr. Curtis calls on us to be ever vigilant, to provide sex-neutral medical care to all patients, when clinical trials don't provide a strong rationale to do otherwise. I'm quoting her here. Another perspective paper by Doctors Mauricio and Khera, addresses statin use in pregnancy. They raise the of whether it is indeed time for a paradigm shift. This article was prompted by the FDA's request to remove the pregnancy Category X label for statins that was issued in July of 2021. The authors encouraged clinicians to use shared decision making. They add that those with atherosclerotic cardiovascular disease events, especially recent ones, should be encouraged to continue statins during pregnancy or resume them as soon as possible, if they're withheld. For those with heterozygous familial hypercholesterolemia, previously reasonable LDL control and no manifest vascular disease, there may be more tolerance for statin deferral during pregnancy, but they definitely highlight the need for dedicated research in this area. The last perspective, led by Doctors Okwuosa and Zaha tells clinicians what they should know about sex differences in cardio-oncology. They highlight sex differences in cancer and cancer treatment, cardiovascular diseases and the intersection of these conditions, that are likely to be quite helpful for clinicians taking care of such patients. Don't forget to check out the Pathways to Discovery section, where you will find a very interesting and motivating dialogue between Dr. Maryjane Farr and Dr. Biykem Bozkurt in which Dr. Bozkurt describes her career journey. I personally enjoyed reading that interview and found it quite inspiring. In closing, I want to express my deepest gratitude to my co-editor Dr. Bozkurt, the Editor-in-Chief for Circulation, Dr. Joseph Hill, the Executive Editor for Circulation, who was with us at the beginning of the podcast, Dr. James de Lemos and all the authors who submitted the research for this issue. I also want wholeheartedly thank and acknowledge the Circulation Associate Editors and Staff, who work tirelessly to enable us to produce an excellent Go Red for Women issue. I am very excited about this issue and hope that you will like it as much as I do. This concludes our Go Red for Women issue, Circulation on the Run podcast. Thank you for listening.
Dr. Greg Hundley:
This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.