Gender-related differences in patients with acute heart failure: management and predictors of in-hospital mortality

Impact of Sex and Diabetes in Patients with Heart Failure

PURPOSE OF REVIEW

Heart failure (HF) is a complex clinical syndrome with a growing global health burden. This review explores the intersection of HF, diabetes mellitus, and sex, highlighting epidemiological patterns, pathophysiological mechanisms, and treatment implications.

RECENT FINDINGS

Despite similar HF prevalence in men and women, diabetes mellitus (DM) appears to exert a more pronounced impact on HF outcomes in women. Pathophysiological differences involve cardiovascular risk factors, severe left ventricular dysfunction, and coronary artery disease, as well as hormonal influences and inflammatory markers. Diabetic cardiomyopathy introduces a sex-specific challenge, with women experiencing common adverse outcomes related to increased fibrosis and myocardial remodeling. Treatment strategies, particularly sodium-glucose cotransporter 2 inhibitors, exhibit cardiovascular benefits, but their response may differ in women. The link between HF and DM is bidirectional, with diabetes significantly increasing the risk of HF, and vice versa. Additionally, the impact of diabetes on mortality appears more pronounced in women than in men, leading to a modification of the traditional gender gap observed in HF outcomes. A personalized approach is crucial, and further research to improve outcomes in the complex interplay of HF, diabetes, and sex is needed.

Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial

AIMS

The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex.

METHODS

This is a post-hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96 h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. The influence of sex on primary, secondary and safety outcomes was evaluated.

RESULTS

One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96 h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all p-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR [95%CI]: 8.68 [3.41-24.63]) than men (OR [95%CI]: 2.5 [0.99-4.87]), p = 0.027. There were no differences in mortality or rehospitalizations at 30/90 days.

CONCLUSION

Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov: NCT01647932; EudraCT Number: 2013-001852-36.

Sex Differences in Acute Heart Failure Management: Is There a Gap in Treatment Quality?

PURPOSE OF REVIEW

Differences between men and women in demographics and clinical phenotype of heart failure have previously been described, as well as disparities in management and outcomes. This review summarizes the latest evidence concerning sex-related differences in acute heart failure and its most severe form, cardiogenic shock.

RECENT FINDINGS

Data from the last 5 years reaffirm the previous observations, with women with acute heart failure being older, more often having preserved ejection fraction and less frequently having an ischemic cause of the acute decompensation. Despite women still receive less invasive procedures and a less optimized medical treatment, the most recent studies find similar outcomes regardless of sex. These disparities persist in the context of cardiogenic shock, where women receive less mechanical circulatory support devices even if they present with more severe forms. This review reveals a different clinical picture of women with acute heart failure and cardiogenic shock compared to men, which translates into disparities in management. More female representation in studies would be needed in order to better understand the physiopathological basis of these differences and minimize inequalities in treatment and outcomes.

Sex differences in cardiovascular outcomes of SGLT-2 inhibitors in heart failure randomized controlled trials: A systematic review and meta-analysis

Background

In patients with heart failure (HF), randomized controlled trials (RCTs) of sodium-glucose transporter-2 inhibitors (SGLT-2is) have proven to be effective in decreasing the primary composite outcome of cardiovascular death and hospitalizations for HF. A recently published meta-analysis showed that the use of SGLT-2is among women with diabetes resulted in less reduction in primary composite outcomes compared with men. This study aims to explore potential sex differences in primary composite outcomes among patients with HF treated with SGLT-2is.

Methods

We systematically searched the medical database from 2017 to 2022 and retrieved all the RCTs using SGLT-2is with specified cardiovascular outcomes. We used the PRISMA (Preferred Reporting Items for a Review and Meta-analysis) method to screen for eligibility. We evaluated the quality of studies using the Cochrane Risk of Bias tool. We pooled the hazard ratio (HR) of the primary composite outcomes in both sexes, performed a meta-analysis, and calculated the odds ratio (OR) of the primary composite outcomes based on sex.

Results

We included 5 RCTs with a total number of 21,947 patients. Of these, 7837 (35.7 %) were females. Primary composite outcomes were significantly lower in males and females taking SGLT-2is compared to placebo (males - HR 0.77; 95 % CI 0.72 to 0.84; p = 0.00001; females - HR 0.75; 95 % CI 0.67 to 0.84; p = 0.00001). Pooled data from four of the RCTs (n = 20,725) revealed a greater occurrence of the primary composite outcomes in females compared with males (OR 1.32; 95 % CI 1.17 to 1.48; p = 0.0002).

Conclusion

SGLT-2is reduce the risk of primary composite outcomes in patients with HF, regardless of sex; however, the benefits were less pronounced in women. Further research needs to be done to better explain these observed differences in outcomes.

Microalbuminúria e seu Significado Prognóstico em Pacientes com Insuficiência Cardíaca Aguda com Fração de Ejeção Preservada, Intermediária e Reduzida

Fundamento

A prevalência e o significado da microalbuminúria não foram bem estudados em pacientes com diferentes subtipos de insuficiência cardíaca.

Objetivo

A prevalência e o significado da microalbuminúria não foram bem estudados em pacientes com diferentes subtipos de insuficiência cardíaca. Portanto, nosso objetivo foi investigar a frequência e o valor prognóstico da microalbuminúria em pacientes hospitalizados por insuficiência cardíaca aguda (ICA) com fração de ejeção preservada (ICFEp), fração de ejeção de faixa média (ICFEfm) e fração de ejeção reduzida (ICFEr).

Métodos

Todos os pacientes adultos consecutivos encaminhados ao hospital devido a ICA entre junho de 2016 e junho de 2019 foram inscritos. A microalbuminúria é definida como o nível de albumina urinária para relação de creatinina (AURC) na faixa de 30–300 mg/g. A mortalidade hospitalar foi o critério de valoração deste estudo.

Resultados

Dos 426 pacientes com ICA (idade média de 70,64 ± 10,03 anos, 53,3% do sexo feminino), 50% tinham ICFEr, 38,3% tinham ICFEp e 11,7% tinham ICFEfm na apresentação. A prevalência de microalbuminúria foi de 35,2%, 28,8% e 28,0% em ICFEr, ICFEp e ICFEfm, respectivamente. Um total de 19 (4,5%) pacientes morreram durante o curso intra-hospitalar, e a mortalidade intra-hospitalar foi maior em pacientes com ICFEr (6,6%) em comparação com pacientes com ICFEr (2,5%) e ICFEfm (2,0%). A análise multivariada mostrou que a presença de microalbuminúria previu mortalidade intra-hospitalar em pacientes com ICFEr e ICFEfm, mas não em ICFEp.

Conclusão

Embora a microalbuminúria fosse comum em todos os subgrupos de pacientes com ICA, descobriu-se que ela prediz o prognóstico apenas em pacientes com ICFEr e ICFEfm.

Heart Failure with Reduced Ejection Fraction-Does Sex Matter?

PURPOSE OF REVIEW

There is an increasing recognition of the importance of sex in susceptibility, clinical presentation, and outcomes for heart failure. This review focusses on heart failure with reduced ejection fraction (HFrEF), unravelling differences in biology, clinical and demographic features and evidence for diagnostic and therapeutic strategies. This is intended to inform clinicians and researchers regarding state-of-the-art evidence relevant to women, as well as areas of unmet need.

RECENT FINDINGS

Females are well recognised to be under-represented in clinical trials, but there have been some improvements in recent years. Data from the last 5 years reaffirms that women presenting with HFrEF women are older and have more comorbidities like hypertension, diabetes and obesity compared with men and are less likely to have ischaemic heart disease. Non-ischaemic aetiologies are more likely to be the cause of HFrEF in women, and women are more often symptomatic. Whilst mortality is less than in their male counterparts, HFrEF is associated with a bigger impact on quality of life in females. The implications of this for improved prevention, treatment and outcomes are discussed. This review reveals distinct sex differences in HFrEF pathophysiology, types of presentation, morbidity and mortality. In light of this, in order for future research and clinical medicine to be able to manage HFrEF adequately, there must be more representation of women in clinical trials as well as collaboration for the development of sex-specific management guidelines. Future research might also elucidate the biochemical foundation of the sex discrepancy in HFrEF.

Sex differences in congestive markers in patients hospitalized for acute heart failure

AIMS

We sought to examine sex differences in congestion in patients hospitalized for acute heart failure (AHF). Understanding congestive patterns in women and men with AHF may provide insights into sex differences in the presentation and prognosis of AHF patients.

METHODS AND RESULTS

In a prospective, two-site study in adults hospitalized for AHF, four-zone lung ultrasound (LUS) was performed at the time of echocardiography at baseline (LUS1) and, in a subset, pre-discharge (LUS2). B-lines on LUS and echocardiographic images were analysed offline, blinded to clinical information and outcomes. Among 349 patients with LUS1 data (median age 74, 59% male, and 87% White), women had higher left ventricular ejection fraction (mean 43% vs. 36%, P < 0.001), higher tricuspid annular plane systolic excursion (mean 17 vs. 15 mm, P = 0.021), and higher measures of filling pressures (median E/e' 20 vs. 16, P < 0.001). B-line number on LUS1 (median 6 vs. 6, P = 0.69) and admission N-terminal pro-B-type natriuretic peptide levels (median 3932 vs. 3483 pg/mL, P = 0.77) were similar in women and men. In 121 patients with both LUS1 and LUS2 data, there was a similar and significant decrease in B-lines from baseline to discharge in both women and men. The risk of the composite 90 day outcome increased with higher B-line number on four-zone LUS2: unadjusted hazard ratio for each B-line tertile was 1.86 (95% confidence interval 1.08-3.20, P = 0.025) in women and 1.65 (95% confidence interval 1.03-2.64, P = 0.037) in men (interaction P = 0.72).

CONCLUSIONS

Among patients with AHF, echocardiographic markers differed between women and men at baseline, whereas B-line number on LUS did not. The dynamic changes in B-lines during a hospitalization for AHF were similar in women and men.

The association of long-term outcome and biological sex in patients with acute heart failure from different geographic regions

AIMS

Recent data from national registries suggest that acute heart failure (AHF) outcomes might vary in men and women, however, it is not known whether this observation is universal. The aim of this study was to evaluate the association of biological sex and 1-year all-cause mortality in patients with AHF in various regions of the world.

METHODS AND RESULTS

We analysed several AHF cohorts including GREAT registry (22 523 patients, mostly from Europe and Asia) and OPTIMIZE-HF (26 376 patients from the USA). Clinical characteristics and medication use at discharge were collected. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model with adjustment for baseline characteristics (e.g. age, comorbidities, clinical and laboratory parameters at admission, left ventricular ejection fraction). In the GREAT registry, women had a lower risk of death in the year following AHF [HR 0.86 (0.79-0.94), P < 0.001 after adjustment]. This was mostly driven by northeast Asia [n = 9135, HR 0.76 (0.67-0.87), P < 0.001], while no significant differences were seen in other countries. In the OPTIMIZE-HF registry, women also had a lower risk of 1-year death [HR 0.93 (0.89-0.97), P < 0.001]. In the GREAT registry, women were less often prescribed with a combination of angiotensin-converting enzyme inhibitors and beta-blockers at discharge (50% vs. 57%, P = 0.001).

CONCLUSION

Globally women with AHF have a lower 1-year mortality and less evidenced-based treatment than men. Differences among countries need further investigation. Our findings merit consideration when designing future global clinical trials in AHF.

Female gender is associated with a worse prognosis amongst patients hospitalised for de-novo acute heart failure

BACKGROUND

Recent evidence showed that new-onset (de-novo) acute heart failure (AHF) is a distinct type of AHF. However, the prognostic implication of gender on these patients remains unclear.

AIMS

We aimed to investigate the impact of gender on both short and long-term mortality outcomes after hospitalisation for de-novo AHF.

METHODS

We analysed the data of 721 patients with de-novo AHF, who were enrolled in the HF survey in Israel between March and April 2003 and were followed until December 2014.

RESULTS

Fifty-four percent (N = 387) of the patients were men. In comparison to women, men patients were more likely to be younger, smokers, and with ischemic HF aetiology. At 30 days, mortality rates were higher in women (12% vs 7%, P = .013). Survival analysis showed that at 1 and 10 years the all-cause mortality rates were significantly higher in women (28% vs 17%, and 78% vs 67%, 1 and 10 years, P < .001, respectively). Consistently, multivariable analysis showed that women had an independently 82% and 24% higher mortality risk at 1 and 10 years, respectively, (1-year hazard ratio = 1.82; 95% confidence interval = 1.07 to 3.11, P = .03; 10-year hazard ratio = 1.24; 95% confidence interval = 1.03 to 1.48, P = .02).

CONCLUSIONS

Amongst patients with de-novo AHF, women had higher mortality rates compared with men. The observed gender-related differences in de-novo AHF patients highlight the need for further and deeper research in this field.

Pregnancy Associated Heart Failure With Preserved Ejection Fraction: Risk Factors and Maternal Morbidity

BACKGROUND

Cardiovascular conditions are leading contributors to increasing maternal morbidity and mortality. Heart failure with preserved ejection fraction (HFpEF) results in the majority of HF admissions in women, yet its impact in pregnancy is unknown. We examined the prevalence rates, risk factors and adverse pregnancy outcomes in women with HFpEF during pregnancy-related hospitalizations in the United States.

METHODS AND RESULTS

We conducted a cross-sectional analysis of pregnancy-related hospitalizations from 2002 through 2014 using the National Inpatient Sample. HFpEF cases were identified using the 428.3 International Classification of Diseases, 9th edition, Clinical Modification code. Weighting variables were used to provide national estimates, unconditional survey logistic regression to generate odds ratios and 95% confidence intervals (CI) representing adjusted associations with adverse pregnancy outcomes and Joinpoint regression to estimate temporal trends. Among 58,732,977 hospitalizations, there were 3840 HFpEF cases, an overall rate of 7 cases per 100,000 pregnancy-related hospitalizations; 56% occurred postpartum, 27% during delivery, and 17% antepartum. The temporal trend for hospitalization increased throughout the timeframe by 19.4% (95% CI 13.9-25.1). HFpEF hospitalizations were more common for Black, older, or poor women. Risk factors included hypertension (chronic hypertension and hypertensive disorders of pregnancy), anemia, obesity, diabetes, renal disease and coronary atherosclerosis; all known risk factors for HFpEF. Women with HFpEF were 2.61-6.47 times more likely to experience adverse pregnancy outcomes.

CONCLUSIONS

The pregnancy-related HFpEF hospitalization prevalence has increased and is associated with adverse pregnancy outcomes. Risk factors resemble those outside pregnancy, emphasizing the need for screening and monitoring women with risk factors during pregnancy for HFpEF.

10 year trends in hospitalization rates due to heart failure and related in-hospital mortality in Poland (2010-2019)

Aims

Heart failure (HF) remains a major public health challenge worldwide. Contemporary epidemiological data on HF hospitalization rates and related in‐hospital mortality are scarce also in Poland. The aim of the study was to determine the trends in hospitalization rates due to HF and related in‐hospital mortality in Poland in the recent decade.

Methods and results

Data on HF hospitalizations and in‐hospital mortality in patients aged >17 years in Poland between 2010 and 2019 were obtained from the central database of the Polish National Health Fund. Hospitalizations with either primary or secondary diagnosis of HF were identified using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes (I50, I42, J81 with extensions, and R57.0). There were 4 259 698 HF hospitalizations and 608 577 in‐hospital deaths (14% in‐hospital mortality) reported during 2010–2019 in Poland. During this period, there was a steady increase in the number of HF hospitalizations per 1000 inhabitants in subsequent years, being more pronounced in men than in women (in 2019: 16 and 13 HF hospitalizations per 1000 inhabitants in men and women, respectively). The relative risk of HF hospitalization was higher in men than in women, and this gender‐related difference steadily increased from 9% in 2010 to 25% in 2019. During 2010–2019, there was an increase in the number of HF hospitalizations per 1000 inhabitants in subsequent age groups, with a trend being more pronounced in men than in women (129 and 99 HF hospitalizations per 1000 inhabitants in men and women aged ≥80 years, respectively). During this period, there was a slight increase in in‐hospital mortality during HF hospitalization in subsequent years, being more pronounced in women than in men (in 2019: 16% and 14% of in‐hospital mortality in women and men, respectively). The relative risk of in‐hospital mortality during HF hospitalization was higher in women than in men, and this gender‐related difference steadily increased from 8% in 2010 to 18% in 2019. During this period, in‐hospital mortality during HF hospitalization was ~12% for women and men aged 18–29 years, whereas the highest values of in‐hospital mortality reached ~19% for patients aged ≥80 years.

Conclusions

We have observed steady growing trends in HF hospitalization rates and related in‐hospital mortality in Poland over the last decade. Both age and gender have differentiated the reported epidemiological patterns.

Gender differences? Factors related to quality of life among patients with Heart failure

Heart failure (HF) is a chronic, progressive disease that substantially decreases patients' quality of life. Few studies have compared quality of life and its related factors across genders in patients with HF. To explore gender differences in quality of life and related factors among adult patients with HF. A comparative study was conducted with 245 HF patients recruited from a medical center and a regional teaching hospital in Taiwan from February 2009 to February 2011. Descriptive and inferential statistics were used, including stepwise multiple regressions. The mean quality of life scores of males were significantly higher than those of females (87.78 ± 13.99 vs. 84.49 ± 11.85). The factors significantly related to quality of life for the male HF patients, in descending order of strength of association were depressive symptoms, physical symptoms, and monthly family income-less than USD 1,000; for the females, the significantly related factors were physical symptoms, depressive symptoms, and monthly family income-less than USD 1,000. The amount variance for which quality of life accounted for male and female HF patients was similar (60% vs. 64%). The results could be used for health professionals to provide more appropriate assessments and care according to gender in the future.

Depression and cardiovascular disease: The deep blue sea of women's heart

Cardiovascular disease (CVD) constitutes a leading worldwide health problem, with increasing evidence of differences between women and men both in epidemiology, pathophysiology, clinical management, and outcomes. Data from the literature suggest that women experience a doubled incidence of CVD related deaths, while angina, heart failure and stroke are increasingly prevalent in females. About 20-25% of women go through depression during their life, and depressive symptoms have been considered a relevant emergent, non-traditional risk factor for CVD in this part of the general population. Underlying mechanisms explaining the link between depression and CVD may range from behavioral to biological risk factors, including sympathetic nervous system hyperactivity and impairment in hypothalamic-pituitary-adrenal function. However, the neuroendocrine-driven background could only partially explain the differences mentioned above for chronic systemic inflammation, altered hemostasis and modulation of cardiac autonomic control. In addition, some evidence also suggests the existence of gender-specific differences in biological responses to mental stress. Given these premises, we here summarize the current knowledge about depression and CVD relationship in women, highlighting the sex differences in physiopathology, clinical presentation and treatments.

Gender and survival of critically ill patients: results from the FROG-ICU study

Purpose

Few studies analyzed gender-related outcome differences of critically ill patients and found inconsistent results. This study aimed to test the independent association of gender and long-term survival of ICU patients.

Materials and methods

FROG-ICU was a prospective, observational, multi-center cohort designed to investigate the long-term mortality of critically ill adult patients. The primary endpoint of this study was 1-year mortality after ICU admission of women compared to men.

Results

The study included 2087 patients, 726 women and 1361 men. Women and men had similar baseline characteristics, clinical presentation, and disease severity. No significant difference in 1-year mortality was found between women and men (34.9% vs. 37.9%, P = 0.18). After multivariable adjustment, no difference in the hazard of death was observed [HR 0.99 (95% CI 0.77–1.28)]. Similar 1-year survival between women and men was found in a propensity score-matched patient cohort of 506 patients [HR 0.79 (95% CI 0.54–1.14)].

Conclusion

Women constituted one-third of the population of critically ill patients and were unexpectedly similar to men regarding demographic characteristics, clinical presentation, and disease severity and had similar risk of death at 1 year after ICU admission.

Trial registration ClinicalTrials.gov NCT01367093; registered on June 6, 2011.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0514-y) contains supplementary material, which is available to authorized users.

Sex differences in 1-year mortality risks in older patients experiencing a first acute heart failure hospitalization

AIM

To assess whether 1-year mortality in older patients experiencing a first admission for acute heart failure was related to sex, and to explore differential characteristics according to sex.

METHODS

We reviewed the medical records of 1132 patients aged >70 years of age admitted within a 3-year period because of a first episode of acute heart failure. We analyzed sex differences. Mortality was assessed using multivariate Cox analysis.

RESULTS

There were 648 (57.2%) women (mean age 82.1 years) and 484 men (mean age 80.1 years). There were some differences in risk factors: women more often had hypertension, and less frequently had coronary heart disease and comorbidities (women more often had dementia, and men more often had chronic obstructive pulmonary disease, chronic kidney disease and stroke). Women were treated more frequently with spironolactone. The 1-year all-cause mortality rate was 30.2% (30.7% women and 29.5% men). Multivariate Cox analysis identified an association between reduced heart failure (hazard ratio [HR] 0.35, 95% confidence interval [95% CI] 0.21-0.59), hemoglobin <10 g/dL (HR 1.99, 95% CI 1.16-3.40), systolic blood pressure (HR 0.98, 95% CI 0.97-0.99), previous diagnosis of dementia (HR 2.07, 95% CI 1.12-3.85), number of chronic therapies (HR 1.12, 95% CI 1.05-1.19) and 1-year mortality in women. In men, an association with mortality was found for low systolic blood pressure (HR 0.97, 95% CI 0.97-0.98) and higher potassium values (HR 1.42, 95% CI 1.01-2.00).

CONCLUSIONS

Among older patients hospitalized for the first acute heart failure episode, there is a slightly higher predominance of women. There are sex differences in risk factors and comorbidities. Although the mortality rate is similar, the factors associated with it according to sex are different. Geriatr Gerontol Int 2019; 19: 184-188.

Sex differences and the prognosis of depressive and nondepressive patients with cardiovascular risk factors: the Japan Morning Surge-Home Blood Pressure (J-HOP) study

Depression is associated with mortality in patients with cardiovascular risk factors. The frequency and severity of depression and the association between depression and cardiovascular events have sex-specific and ethnic differences. We conducted this study to evaluate the sex-specific difference in the association between depression and cardiovascular prognosis in patients with cardiovascular risk factors. We enrolled 4025 patients (64.7 ± 10.9 years, 53% women, 47% men) with cardiovascular risk factors in the Japan Morning Surge-Home Blood Pressure study. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). The follow-up period was 47 ± 24 months. The primary end points were all-cause mortality and nonfatal cardiovascular events. The BDI scores and the prevalence of depression were significantly higher in women than in men. When a BDI score of 16 was the cutoff, the primary end points in the depression group (n = 217) were significantly higher than those in the nondepression group (n = 1677) among men (adjusted hazard ratio 1.76, 95% confidence interval: 1.17, 2.64; P = 0.007). In women, the primary end points in the depression and nondepression groups were similar when BDI scores of 16, 14, and 10 were the cutoffs. In conclusion, depression defined by a BDI score ≥16 was associated with cardiovascular events in men with cardiovascular risk factors.

Female gender and mortality risk in decompensated heart failure

BACKGROUND

Still there is conflicting evidence about gender-related differences in prognosis among patients with heart failure. This prognostic uncertainty may have implications for risk stratification and planning management strategy. The aim of the present study was to explore the association between gender and one-year mortality in patients admitted with acute decompensated heart failure (ADHF).

METHODS

We studied 1513 patients. The Cumulative Incidence Function (CIF) method was used to estimate the absolute rate of mortality, heart transplantation (HT)/ventricular assist device (VAD) implantation, and survival free of HT/VAD implantation at 1year. An interaction analysis was performed to assess the association between covariates, gender, and mortality risk. Propensity score matching and Cox regression were used to compare mortality rates in the gender subgroups.

RESULTS

The CIF estimates of 1-year mortality, HT/VAD implantation, and survival free of HT/VAD implantation at 1year were 33.1%, 7.0%, and 59.9% for women and 30.2%, 10.2%, and 59.6% for men, respectively. Except for diabetes, there was no significant interaction between gender, covariates, and mortality risk. In the matched cohort, the hazard ratio of death for women was 1.19 (95% confidence intervals [CIs]: 0.90-1.59; p=.202). After adjusting for age and baseline risk, the hazard ratio of death for women was 1.18 (95% CIs: 0.95-1.43; p=.127). The use of gender-specific predictive models did not allow improving the accuracy of risk prediction.

CONCLUSIONS

Our data strongly suggest that women and men have comparable outcome in the year following a hospitalization for ADHF.

Gender Differences in Presentation, Treatment, and In-Hospital Outcome of Patients Admitted With Heart Failure Complicated by Atrial Fibrillation (from the Get With the Guidelines-Heart Failure [GWTG-HF] Registry)

Almost 25% of patients with heart failure (HF) have coexisting atrial fibrillation (AF), the latter of which may increase morbidity and mortality. Despite the high prevalence of HF with concomitant AF, this subgroup of patients remains understudied. This study examines gender differences in presentation, treatment and in-hospital outcome of patients with HF and AF. The Get With the Guidelines-Heart Failure (GWTG-HF) database enrolled 6,496 patients with HF who presented to Cooper University Hospital from 2005 to 2012. Twenty-four percent (1,561 patients) had concomitant AF. Pearson chi-square tests and the Student T-tests were used to compare patient characteristics by gender. Multivariate logistic regression was used to predict in-hospital mortality. Six hundred sixty-nine (42.8%) patients with HF and AF were women. Women were older (p <0.001), had a higher ejection fraction (p <0.001), had systolic hypertension (p <0.001), and were more likely to have health insurance (p <0.001). Despite a higher CHADS2 score in women (p = 0.007), there was no gender difference in percent of anticoagulation medications prescribed before admission. Women were less likely to present with dizziness, lightheadedness, or syncope, and were more likely to be compliant with medications and diet recommendations before admission. Despite differences in presentation, co-morbidities, and therapy, in-hospital mortality was similar between men and women. Decreased appetite or early satiety predicted in-hospital mortality in women, whereas age, chest pain on admission, and decreased appetite or early satiety predicted in-hospital mortality in men. In conclusion, women presenting with HF complicated by AF clinically differ from men, but despite these differences, both groups shared similar symptom presentation and in-hospital mortality rates.

Prognostic Impact of Diabetes on Long-term Survival Outcomes in Patients With Heart Failure: A Meta-analysis

OBJECTIVE

Several studies have explored the impact of diabetes on mortality in patients with heart failure (HF). However, the extent to which diabetes may confer risk of mortality and hospitalization in this patient population remains imperfectly known. Here we examine the independent prognostic impact of diabetes on the long-term risk of mortality and hospitalization in patients with HF.

RESEARCH DESIGN AND METHODS

PubMed, Scopus, and Web of Science from January 1990 to October 2016 were the data sources used. We included large (n ≥1,000) observational registries and randomized controlled trials with a follow-up duration of at least 1 year. Eligible studies were selected according to predefined keywords and clinical outcomes. Data from selected studies were extracted, and meta-analysis was performed using random-effects modeling.

RESULTS

A total of 31 registries and 12 clinical trials with 381,725 patients with acute and chronic HF and 102,036 all-cause deaths over a median follow-up of 3 years were included in the final analysis. Diabetes was associated with a higher risk of all-cause death (random-effects hazard ratio [HR] 1.28 [95% CI 1.21, 1.35]), cardiovascular death (1.34 [1.20, 1.49]), hospitalization (1.35 [1.20, 1.50]), and the combined end point of all-cause death or hospitalization (1.41 [1.29, 1.53]). The impact of diabetes on mortality and hospitalization was greater in patients with chronic HF than in those with acute HF. Limitations included high heterogeneity and varying degrees of confounder adjustment across individual studies.

CONCLUSIONS

This updated meta-analysis shows that the presence of diabetes per se adversely affects long-term survival and risk of hospitalization in patients with acute and chronic HF.

Obesity paradox in heart failure patients - Female gender characteristics-KAMC-single center experience

Background/Introduction

The correlation between low body mass index (BMI) and congestive heart failure (obesity paradox) has been described in the literature; However, the association between BMI and clinical outcome measures is not well characterized. Little is known about CHF in the Middle Eastern female population; most of the gender-specific information on heart failure comes from higher income “Western” countries.

Objectives

We aimed to identify the correlation between heart failure patients especially those with low BMI and clinical/safety outcome measures with focusing on female patients subgroup characteristics.

Methods

We performed group comparisons of statistically relevant variables using prospectively collected data of HFrEF patients hospitalized over a 12 month period.

Results

The 167 patients (Group I) enrolled by this study with mean age of 59.64 ± 12.9 years, an EF score of 23.96 ± 10.14, 62.9% had ischemic etiology, 12.5% were smoker, 18% had AF, 31.1% had received ICD/CRT-D and an estimated 8.85 ± 9.5 days length of stay (LOS). The low BMI group of patients (Group II) had means age of 58.7 ± 14.5 years, a significant lower EF score of 20.32 ± 8.58, significantly higher 30, 90 days readmission rates and in-house mortality (22%, 36.6% and 17.1% vs 10.2%, 20.4% and 6.6% respectively) and higher rates of CVA, TIA and unexplained syncope (19.5% vs 7.2%). Similarly, female patients with low BMI (Group IV) had lower EF score of 22.0 ± 53, higher 30,90 days readmission rates and in-house mortality (34.4%,43.8% and 25% vs 13.5%,21.6% and 5.4% respectively) and higher rates of CVA, TIA and unexplained syncope(10% vs 0%).

Conclusion

Our findings showed that heart failure patients with low BMI had poor adverse clinical outcome measures (poor EF, recurrent readmission, mortality and composite rates of CVA, TIA and unexplained syncope) which reflect the effect of obesity paradox in those patients with HFrEF. Female patient subgroup showed similar characteristic findings which also might reflect the value of gender-specific BMI related clinical outcomes.

Clinical characteristics of patients hospitalized for acute heart failure according to hospital arrival timing

BACKGROUND

Whether clinical characteristics and outcomes in patients suffering acute heart failure (AHF) vary according to the timing of hospital arrival is unclear. We aimed to evaluate differences between subjects presenting in the daytime and nighttime.

METHODS

A total of 679 patients with AHF were examined, classified into the two groups from the viewpoint of hospital arrival period into daytime (n=370; 8am-6pm) and nighttime (n=309; 6pm-8am).

RESULTS

The prevalence of malnutrition and longer pre-hospital delay (≥48h) were greater, whereas a previous history of myocardial infarction, proportion of arrival by ambulance, and the frequency of New York Heart Association class IV symptoms, as well as systolic and diastolic blood pressure, and heart rate were lower in subjects presenting in the daytime. Patients with malnutrition defined as 5≥of the Controlling Nutrition Status scores demonstrate a longer pre-hospital delay compared to those without (34.2% vs. 19.9%, p<0.05). There was no significant difference in the 30-day outcomes but length of stay was significantly longer in subjects presenting in the daytime than in the nighttime. Multivariable logistic regression analysis revealed that systolic blood pressure, malnutrition, and chronic kidney disease were significantly related to prolonged length of stay.

CONCLUSIONS

Our present results suggest that patients with AHF who present in the daytime may have higher rate of malnutrition status and lower systolic blood pressure compared to those presenting in the nighttime.

Sex Differences in Patients With Acute Decompensated Heart Failure: Insights From the Heart Function Assessment Registry Trial in Saudi Arabia

We assessed sex-specific differences in clinical features and outcomes of patients with acute heart failure (AHF). The Heart function Assessment Registry Trial in Saudi Arabia (HEARTS), a prospective registry, enrolled 2609 patients with AHF (34.2% women) between 2009 and 2010. Women were older and more likely to have risk factors for atherosclerosis, history of heart failure (HF), and rheumatic heart and valve disease. Ischemic heart disease was the prime cause for HF in men and women but more so in men (P < .001). Women had higher rates of hypertensive heart disease and primary valve disease (P < .001, for both comparisons). Men were more likely to have severe left ventricular systolic dysfunction. On discharge, a higher use of angiotensin-converting enzyme inhibitors, β-blockers, and aldosterone inhibitors was observed in men (P < .001 for all comparisons). Apart from higher atrial fibrillation in women and higher ventricular arrhythmias in men, no differences were observed in hospital outcomes. The overall survival did not differ between men and women (hazard ratio: 1.0, 95% confidence interval: 0.8-1.2, P = .981). Men and women with AHF differ significantly in baseline clinical characteristics and management but not in adverse outcomes.

Gender differences in the management and outcome of atrial fibrillation complicating acute heart failure

BACKGROUND

Little is known about sex differences in the prevalence, treatment, and outcome of atrial fibrillation complicating acute heart failure.

METHODS AND RESULTS

Among 957 patients (429 women, 528 men), included in the BIO-HF registry, 45.2% (n = 194) of the women and 45.1% (n = 238) of the men were admitted with atrial fibrillation. The primary end point was a composite of 1-year all-cause mortality and hospitalization for heart failure. Adjusted 1-year mortality and hospitalization rates were similar between sexes (women 38.5%, men 36.0%; OR for female gender: 1.1, 95% CI 0.65-1.86; P = .71. A significant interaction between female sex and age (P = .002) was observed; with worse prognosis for women <75 years (OR 7.17, 95% CI 1.79-28.66; P = .005) compared with men <75 years. No sex differences in in-hospital treatment, restoration of sinus rhythm (16.5% in women vs 14.2% in men; P = .58), or in-hospital mortality (5.7% in women vs 6.7% in men; P = .69) were observed.

CONCLUSIONS

Among patients hospitalized with acute heart failure, no sex differences in the prevalence and management of atrial fibrillation were observed. In-hospital mortality and the composite of 1-year mortality and rehospitalization were not different between sexes, but a significant sex-age interaction was observed, with worse outcome in women <75 years versus men <75 years of age.