Traditionally, women have focused more on their gynecological health and screening rather than on cardiovascular risk. Most women, for instance, are far more concerned about developing breast cancer than having a heart attack or stroke. Yet, as we have discovered over the last decade, heart disease kills more women than all types of cancer combined. Breast cancer screening and awareness is much more prevalent among young women, but heart disease awareness is not. Because of the way in which women have increasingly actively adopted screening for breast and uterine/ cervical cancer, many female patients faithfully see their gynecologist on an annual basis. Unfortunately, the number of women who regularly see a family physician or general internist in addition to the gynecologist is much smaller.

Yet these routine visits with the gynecologist do present an excellent opportunity for patient engagement, education and screening for heart disease. OB/GYN physicians are well trained and expert in all areas of gender-specific gynecologic disease, breast disease and other issues of women’s health. However, when they are also faced with providing primary care services for their patients, they are often overwhelmed. Primary care is a specialty all to its own and those who train for the delivery of primary care spend countless hours in outpatient clinics and ambulatory care centers. In contrast, the OB/GYN physicians are trained as surgeons, who provide highly skilled surgical intervention for women with gynecological and obstetrical needs. Although they do have training in a clinical setting during residency, the bulk of their time is spent in the operating room. Most of their clinic-based work is focused on pre-operative and postoperative exams, pregnancy follow-up, and routine yearly gynecological exams. Nonetheless, many of these providers are faced with addressing primary care issues such as hypertension, depression, obesity and diabetes. They must rely on contacts with colleagues and referrals to specialists in order to ensure that their patients get the care they need. While many OB/GYN physicians do in fact counsel patients to obtain other primary care physicians for their general medicine needs, many of the patients simply refuse and assume that the OB/GYN will continue to treat all of their medical problems.

The OB/GYN physician develops long-standing relationships with most of his or her patients due to the regularity of visits for annual screening and women’s health maintenance. The relationship between women’s health providers tends to have lifelong continuity of care. Continuity of care has been shown to be essential in patient engagement and providing positive outcomes.1 In addition, women who have had children develop a special bond through the process of pregnancy and delivery with their OB/ GYN physician. In many cases women with multiple children have had the same provider provide prenatal, pre-partum and postpartum care. This relationship results in a very high level of trust. When a female trusts another human being with the delivery of her child, a special bond is formed. For this reason, many women only trust their OB/GYN to provide care and are more apt to listen to them and comply with their recommendations.

When an OB/GYN is asked to provide primary care, they must assume a great responsibility. They must be willing to learn and educate others in their office about primary care issues. A key factor for successful primary care in a busy OBY/GYN office is the utilization of physician extenders such as nurse practitioners (NPs) and physician assistants (PAs). These practitioners tend to have more time to spend with each patient (which is a must when providing primary care visits). Extenders such as these are also trained in primary care as they receive their certifications and this allows them to be more prepared to screen and treat common medical problems. Most NPs and PAs are excellent communicators and enjoy spending time getting to know the patients on a personal level. The bond that is formed can be incredibly impactful on a provider’s ability to engage with a patient and effect changes in lifestyle, diet and exercise — all of which are key components to the delivery of primary care.

As exclusive providers of healthcare for women, the OB/GYN physician is in a unique position to impact care and effect change in women’s cardiovascular health. Women will make contact with the OB/GYN at least annually and this provides an excellent opportunity to screen for heart disease. In addition, when OB/ GYN providers are educating patients about breast cancer screenings and the importance of self-exams at the annual visit they can also discuss heart disease risk factors and screening tests. As a whole, OB/GYN physicians are great educators and patient motivators — so much of prevention in gynecological disease requires patient engagement and patient education as to the risk and prevention of disease. For example, breast self-exams have been shown to be incredibly effective at detecting breast cancers in early stages — leading to better treatment options and more favorable long-term outcomes. In the case of screening for heart disease or its risk factors, simple questions can prompt further investigation and referral to a cardiologist for more advanced treatment and testing. Without this vital contact point with the OB/GYN provider, many women will go unnoticed and undiagnosed until they present with a potentially life-threatening cardiac event later in life.

But, as with most physicians, OB/GYN providers are overwhelmed with an increasing volume of patients and busy clinical schedules. How can these providers add additional responsibilities, such as screening for heart disease, into a routine clinic visit? One simple solution is to provide a “Risk Questionnaire” to patients as they sign in for their appointments in the waiting area. Data from previous studies have shown that self-administered cardiovascular screening tests are quite effective and reduce healthcare costs.2 While patients wait for their turn in the exam room they can fill out a simple set of questions to evaluate their risk for heart disease. When the patient reaches the exam room, the nurse can review the questionnaire as part of the routine intake and alert the physician, NP or PA to a patient that provides worrisome answers on the screening tool. These patients are then identified to the providers as someone who will need more extensive screening and questioning during the office encounter. The American Heart Association has many useful tools for quick screening. These can be reproduced and placed in the office for use by patients. Many provide a quick score that predicts risk for future cardiovascular events. Obviously, those with low-risk scores can be simply counseled about the fact that women are at risk for disease and educated as to how to continue to remain low risk. Those with intermediate or high-risk scores can be actively treated and referred to other specialists for further testing and intervention.

How can the OB/GYN physician make a difference in cardiovascular death rates in women?

Engagement is key. Women tend to bond with their OB/GYN and trust them deeply. The OB/GYN thus has the opportunity to educate and engage the female patient in a way that may produce more positive cardiovascular outcomes. In addition, many women see the same OB/GYN for life. That means that a physician can engage with a young woman in her early 20s and follow her throughout her life. These physicians have the strength of long-term follow-up and an incredible continuity of care. Recent data has demonstrated that continuity of care in the treatment of diseases such as hypertension in younger patients may have a significant impact on cardiovascular events that occur later in life.3 In this one particular study the trajectory of patient’s blood pressure predicted the presence of heart disease later in life. Ultimately it argues for earlier screening and treatment of risk factors such as hypertension. This hypertension study is just one example where early intervention can make an enormous preventative difference. Given that OB/GYN physicians see women at early stages of adulthood, they have the opportunity to make a great impact. Additionally, hypertension during pregnancy has been shown to predict increase risk for stroke in women. Treatment guidelines from the American Heart Association warn of pregnancy-related hypertension and encourage timely treatment in order to decrease strokes in women later in life.⁴ Clearly, OB/GYN providers may be able to play a critical role in the prevention of heart disease in women.

How can cardiologists help OB/GYN colleagues succeed in preventing heart disease?

One of the most important things that cardiologists, as non-OB/ GYN providers, can do is to support and educate their colleagues. Events such as roundtable discussions and educational symposia directed specifically at OB/GYN physicians and extenders are critical to helping them feel comfortable with the diagnosis and screening of heart disease and its risk factors. Making sure that these providers understand the risk factors for heart disease, typical and atypical presentations of disease and (most importantly) when to refer patients is paramount in supporting them as they work to identify at-risk women. Although typical referral patterns in the past have not been established between OB/GYN providers and cardiologists (except in rare instances of peri-partum cardiomyopathies and other pregnancy-related cardiac complications), cardiologists must make it easy for their colleagues to refer and discuss patients with them. As specialists (as well as other primary care doctors), cardiologists must be easily reachable and readily available to provide help and support when the OB/GYN requests. Through cooperation amongst different specialties, we may be able to improve outcomes for women with heart disease.

Women continue to die from heart disease at alarming rates. The status quo is not working and more women continue to fall through the cracks. In order to reduce disease burden and improve outcomes for females, we must become innovative and find new ways to reach the at-risk women across the world. Engaging the OB/GYN in screening and diagnosing women with heart disease may be an important strategy. As providers of care to women all over the world, these specialists provide a unique opportunity to educate, engage and effect change in female patients. Ultimately, no specialty can handle the burden of heart disease alone — we must all work together to improve mortality and ensure that women are no longer undertreated and underserved.

1 Van Walraven, C., Oake, N., Jennings, A. et al. (2010). The association between continuity care and outcomes: a systematic and critical review. J Eval Clin Pract, Volume 16(5), 947–956.

² Cameron, J. D., Jennings, G. L., Kay, S. et al. (1997). A self-adminsitered questionnaire for detection of unrecognised coronary heart disease. Aust N Z J Publica Health, Volume 21(5), 545–547.

³ Alllen, N. B., Siddique, J., Wilkins, J. T. et al. (2014). Blood pressure trajectories in early adulthood and subclinical artherosclerosis in middle age. JAMA, Volume 311(5), 490–497.

⁴ AHA/ASA Guidelines (2014). A statement for healthcare professionals from the American Heart Association/American Stroke Association. 01.str.0000442009. 06663.48.