Heart Health from Trimester to Trimester

Joining us on the podcast is Doctor Joe Puma, Founder and President of Sorin Medical. This conversation will cover the complexities of Cardiovascular Health and its correlation to pregnancy throughout each trimester.

Episode Transcript

(00:01):
Me turn. In our practice,we take care of anyone who walks in
and wants to see us. Weare a part of the community, and
to some degree we hope that there'senough people who have insurance that will cover
everyone else. But you know,again, this is one of the access
issues. Not everyone in underserved communitieshas insurance. Welcome to Eternal Home to

(00:26):
access and information for mothers of color. Joining us on the podcast is doctor
Joe Puma, founder and president ofSORE and Medical. This conversation will cover
the complexities of cardiovascular health and itscorrelation to pregnancy throughout each trimester. You
know, we have, in thesimplest of terms of problems, there's a

(00:47):
real unmet need. There's certain communities, you know, we're talking about communities
of color because they are rates ofunderlying diseases so much higher and it translates
into worse outcomes death, infant mortality, and so we have a real opportunity
to both understand this better and dosomething about it. I mean, why

(01:12):
would we let of maternal deaths arepreventable? How could you from a moral
and ethical perspective, go to sleepat night and not say what can I
do to change that? Sure,and statistically when we take a look at
some of the numbers, so Isee here African Americans are forty percent more

(01:34):
likely to have high blood pressure,six sixty percent more likely to have diabetes,
thirty percent more likely to die froma cardiac related That's exactly right.
So that's for the most part,from a medical standpoint, why outcomes are
worse in the black community from maternalhealth. But then there are a lot

(01:57):
of other issues or access is,insurance issues, bias issues, And we
talk about these things not because we'retrying to make people uncomfortable, but we
talk about it because we're trying tomake people uncomfortable so they do something about
it, and we have new programsor new approaches to improve access. I

(02:17):
think the first thing we need todo is define when access is. Maternal
mortality in communities of color is fourtimes higher than in white communities. So
clearly something good is happening in whitecommunities. But what are the issues for
access? Some of the issues areeconomic, some of the issues are physical.

(02:38):
Right, communities of color are lesslikely to be In short, the
goal of the Affordable Care Act wasto get everyone insured. Right that healthcare
healthcare wasn't a privilege, but itwas a right, and I'm not sure
we've all lived up to that.Large health systems, while they invest in

(03:01):
programs, the programs are typically centrallylocated at their main campus, not where
the patients that don't have insurance,that don't have a primary care provider or
a primary obgy end physician where theyreside. And that's a problem because it

(03:22):
becomes more difficult to take a dayoff from work to take the subway or
get transportation to navigate a large healthsystem. And all of these beautiful women's
centers that we often see around thecountry, where are they usually located.
They're not necessarily located in underserved communities. So I think in general, we

(03:45):
really need to have the same definitionof what access it is, to just
be honest about what's stopping us fromproviding care. You have unnecessary every deaths,
eighty percent of which are preventable,and even even if you look at
it from the perspective of okay,well someone didn't die, but they but

(04:14):
communities of color also because of theseproblems, have either low or no prenatal
care, which leads to low birthweight, increased infant mortality. And these
are all devastating problems for a family, especially if there's not good social support.

(04:36):
So I think these are all problemsthat we can conquer. But you
know, Maternal, your website,the work you've done Kenya has been just
a revelation to me in terms ofnot only developing awareness educating people, but
when you look on your website,all the resources that you've shown that are

(04:59):
out there, resources in underserved communities, and that's been an incredible first step.
Well, I appreciate that, andthat was the goal of the platform,
was to make sure that we createdaccess and information for not just communities
of color, but like mothers ingeneral. Right, because I feel like
I've read this quote from Charles fromCare for Moms, it's the maternal health

(05:23):
crisis is the American health crisis,right, So we're not just addressing this
for communities of color, We're addressingthis for all Americans because it carries on
a continual burden into the healthcare systemand just beyond right. So I also
love your approach right at Soren becauseyou're doing something very similar and that you're
creating access in communities of color withcardiac preventative healthcare. So talk a little

(05:46):
bit about that. Sure, well, excuse me, sare and Medical is
now, I guess nine or tenyears old, and I founded sore in
Medical. I'm an interventional cardiologist,but I founded sore in Medical because I
saw there a lot of unmet needs. After the Affordable Care Act was approved,
one of the things that I'm notsure people appreciated was it led to

(06:11):
the creation of these big health systems. And ten years later, now we
can see that what's happened with thesebig health systems is kind of the mothership
or the main campus of all thesehealth systems are thriving and busy, but
the smaller community hospitals or the smallercommunity based services are underfunded, don't have

(06:33):
physicians, and in many cases,you know, we live in New York
City, we know a lot ofhospitals in communities that have closed because of
this. So I wanted to takecare of people that needed my care.
I wasn't really interested in, youknow, sitting in on Park Avenue and

(06:54):
waiting for people to come to me. And so what we embarked on was
a plan to identify through some demographicdata, areas where they were high rates
of cardiovasial disease, and these arealmost exclusively in underserved communities, lower socioeconomic
communities. And I've been pretty fortunateto be able to convince some very talented,

(07:21):
high quality physicians that we're going togo to those communities, set up
offices, their partner with primary carephysicians or general cardiologists and become part of
the community. In doing that,we've now been able to overtime to transition
from just acute care or disease careto start, as we've built our relationships

(07:44):
to start working on prevention. Twoof the biggest issues you have in communities
of color which significantly affect maternal careour hypertension, high blood pressure, and
diabetes, or the rates of highblood pressure and black women are more than
twice as high as in white women. The same with diabetes, and if

(08:09):
you have those as pre existing conditions, then both the morbidity and mortality.
So kind of bad stuff happening duringthe pregnancy, but the risk of dying
from the pregnancy is higher. Sowe've been able to work to identify patients
and follow them and work with themlongitudinally. In our practice, we take

(08:35):
care of anyone who walks in andwants to see us. We are a
part of the community, and tosome degree we hope that there's enough people
who have insurance that will cover everyoneelse. But in general, you know,
you're you know again, this isone of the access issues. Not
everyone in underserved communities has insurance,right, which creates these healthcare deserts,

(08:56):
which we were talking a little bitabout before the podcast starts, right,
So let's let's go into that alittle bit more. So, you know,
you have these communities of color thatdon't have quality access to healthcare in
their particular vicinity. There's healthcare accessthat's an issue, and then there's maternal
healthcare access, which is another issue. So you have these layers of inequality

(09:18):
that are going on in communities ofcolor. What can we be doing as
a community and as providers to helpalleviate some of these things that are going
on? So those are great thoseare great points. And healthcare deserts,
i think is the right way todescribe it. And that obviously builds off
of the food deserts that we arewell aware of. Right. You know,

(09:39):
there's plenty of bodegas in the communities, but it's hard to find a
whole foods, right it's hard tofind good fruits and vegetables and things like
that. Well, it's the samething. Would I would tell you you'd
be hard pressed to find high qualityob GYN practices in underserved communities. Most

(10:00):
of them are in higher net worthcommunities, white communities, and hospital hospital
base and so that's challenge number one. On the positive side, however,
I think that again, through yourefforts and when you look at and the
services that you're showing that people havein these communities, midwives due laws are

(10:26):
now starting to fill some of theseneeds. But one of the other issues
why it's a healthcare desert is manyof these patients have Medicaid only, and
while that's a government insurance, ittypically pays much lower rates than Medicare or
other private insurance. And so ifwe were at least being honest, it's

(10:50):
difficult for whether it's a private practitionera health system, to create an economic
model that works for them. Butthat doesn't mean it can't be done.
And I think there needs to bea willingness to look at the communities where
they have the most need. Andeven if it's pilot programs, again you

(11:11):
look at what we've done, it'sor in medical you might look at it
just as a pilot program. Nowwe did it privately and independently, but
I can tell you ten years laterwe've had great success. Sure, and
when you take a look at apreventative healthcare model, like how much of
a cost savings is that to thecommunity and the health system at large,
would you say, well, wehave some data just from our practice to

(11:37):
show that if you work to provideaccess to care in the community, not
tell people come to me, butyou go to them. If you work
to use technology to your advantage tohave the more advanced testing so that you
essentially can evaluate patients better, faster, and then you can create a model

(12:01):
that not only financially works Again inour program on the cardiovascular side for adults,
not just pregnant women, we canshow that would our model if you
use it across New York State forthe detection of carnary disease and the treatment
of carnary disease, you could saveabout two billion dollars a year can be

(12:24):
taken out of healthcare costs. Sure. Wow, And what would you say,
are some of the conditions in thecomplications during pregnancy that later affect heart
health. So the most common onesis pregnant women today of every different than
pregnant women thirty or forty years ago. And some of the differences that you

(12:46):
see is Number one, women aregetting pregnant later in life, so it's
not unusual thirty five and old orforty and older that you have pregnant women.
Number two, women who may havehad congenital heart disease. Because our
treatment and of congenital heart disease inchildren and the detection of it is so
much better today than it was thirtyor forty years ago. These women are

(13:07):
now living to adulthood so that theycan have reach childbearing age. So number
one, older women getting pregnant.Number two women with congenital heart disease,
and then number three because they're older. High blood pressure typically the two peaks
in life where people get diagnosed withhigh blood pressures in their thirties and in

(13:28):
their fifties. Interesting, so therewere a fair number of women pregnant in
their thirties that already have underlying heartdisease. So what is high blood pressure?
So what does this lead to?Well, pregnancy is a volume overload
state the blood volume and pregnancy canincrease by forty to forty five. Your

(13:52):
heart rate goes up when you're pregnantby ten to twenty beats. Your cardiac
output the heart has to pump heartand faster to get to handle all this
blood volume and to support the childincreases by thirty to fifty percent by the
third trimester, and if you havetwins, it can be even as high

(14:13):
as sixty percent. So pregnant womenoften in general, when they're normal,
may feel tired or fatigued, feeldizzy or light headed, short of breadth,
or palpitations. Now the challenges thoseare also the symptoms that you might
get if you have heart disease,so there's a fair amount of overlap.

(14:37):
So I would still say that highblood pressure in general is the biggest issue.
Right if you're considered to have gestationalhigh blood pressure, if your pressure
is one forty over ninety after twentyweeks, But that in and of itself
isn't a bad problem unless you startshowing protein in your urine, because that's

(15:00):
a sign that the blood pressure isdamaging the organs, and that's called pre
acclampsia, and that may be thebiggest challenge of the most common problem.
Pre acclampsia can lead to seizures orwhat we call acclampsia, and when that
occurs, the risk of that significantlyincreases, not just during the pregnancy,

(15:20):
but within that first year after thepregnancy. And so again the challenge there
is, let's go back to insurance. If you have Medicaid, oftentimes Medicaid
will only cover the pregnancy up tosix months after the pregnancy. So there
are significant medical issues that occurs aswomen age and have children, and also

(15:43):
continued ongoing significant barriers to getting goodhealthcare sure and even into the postpartum phase,
which is just as important and duringwhile you're pregnant, absolutely just as
important. You know, the awarenessstuff, you know, kind of the
work that you're doing is so importantearly on because we know when women don't

(16:04):
have good prenatal care, if we'renot checking their blood pressures regularly, checking
the urans regularly, or known prenatalcare, that can lead to problems not
just with the mother but with thechild. Increases, infant mortality, increases,
low birth rate, children who longterm can have problems developmentally educationally,

(16:30):
and so these are all kind ofdifficult to define, but long term burdens
on the family, on society,on the healthcare system that we know about,
but all that could be prevented.So what would you say, are
we talked a little bit about someof the barriers to healthcare right, but
what would you say are some prominentones if you had to kind of spell

(16:52):
out, maybe the top two orthree. So the top two or three,
I would say that all can beprevented. By the way is if
would be congenital heart disease, preexisting conditions, and then high blood pressure.
But we really got to add diabetesin as well, so that would
be the top the top three therisk. Women who develop gestational diabetes diabetes

(17:18):
during pregnancy often have double cardiovascular deathrate later in life, so these are
early signs of long term issues.They don't live as long and mostly it's
because of cardiovasia disease. One inthree deaths from pregnancy is due to cardiovascular

(17:38):
disease, but number one congenital heartdisease, especially women that may have immigrated
to the United States from countries whererheumatic fever is still a problem. Because
rheumatic fever over time typically leads tovalvular heart disease, mitral stenosis, or
other valvular problems and depending on howsevere the valvular heart disease is, if

(18:04):
patients had been evaluated initially, someof them, we might have recommended that
they not get pregnant because of therisk to the mother during the pregnancy from
the volume overload that the body goesthrough. Very interesting. And then before
the podcast you shared with me astatistic that says that one in five women,
right, or people who are likelyto have diabetes, will suffer from

(18:26):
a silent heart attack. Can youtalk a little bit about that. Sure,
that's exactly right. I like totell patience when they come see me,
and they're not coming in to seeGeorge Clooney, and you are right,
that's not the way medicine really is, and it's certainly not when they
come to see me. But evenheart disease isn't like the movies where people
come to the emergency room clutching theirchest. Everything is out in the open.

(18:48):
Women in general and diabetics in particular, often have a typical symptoms of
heart disease. They're not getting thetypical crushing chests comfort. So it really
takes a relationship between the patient andthe physician. And as you probably know

(19:10):
as well as I do. Relationshipstake time, lots of interactions, and
then you could start understanding people andyou understand the way disease affects them.
But one in five heart attacks aresilent. People didn't even know they had
it. So if you're not someonewho's getting regular medical care, who doesn't

(19:32):
have access to care, who doesn'thave insurance to get care, hasn't been
able to build a relationship with thephysician, all things we should all not
only aspire to, but we shouldall have a right to, then you're
at risk. You're at risk.Spontaneous carnary artery dissection actually occurs, that's

(19:56):
a heart attack in women who arepregnant, but can occur up to six
months after the pregnancy. So thelongitudinal care. You find out you have
pregnant, that's a beautiful day,everybody's happy. Go to the doctor,
get your blood pressure checked. Continuethat care right through at least a year

(20:18):
after the pregnancy, because that entiretime, it's almost a two year period
where your body is changing so much. Right you have the expansion and then
the contraction again, but you needoversighting care throughout that entire time. How
do you know you're having a silentheart attack. It sounds scary. Well,
that's the problem. You don't know. Oftentimes the symptoms are. You

(20:40):
may think you have the flu.You may just feel fatigued. You may
feel a little tired, you maybe walking up the stairs. Jesus,
don't have as much energy as Idid. I'm a little bit short of
breath. You don't find out aboutit until you've been to a physician and
they've done an EKG or an examinationof your heart with you know, listening
with a stethoscope. They may heara new murmur or an ultrasound of the

(21:03):
heart where they can see how theheart muscle is functioning. So you won't
know about it, but you willknow you just don't feel quite as well.
And that's really all the stuff thatyou can help people do when they
do this scan. Right, Solet's talk a little bit about the scan
and how it helps people. Sure, absolutely, there are lots of ways
to evaluate heart disease. The mostimportant first step is just going to see

(21:26):
a doctor, but there are otherways to evaluate heart disease, and mostly
we use imaging. Right, peoplehave heard of stress tests and nuclear stress
tests and pet scans, and allthese different things and MRIs. The technology
though now is so advanced that wehave these super fast cat scans and in
less than three or four minutes wecan get a picture of your heart,

(21:48):
all its chambers, how it's pumping, its valves, and the arteries to
tell if you have any blockage atall. And this test is as good
as going into the high hospital andhaving an invasive procedure. It also happens
to be the least expensive of allthe tests. Talking about that, Yeah,
it's affordable, it's affordable, insurancecovers it, it's fast, higher

(22:15):
quality, and unfortunately, or maybepredictably, it's the least used tests in
the United States right now, buthopefully with advocacy and awareness and education over
time that'll change. So how longwill it take you to evaluate someone's heart
health? So in our practice,we can do it in one visit.

(22:36):
You come in, you get ahistory, physical exam, vital signs taken,
EKG, and if you need acat scan or an ultrasound, you'll
have it all in one visit.So in one hour we can know a
whole lot about you, and statisticallywe can give you a pretty much a
survival curve for the rest of yourlife, which is great, whether it's

(23:00):
good or bad. By the way, it's really important to know where you
are, to know where you are, to know what your next steps are
to be, and to plan yourhealthcare for the future. Or if it's
all normal to take that anxiety andworry at if your life. Yeah,
and speaking of anxiety and worry,the scan itself, right, it's how
many minutes, would you say,three and a half four minutes tops,

(23:22):
right, So you're in, you'reout. It's quick, it's not evasive,
that's exactly right. And it's ashigh quality and as accurate as an
invasive catheterization or angigram. And whatare you looking at exactly when you're doing
the scan? So we see theentire heart, We see the four cardiac
chambers, We see how the pumpingchamber of the heart is pumping. We

(23:44):
can see all four cardiac valves andwhether there's any stenosis or blockage, if
they're opening properly, if there's anyleakage. And most importantly, what we
are primarily looking at is the arteriesto see if there's any blockage. And
so we can see from you know, it's as predictive if the arteries are
completely normal and there's no hardening,or what we call a calcium score of
zero from a predictive standpoint with me, you have a less than two percent

(24:07):
chance of having a heart attack orcardiac death over the next eight years.
Or if there's a severe blockage,potentially in the widowmaker area, where even
if you didn't have any symptoms,there are certain blockages and certain locations where
if you get them fixed, youwill live longer. Because ultimately, the
only two things we could do forpeople, pregnant women, non pregnant women,

(24:29):
all people is either make them feelbetter or live longer. And so
we really try and keep it simple. We try and keep it efficient,
low cost for all patients. Andif people do need something right, so
they need something done operational wise.Like you have a beautiful facility that I
was at, which it's clean,very modern, it doesn't feel like a
hospital, which sometimes can be scary. Right, people are happy to be

(24:53):
there. We make it comfortable forthem, and again I think the efficiency
is just as important. But allof that is built out of relationships,
right, It's the personal relationship betweenthe patient and the physician and providing for
everyone that comes through your doors.That's great, an appropriate facility for them,
right, because that's what everybody deserves. It doesn't matter what insurance they

(25:15):
have, it doesn't matter where theycome from. That's important. And going
back to like, you know,pregnant women and what we I'm not pregnant,
but what they can do that's okay, neither up to take care of
themselves. What can they be doingtoo? Like can they exercise? Like
what can you be doing while you'repregnant to keep your cardiac health up?

(25:36):
So ultimately the basic things they cando is what what our moms have been
telling us since we're little kids.Eat right, low salt, vegetables,
fruits, even exercise. When whenwe counsel people to exercise, we're not
telling them to get ready to runthe marathon, right, we don't want

(25:57):
to see a lot of third trymester pregnant women running the New York City
Marathon next year. But sometimes it'sjust as simple as taken a walk around
the block or you know, acouple of blocks before dinner every night.
It's keeping mobile, all of theselittle things time to yourself, whether it's
stretching, yoga, some meditation,it's all of these little things kind of

(26:21):
self care things that help you leada healthier life. Reduce the risk of
high blood pressure or prevent it fromgetting out of control, reduce the risk
of diabetes, or prevent it ifyou have it, from getting out of
control. It really is a balance. Wouldn't it be great if we didn't
need to use medications for some ofthese things, and so people really can

(26:48):
impact their own life. In pregnantwomen that have high blood pressure or have
diabetes or pre diabetes, we actuallycancel them to do all of these things
to the extent that they're they're ableto, because it may mean that they
don't need medications later in the pregnancy, because all medications have a chance to
affect the fetus. Right, So, if we can prevent the use of

(27:11):
medications, if we can reduce therisk of pre acclampsia, if we can
increase the likelihood of a term pregnancywithout gestational diabetes, then maybe what we
can do is reduce the risk ofmaternal mortality, especially in the black community.

(27:33):
Four times higher risk of death frompregnancy in the black community compared to
the white community, and that tome is just incredibly troubling, especially when
eighty percent of those deaths. Again, I know I said it before,
but I'll keep saying it until peoplestart getting active and doing something. Eighty
percent of those deaths, four outof five, are preventable, which is

(27:56):
crazy to me. Right, sowe can prevent something, then why are
we not doing? Why are wenot doing? And it maybe as simple
as just figuring out a process ora way to get doctors midwives opening practices
in certain communities that they otherwise maynot have thought to open. But that's
where the need is. And there'ssuch a great feeling when you're helping people
that have a need can make animpact and creating that affordability factor because if

(28:21):
people know it's affordable, then theyknow it's accessible and they'll actually do it.
That's exactly right. If you makeit easy for them affordable, then
you'll likely be successful. Very goodstuff. So any signs anybody should be
looking for, like say they're havingsome symptoms, they're not feeling well,
when should they call their cardiologists ortheir doctor. So in pregnancy, it's

(28:45):
actually very important if they're starting tonotice ankle swelling more fatigued than they had
been noticing, especially if they're nowin this second trimester, right, this
is when high blood pressure pre acclamps. Yeah, these are when these complications
happen. If they have a homeblood pressure monitoring. You know many many
people today have home blood pressure monitors. They have these wearable devices that you

(29:07):
know, they can see if theirheart rates going up more than it has
been. Heart rate usually increases tento twenty beat storing or pregnancy. If
you're starting to notice your heart ratesgoing up, you're feeling palpitation, you're
more short of breadth than you hadbeen a week or so ago. These
are all reasons to not wait foryour next appointment. Go see your ob
gyn or even see your interns.Get into the system, get to see

(29:30):
your healthcare provider. They'll navigate itfor you. They'll know what what to
look for to determine if you're atrisk. That's good to know. And
then how can people get in touchwith your practice. We're online at surign
medical y dot com. We're onInstagram even that's been in the in the
last year, and and they're welcometo visit us, send us an email.

(29:56):
We always respond and we're always happyto help doing great things in the
community. And I appreciate you asa black woman, right for taking that
initiative to make sure that you're visibleand communities of color because we need that
right, We need to have thatpreventative approach and know that our health is
important. Their resources there, there'saccess and there's also information. So thank

(30:18):
you for your initiative there, Kenya, I need to thank you. After
we've met and we talked, youjust reinspired me for all the work you've
done, all the good you've doneme turn all the website, the bringing
people together. It's amazing. Youwould think that people would see needs and
want to respond to it, butsometimes it takes an advocate, an activist,

(30:42):
a leader. I don't know howyou consider yourself, but I think
it's inspiring and amazing and we lookforward to continue to work with you and
to continue to help people who needour help and figuring out all the avenues
and ways we can do. Iappreciate that and thank you. You know,

(31:02):
like I was telling you earlier,we're just we're doing God's work,
right, We're trying anyway. Yeah, yeah, good stuff. Or you're
listening to Meternal on iHeartRadio. Iam Kenya Gibson. I'm sitting here with
doctor Joe Puma of Soren Medical andwe have another episode coming up really soon,
so be sure to visit me tnaldot info for more information about how

(31:22):
iHeartRadio is partnering to create access andresources and communities of color. Until next
time, thank you for listening toMeternal. The journey of becoming a mother
can be very taxing upon the body. One in five women are at risk
from experiencing a silent heart attack.However, most heart complications are preventable.

(31:44):
This episode will teach mothers of colorthe importance of heart health and how pregnancy
related heart complications can be prevented.Visit Meternal dot info to learn more.