Patients who have been pregnant and especially those who had complicated pregnancies are at higher risk for cardiovascular disease, but the condition typically arises 10 or 15 years after the pregnancy.

Patients are screened months after their pregnancy for cardiovascular disease, but as the patient ages, pregnancy is a very important part of their medical history, especially when it comes to heart disease.

“When they come to women’s cardiology, we always, always ask about their pregnancies, any pregnancy loss, any complications and did they deliver preterm,” said Li Zhou, M.D., Ph.D., medical director of the Norton Heart & Vascular Institute Women’s Heart Program.

Preterm birth, stillbirth and other pregnancy complications were shown to be associated with cardiovascular mortality and cardiovascular disease, according to a 2022 study, “Pregnancy Complications and Risk of Cardiovascular Disease Later in Life: A Nationwide Cohort Study,” published in the Journal of the American Heart Association.

About 10% to 20% of pregnancies are complicated with adverse outcomes, and that increases the mother’s risk of cardiovascular disease.

Women who have risk factors for heart disease will benefit from a review of warning signs and how a heart attack might look different for them versus for a man. Once any red flags are identified, the sooner they get stress testing and a referral to a cardiologist, the better.

“When your female patient comes to you complaining of excess fatigue and weakness, don’t overlook those symptoms,” Dr. Zhou said on a recent episode of “MedChat,” a Norton Healthcare continuing medical education podcast.

“At the time of heart attack, many women do not have chest pain and may complain of indigestion. If you’re not certain, refer them to us” at Norton Heart & Vascular Institute Women’s Heart Program

In a 2003 study, 43% of females did not have chest pain on the day of the heart attack. The most common complaint was unusual fatigue. Even weeks before the heart attack, the patients recalled fatigue, according to Dr. Zhou.

When it comes to ordering stress tests, keep in mind that many patients may have difficulty with balance or may have knee pain on a treadmill. In those cases, pharmacological stress — using medication to impose stress — can help with diagnosis.

“For an intermediate-risk patient you want to consider combining ECG with imaging modality — echocardiogram or a nucleus study,” she said.

For females, especially for pre-menopausal females, Dr. Zhou recommends using echocardiogram for stress testing if possible. Nuclear studies like SPECT (single-photon emission computed tomography) or PET (positron emission tomography) will give the patient radiation that could increase risks of cancer later in her life or cause fetal abnormality if she becomes pregnant later, according to Dr. Zhou.

Referring the patient to the Women’s Heart Program as early as possible helps make sure the patient gets the optimized cardiovascular tests for her conditions.

“Females usually have smaller arteries, more tortuosity and more complications from vascular access, and higher mortality after coronary artery bypass grafts,” she said. “We want to make sure we screen the patient appropriately before we get them to the cath lab.”

Using alternatives such as CT coronary angiogram to catheterizing through the femoral or radial arteries, a cardiologist can get the same imagery using contrast through the peripheral vein to visualize the coronary arteries to reduce the risk of procedural complications.