Sex differences in patients with acute decompensated heart failure in Japan: observation from the KCHF registry

Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure

Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.

Gender-Related Differences in Patients with Acute Heart Failure: Observation from the Journey Heart Failure-Turkish Population Study

BACKGROUND

Gender-related clinical variations in patients with acute heart failure have been described in previous studies. However, there is still a lack of research on gender differences in patients hospitalized for acute heart failure in Türkiye. The aim of this study is to compare the clinical features, in-hospital approaches, and outcomes of male and female patients hospitalized for acute heart failure.

METHODS

Differences in clinical characteristics, medication prescription, hospital management, and outcomes between males and females with acute heart failure were investigated from the Journey Heart Failure-Turkish Population study.

RESULTS

Nine hundred eighteen patients (57.2%) were men and 688 (42.8%) were women. Women were older than men (70.48 ± 13.20 years vs. 65.87 ± 12.82 years; P <.001). The frequency of comorbidities such as hypertension (72.7% vs. 62.4%, P <.001), diabetes (46.5% vs. 38.5%, P = .001),  atrial  fibrillation  (46.5%  vs.  33.4%,  P <.001), New York Heart Association class III-IV symptoms (80.6% vs. 71.2%, P =.001), and dyspnea in the rest (73.8% vs. 68.3%, P =.044) were more common in women on admission. Male patients were more frequently hospitalized with reduced left ventricular ejection fraction (51.0% vs. 72.4%, P <.001). In-hospital mortality was higher among female patients (9.3% vs. 6.4%, P =.022). Higher  New  York  Heart  Association  class,  lower  estimated  glomerular  filtration  rate, higher N-terminal pro-B type natriuretic peptide on admission, and mechanical ventilation usage were the independent parameters of in-hospital mortality, whereas the female gender was not.

CONCLUSION

Our study clearly demonstrated the diversity in presentation, management, and in-hospital outcomes of acute heart failure between male and female patients. Although left ventricular systolic functions were better in female patients, in-hospital mortality was higher. Recognizing these differences in the management of heart failure in different sexes will serve better results in clinical practice.

Prognostic Clinical Phenotypes of Patients with Acute Decompensated Heart Failure

INTRODUCTION

Acute decompensated heart failure (AHF) is a clinical syndrome with a poor prognosis.

AIM

This study was conducted to identify clusters of inpatients with acute decompensated heart failure that shared similarities in their clinical features.

METHODS

We analyzed data from a cohort of patients with acute decompensated heart failure hospitalized between February 2013 and January 2017 in a Department of Cardiology. Patients were clustered using factorial analysis of mixed data. The clusters (phenotypes) were then compared using log-rank tests and profiled using a logistic model. In total, 458 patients (255; 55.7% male) with a mean (SD) age of 72.7 (11.1) years were included in the analytic dataset. The demographic, clinical, and laboratory features were included in the cluster analysis.

RESULTS

The two clusters were significantly different in terms of time to mortality and re-hospitalization (all P < 0.001). Cluster profiling yielded an accurate discriminating model (AUC = 0.934). Typically, high-risk patients were elderly females with a lower estimated glomerular filtration rate and hemoglobin on admission compared to the low-risk phenotype. Moreover, the high-risk phenotype had a higher likelihood of diabetes type 2, transient ischemic attack/cerebrovascular accident, previous heart failure or ischemic heart disease, and a higher serum potassium concentration on admission. Patients with the high-risk phenotype were of higher New York Heart Association functional classes and more positive in their medication history.

CONCLUSIONS

There are two phenotypes among patients with decompensated heart failure, high-risk and low-risk for mortality and re-hospitalization. They can be distinguished by easy-to-measure patients' characteristics.

Heart failure: an update from the last years and a look at the near future

In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.

Appetite loss at discharge from acute decompensated heart failure: Observation from KCHF registry

Objective

The complex link between nutritional status, protein and lipid synthesis, and immunity plays an important prognostic role in patients with heart failure. However, the association between appetite loss at discharge and long-term outcome remains unclear.

Methods

The Kyoto Congestive Heart Failure registry is a prospective cohort study that enrolled consecutive patients hospitalized for acute decompensated heart failure (ADHF) in Japan. We assessed 3528 patients alive at discharge, and for whom appetite and follow-up data were available. We compared one-year clinical outcomes in patients with and without appetite loss at discharge.

Results

In the multivariable logistic regression analysis using 19 clinical and laboratory factors with P value < 0.1 by univariate analysis, BMI < 22 kg/m² (odds ratio (OR): 1.57, 95% confidence interval (CI): 1.11–2.24, P = 0.01), CRP >1.0mg/dL (OR: 1.49, 95%CI: 1.04–2.14, P = 0.03), and presence of edema at discharge (OR: 4.30, 95%CI: 2.99–6.22, P<0.001) were associated with an increased risk of appetite loss at discharge, whereas ambulatory status (OR: 0.57, 95%CI: 0.39–0.83, P = 0.004) and the use of ACE-I/ARB (OR: 0.70, 95% CI: 0.50–0.98, P = 0.04) were related to a decreased risk in the presence of appetite loss. The cumulative 1-year incidence of all-cause death (primary outcome measure) was significantly higher in patients with appetite loss than in those without appetite loss (31.0% vs. 15.0%, P<0.001). The excess adjusted risk of appetite loss relative to no appetite loss remained significant for all-cause death (hazard ratio (HR): 1.63, 95%CI: 1.29–2.07, P<0.001).

Conclusions

Loss of appetite at discharge was associated with worse 1-year mortality in patients with ADHF. Appetite is a simple, reliable, and useful subjective marker for risk stratification of patients with ADHF.

Gender difference in heart failure with preserved ejection fraction: clinical profiles, examinations, and prognosis

Heart failure with preserved ejection fraction (HFpEF) has currently become a major concern in the aging society owing to its substantial and growing prevalence. Recent investigations regarding sacubitril/valsartan have suggested that there is a gender difference in the efficacy of the medication in HFpEF cohort. However, information of gender difference in clinical profiles, examination, and prognosis have not been well investigated. The present study aimed to evaluate the differences in baseline characteristics and outcomes between women and men in a Japanese HFpEF cohort. We analyzed the data from our prospective, observational, and multicenter cohort study. Overall, 1036 consecutive patients hospitalized for acute decompensated heart failure were enrolled. We defined patients with an ejection fraction (EF) of ≥ 50% as HFpEF. Patients with severe valvular disease were excluded; the remaining 379 patients (women: n = 201, men: n = 178) were assessed. Women were older than men [median: 85 (79–89) years vs. 83 (75–87) years, p = 0.013]. Diabetes mellitus, hyperuricemia, and coronary artery disease were more prevalent in men than in women (34.8% vs. 23.9%, p = 0.019, 23.6% vs. 11.4%, p = 0.002, and 23.0% vs. 11.9%, p = 0.005, respectively). EF was not significantly different between women and men. The cumulative incidence of cardiovascular death or hospitalization for congestive heart failure (CHF) was significantly lower in women than in men (log-rank p = 0.040). Women with HFpEF were older and less often exhibited an ischemic etiology; further, they were associated with a lower risk for cardiovascular death or hospitalization for CHF compared with men in the Japanese population.

The Cardiology Society of India-Kerala Acute Heart Failure Registry: poor adherence to guideline-directed medical therapy

AIMS

Data on the burden of acute heart failure (AHF) admissions, practice patterns, and outcomes are rare from India and other low- and middle-income countries. We aimed to describe the baseline characteristics, guideline-directed medical therapy (GDMT) prescribing patterns and 90-day mortality rates in patients admitted with AHF in Kerala, India.

METHODS AND RESULTS

The Cardiology Society of India-Kerala Acute Heart Failure Registry (CSI-KHFR) is an observational registry from 50 hospitals in Kerala, India, with prospective follow-up. Consecutive patients with AHF, who consented to participate, were enrolled. The 2016 European Society of Cardiology criteria were used for the diagnosis of AHF. Kaplan-Meier survival analysis and Cox-proportional hazard models were used for data analysis. The variables in the MAGGIC risk score were used in the multivariable model. A total of 7507 patients with AHF (37% female) participated in the CSI-KHFR. The mean age was 64.3 (12.9) years. More than two-third had reduced ejection fraction (EF) (67.5%). Nearly one-fourth (28%) of patients with heart failure (HF) with reduced EF received GDMT. Overall, in-hospital and 90-day mortality rates were 7% and 11.6%, respectively. Prescriptions of different components of GDMT were independently associated with 90-day mortality.

CONCLUSION

The CSI-KHFR recorded an in-hospital and 90-day mortality of 7% and 11.6%, respectively. Only one of four patients received GDMT. AHF mortality was independently associated with GDMT initiation. Quality improvement initiatives that focus on increasing GDMT prescription may improve the survival of HF patients in India.

Prognostic value of reduction in left atrial size during a follow-up of heart failure: an observational study

OBJECTIVE

The association between sequential changes in left atrial diameter (LAD) and prognosis in heart failure (HF) remains to be elucidated. The present study aimed to investigate the link between reduction in LAD and clinical outcomes in patients with HF.

DESIGN

A multicentre prospective cohort study.

SETTING

This study was nested from the Kyoto Congestive Heart Failure registry including consecutive patients admitted for acute decompensated heart failure (ADHF) in 19 hospitals throughout Japan.

PARTICIPANTS

The current study population included 673 patients with HF who underwent both baseline and 6-month follow-up echocardiography with available paired LAD data. We divided them into two groups: the reduction in the LAD group (change <0 mm) (n=398) and the no-reduction in the LAD group (change ≥0 mm) (n=275).

PRIMARY AND SECONDARY OUTCOMES

The primary outcome measure was a composite of all-cause death or hospitalisation for HF during 180 days after 6-month follow-up echocardiography. The secondary outcome measures were defined as the individual components of the primary composite outcome measure and a composite of cardiovascular death or hospitalisation for HF.

RESULTS

The cumulative 180-day incidence of the primary outcome measure was significantly lower in the reduction in the LAD group than in the no-reduction in the LAD group (13.3% vs 22.2%, p=0.002). Even after adjusting 15 confounders, the lower risk of reduction in LAD relative to no-reduction in LAD for the primary outcome measure remained significant (HR 0.59, 95% CI 0.36 to 0.97 p=0.04).

CONCLUSION

Patients with reduction in LAD during follow-up after ADHF hospitalisation had a lower risk for a composite endpoint of all-cause death or HF hospitalisation, suggesting that the change of LAD might be a simple and useful echocardiographic marker during follow-up.

Analysis of standards of quality for outcomes in acute heart failure patients directly discharged home from emergency departments and their relationship with the emergency department direct discharge rate

OBJECTIVE

Experts recommended that direct discharge without hospitalization (DDWH) for emergency departments (EDs) able to observe acute heart failure (AHF) patients should be >40%, and these discharged patients should fulfil the following outcome standards: 30-day all-cause mortality <2% (outcome A); 7-day ED revisit due to AHF < 10% (outcome B); and 30-day ED revisit/hospitalization due to AHF < 20% (outcome C). We investigated these outcomes in a nationwide cohort and their relationship with the ED DDWH percentage.

METHODS

We analyzed the EAHFE registry (includes about 15% of Spanish EDs), calculated DDWH percentage of each ED, and A/B/C outcomes of DDWH patients, overall and in each individual ED. Relationship between ED DDWH and outcomes was assessed by linear and quadratic regression models, non-weighted and weighted by DDWH patients provided by each ED.

RESULTS

Among 17,420 patients, 4488 had DDWH (25.8%, median ED stay = 0 days, IQR = 0-1). Only 12.9% EDs achieved DDWH > 40%. Considering DDWH patients altogether, outcomes A/C were above the recommended standards (4.3%/29.4%), while outcome B was nearly met (B = 10.1%). When analyzing individual EDs, 58.1% of them achieved the outcome B standard, while outcomes A/C standards were barely achieved (19.3%/9.7%). We observed clinically relevant linear/quadratic relationships between higher DDWH and worse outcomes B (weighted R² = 0.184/0.322) and C (weighted R² = 0.430/0.624), but not with outcome A (weighted R² = 0.002/0.022).

CONCLUSIONS

The EDs of this nationwide cohort do not fulfil the standards for AHF patients with DDWH. High DDWH rates negatively impact ED revisit or hospitalization but not mortality. This may represent an opportunity for improvement in better selecting patients for early ED discharge and in ensuring early follow-up after ED discharge.

Sex differences in patients with acute decompensated heart failure in Japan: observation from the KCHF registry

Aims

The association between sex and long‐term outcome in patients hospitalized for acute decompensated heart failure (ADHF) has not been fully studied yet in Japanese population. The aim of this study was to determine differences in baseline characteristics and management of patients with ADHF between women and men and to compare 1‐year outcomes between the sexes in a large‐scale database representing the current real‐world clinical practice in Japan.

Methods and results

Kyoto Congestive Heart Failure registry is a prospective cohort study enrolling consecutive patients hospitalized for ADHF in Japan among 19 centres. Baseline characteristics, clinical presentation, management, and 1‐year outcomes were compared between men and women. A total of 3728 patients who were alive at discharge constituted the current study population. There were 1671 women (44.8%) and 2057 men. Women were older than men [median (IQR): 83 (76–88) years vs. 77 (68–84) years, P < 0.0001]. Hypertensive and valvular heart diseases were more prevalent in women than in men (28.0% vs. 22.5%, P = 0.0001; and 26.9% vs. 14.0%, P < 0.0001, respectively), whereas ischaemic aetiology was less prevalent in women than in men (20.0% vs. 32.5%, P < 0.0001). Women less often had reduced left ventricular ejection fraction (<40%) than men (27.5% vs. 45.1%, P < 0.0001). The cumulative incidence of all‐cause death or hospitalization for heart failure was not significantly different between women and men (33.6% vs. 34.3%, P = 0.71), although women were substantially older than men. After multivariable adjustment, the risk of all‐cause death or hospitalization for heart failure was significantly lower among women (adjusted hazard ratio: 0.84, 95% confidence interval: 0.74–0.96, P = 0.01).

Conclusions

Women with heart failure were older and more often presented with preserved EF with a non‐ischaemic aetiology and were associated with a reduced adjusted risk of 1‐year mortality compared with men in the Japanese population.