The 'real' woman with heart failure. Impact of sex on current in-hospital management of heart failure by cardiologists and internists

Sex-based differences in referral of heart failure patients to outpatient clinics: a scoping review

BACKGROUND

Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to an outpatient HF clinic (HFC) within 2 weeks of discharge. Our study aims were (i) to assess the current literary landscape on the impact of patient sex on HFC referral and outcomes and (ii) to provide a qualitative overview of possible considerations for the impact of sex on referral patterns and HF characteristics including aetiology, symptom severity, investigations undertaken and pharmacologic therapy.

METHODS AND RESULTS

We conducted a scoping review using the Arksey and O'Malley framework and searched Medline, EMBASE, PsychINFO, Cochrane Library, Ageline databases and grey literature. Eligible articles included index HF hospitalizations or presentations to the Emergency Department (ED), a description of the HFC referral of patients not previously followed by an HF specialist and sex-specific analysis. Of the 11 372 potential studies, 8 met the inclusion criteria. These studies reported on a total of 11 484 participants, with sample sizes ranging between 168 and 3909 (25.6%-50.7% female). The included studies were divided into two groups: (i) those outlining the referral process to an HFC and (ii) studies which include patients newly enrolled in an HFC. Of the studies in Group 1, males (51%-82.4%) were more frequently referred to an HFC compared with females (29%-78.1%). Studies in Group 2 enrolled a higher proportion of males (62%-74% vs. 26%-38%). One study identified independent predictors of HFC referral which included male sex, younger age, and the presence of systolic dysfunction, the latter two more often found in males. Two studies, one from each group reported a higher mortality amongst males compared with females, whereas another study from Group 2 reported a higher hospitalization rate amongst females following HFC assessment.

CONCLUSIONS

Males were more likely than females to be referred to HFCs after hospitalization and visits to the Emergency Department, however heterogeneity across studies precluded a robust assessment of sex-based differences in outcomes. This highlights the need for more comprehensive longitudinal data on HF patients discharged from the acute care setting to better understand the role of sex on patient outcomes.

Sex-Specific Clinical Outcomes of the PACT-HF Randomized Trial

BACKGROUND

Transitional care may have different effects in males and females hospitalized for heart failure. We assessed the sex-specific effects of a transitional care model on clinical outcomes following hospitalization for heart failure.

METHODS

In this stepped-wedge cluster randomized trial of adults hospitalized for heart failure in Ontario, Canada, 10 hospitals were randomized to a group of transitional care services or usual care. Outcomes in this exploratory analysis were composite all-cause readmission, emergency department visit, or death at 6 months; and composite all-cause readmission or emergency department visit at 6 months. Models were adjusted for stepped-wedge design and patient age.

RESULTS

Among 2494 adults, mean (SD) age was 77.7 (12.1) years, and 1258 (50.4%) were female. The first composite outcome occurred in 371 (66.3%) versus 433 (64.1%) males (hazard ratio [HR], 1.04 [95% CI, 0.86-1.26]; P=0.67) and in 326 (59.9%) versus 463 (64.8%) females (HR, 0.83 [95% CI, 0.69-1.01]; P=0.06) in the intervention and usual care groups, respectively (P=0.012 for sex interaction). The second composite outcome occurred in 357 (63.8%) versus 417 (61.7%) males (HR, 1.03 [95% CI, 0.85-1.24]; P=0.76) and 314 (57.7%) versus 450 (63.0%) females (HR, 0.81 [95% CI, 0.67-0.99]; P=0.037) in the intervention and usual care groups, respectively (P=0.024 for sex interaction). The sex differences were driven by a reduction in all-cause emergency department visits among females (HR, 0.66 [95% CI, 0.51-0.87]; P=0.003), but not males (HR, 1.10 [95% CI, 0.85-1.43]; P=0.46), receiving the intervention (P<0.001 for sex interaction).

CONCLUSIONS

A transitional care model offered a reduction in all-cause emergency department visits among females but not males following hospitalization for heart failure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02112227.

Association of Race/Ethnicity, Gender, and Socioeconomic Status With Sodium-Glucose Cotransporter 2 Inhibitor Use Among Patients With Diabetes in the US

IMPORTANCE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors significantly reduce deaths from cardiovascular conditions, hospitalizations for heart failure, and progression of kidney disease among patients with type 2 diabetes. Black individuals have a disproportionate burden of cardiovascular and chronic kidney disease (CKD). Adoption of novel therapeutics has been slower among Black and female patients and among patients with low socioeconomic status than among White or male patients or patients with higher socioeconomic status.

OBJECTIVE

To assess whether inequities based on race/ethnicity, gender, and socioeconomic status exist in SGLT2 inhibitor use among patients with type 2 diabetes in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of commercially insured patients in the US was performed from October 1, 2015, to June 30, 2019, using the Optum Clinformatics Data Mart. Adult patients with a diagnosis of type 2 diabetes, including those with heart failure with reduced ejection fraction (HFrEF), atherosclerotic cardiovascular disease (ASCVD), or CKD, were evaluated in the analysis.

MAIN OUTCOMES AND MEASURES

Prescription of an SGLT2 inhibitor. Multivariable logistic regression models were used to assess the association of race/ethnicity, gender, and socioeconomic status with SGLT2 inhibitor use.

RESULTS

Of 934 737 patients with type 2 diabetes (mean [SD] age, 65.4 [12.9] years; 50.7% female; 57.6% White), 81 007 (8.7%) were treated with an SGLT2 inhibitor during the study period. Between 2015 and 2019, the percentage of patients with type 2 diabetes treated with an SGLT2 inhibitor increased from 3.8% to 11.9%. Among patients with type 2 diabetes and cardiovascular or kidney disease, the rate of SGLT2 inhibitor use increased but was lower than that among all patients with type 2 diabetes (HFrEF: 1.9% to 7.6%; ASCVD: 3.0% to 9.8%; CKD: 2.1% to 7.5%). In multivariable analyses, Black race (adjusted odds ratio [aOR], 0.83; 95% CI, 0.81-0.85), Asian race (aOR, 0.94; 95% CI, 0.90-0.98), and female gender (aOR, 0.84; 95% CI, 0.82-0.85) were associated with lower rates of SGLT2 inhibitor use, whereas higher median household income (≥$100 000: aOR, 1.08 [95% CI, 1.05-1.10]; $50 000-$99 999: aOR, 1.05 [95% CI, 1.03-1.07] vs <$50 000) was associated with a higher rate of SGLT2 inhibitor use. These results were similar among patients with HFrEF, ASCVD, and CKD.

CONCLUSIONS AND RELEVANCE

In this cohort study, use of an SGLT2 inhibitor treatment increased among patients with type 2 diabetes from 2015 to 2019 but remained low, particularly among patients with HFrEF, CKD, and ASCVD. Black and female patients and patients with low socioeconomic status were less likely to receive an SGLT2 inhibitor, suggesting that interventions to ensure more equitable use are essential to prevent worsening of well-documented disparities in cardiovascular and kidney outcomes in the US.

Sex differences in heart failure medications targeting the renin-angiotensin-aldosterone system

Heart failure (HF) is a major healthcare problem. Sex-related differences in clinical manifestations, outcomes, risk factors and symptoms in HF have been described in the literature. Sex-related differences have also been described in the regulation of the renin-angiotensin-aldosterone system (RAAS), which is at the core of the pathophysiology of HF. Considering that drugs targeting RAAS are cornerstones in the treatment of HF, it is important to determine whether sex-related differences exist in the use of angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs) and ARB/neprilysin inhibitors (ARNIs). In regards to the relative efficacy of RAAS drugs in men vs. women in HF, there are conflicting results, which may stem from the fact that a lot of clinical trials were not specifically designed to investigate sex differences, with many of them having an underrepresentation of women. With respect to optimal dosage of RAAS drugs, even though, current HF guidelines, recommend up-titration to the same target dose in both men and women, evidence suggests that lower doses could be used in women. Furthermore, several studies have reported underutilization of guideline-directed medical therapy in women, including ACEIs, ARBs and MRAs, which may be at least partially attributed to increased prevalence of HF with a preserved ejection fraction and increased propensity for adverse effects in women. Overall, these investigations have shed some light on sex-related differences but there is scope for conducting further studies to determine the optimal use of RAAS drugs in men and women with failing hearts.

Physicians' information seeking behavior in patients presenting with heart failure symptoms - Does gender of physician and patient matter?

OBJECTIVE

To examine differences in the anamnesis in heart failure patients by patient and physician gender.

METHODS

A factorial experimental design with video vignettes was applied. While the dialog of an initial encounter because of heart failure symptoms was identical in all videos, patients, played by professional actors, differed in terms of gender (male/female), age (55 years/75 years) and Turkish migration history (no/yes). After viewing the video, 128 physicians (50 % female) were asked if they wanted to ask additional questions (yes/no) and if so, what they wanted to ask (open ended). A coding frame was conducted for the open ended question.

RESULTS

Compared to male physicians, female physicians more often said they wanted to ask additional questions, especially about psychosocial aspects. Physicians, particularly female physicians, wanted to ask male patients more often about lifestyle aspects compared to female patients.

CONCLUSION

Although the dialog was identical in all videos, some variations in the anamnestic approach regarding physician and patient gender were identified. This is in contrast to current heart failure guidelines that recommend a detailed anamnesis in all patients presenting themselves with heart failure symptoms.

PRACTICE IMPLICATIONS

Primary care physicians should reflect how possible gender stereotypes may influence their anamnestic behavior.

Readmission rates following heart failure: a scoping review of sex and gender based considerations

Background

Although hospital readmission for heart failure (HF) is an issue for both men and women, little is known about differences in readmission rates by sex. Consequently, strategies to optimize readmission reduction programs and care strategies for women and men remain unclear. Our study aims were: (1) to identify studies examining readmission rates according to sex, and (2) to provide a qualitative overview of possible considerations for the impact of sex or gender.

Methods

We conducted a scoping review using the Arksey and O’Malley framework to include full text articles published between 2002 and 2017 drawn from multiple databases (MEDLINE, EMBASE), grey literature (i.e. National Technical information, Duck Duck Go), and expert consultation. Eligible articles included an index heart failure episode, readmission rates, and sex/gender-based analysis.

Results

The search generated 5887 articles, of which 746 underwent full abstract text consideration for eligibility. Of 164 eligible articles, 34 studies addressed the primary outcome, 103 studies considered sex differences as a secondary outcome and 25 studies stratified data for sex. Good inter-rater agreement was reached: 83% title/abstract; 88% full text; kappa: 0.69 (95%CI: 0.53–0.85). Twelve of 34 studies reported higher heart failure readmission rates for men and six studies reported higher heart failure readmission rates for women. Using non composite endpoints, five studies reported higher HF readmission rates for men compared to three studies reporting higher HF readmission rates for women. Overall, there was heterogeneity between studies when examined by sex, but one observation emerged that was related to the timing of readmissions. Readmission rates for men were higher when follow-up duration was longer than 1 year. Women were more likely to experience higher readmission rates than men when time to event was less than 1 year.

Conclusions

Future studies should consider different time horizons in their designs and avoid the use of composite measures, such as readmission rates combined with mortality, which are highly skewed by sex. Co-interventions and targeted post-discharge approaches with attention to sex would be of benefit to the HF patient population.

Differences in medical treatment and clinical characteristics between men and women with heart failure – a single-centre multivariable analysis

Purpose

The aims of this study were to examine sex differences in a heart failure population with regards to treatment and patient characteristics and to investigate the impact of sex on achieved doses of heart failure medications.

Methods and results

A total of 1924 patients with heart failure in a regional hospital were analysed, 622 patients had ejection fraction ≤ 40% of which 30% were women. In patients with reduced ejection fraction, women were older (79 ± 11 vs. 74 ± 12 years, P < 0.001), had lower body weight (70 ± 17 vs. 86 ± 18 kg, P < 0.001), lower estimated glomerular filtration rate (eGFR) (49 ± 24 vs. 71 ± 30 ml/min, P < 0.001) and received lower doses of heart failure medications than men. Multivariable linear regression on patients with reduced ejection fraction showed that sex was not associated with achieved dose of any heart failure medication. For angiotensin-converting enzyme inhibitors and angiotensin receptor blockers associated factors were eGFR, systolic blood pressure, age, ejection fraction, and heart rate. For beta-blockers associated factors were body weight, atrial fibrillation and age. For mineralocorticoid receptor antagonists associated factors were eGFR, serum potassium, age, systolic blood pressure, ejection fraction and heart rate.

Conclusion

Women with heart failure and reduced ejection fraction were prescribed lower doses of heart failure medications, were older, had worse renal function, and lower body weight than men. Sex was not independently associated with achieved doses of heart failure medications, instead age, renal function and body weight explained the differences in treatment.

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.

Gender differences in Egyptian patients hospitalized with heart failure: insights from the European Society of Cardiology Heart Failure Long-Term Registry

Aims

This analysis evaluates gender differences in the Egyptian cohort of patients hospitalized for acute heart failure (AHF) in the European Society of Cardiology Heart Failure Long‐Term Registry.

Methods and results

From April 2011 to September 2014, 1634 patients hospitalized with AHF were enrolled by 20 hospitals all over Egypt. Of these patients, 1112 (68%) patients were male and 522 (32%) were female. Women presented with a higher admission systolic blood pressure and resting heart rate. Compared with men, women had a higher body mass index (32.5 ± 9.0 vs. 29.3 ± 4.9, P < 0.001), more frequent atrial fibrillation (34.7% vs. 22.4%, P < 0.001), and anaemia defined by haemoglobin < 12 g/dL (83.1% vs. 58.4%, P < 0.001). Women were more likely to present with heart failure with preserved ejection fraction (29.7% vs. 10.6%, P < 0.001). Women had more frequent diabetes mellitus (48.1% vs. 41.6%, P < 0.05) and hypertension (48.7% vs. 39.3%, P < 0.001) than had men, whereas smoking was rare among them (8.8% vs. 82.9%, P < 0.005). There was no significant difference in the primary aetiology of heart failure between both sexes. ACE inhibitors, beta‐blockers, mineralocorticoid receptor antagonists, antiplatelets, statins, and nitrates were less frequently prescribed to women, whereas they more often received digoxin, amiodarone, anticoagulants, and calcium channel blockers. There was no significant difference in in‐hospital (5.7% vs. 4.6%, P = 0.39) and 1 year mortality (27.9% vs. 25.9%, P = 0.48) between women and men, respectively.

Conclusions

Men and women with AHF differ significantly in baseline clinical characteristics and management but not in adverse outcomes. These findings emphasize the importance of individualized management and need for more comprehensive recruitment of women in clinical trials.

The usefulness of age and sex to predict all-cause mortality in patients with dilated cardiomyopathy: a single-center cohort study

Objective

Recent studies have shown that sex and age are associated with outcomes in patients with cardiomyopathy. The purpose of this study was to determine the all-cause mortality of dilated cardiomyopathy (DCM) by age and sex.

Methods and results

The patients were divided into non-elderly (age <60 years, n=811) and elderly (age ≥60 years, n=331) groups. No difference in the all-cause mortality rate was observed between elderly and non-elderly patients (27.2% vs 22.2%, log-rank χ²=2.604, P=0.107). Furthermore, no significant difference in mortality was observed between the male and female patients (23.3% vs 24.5%, log-rank χ²=0.707, P=0.400). However, subgroup analysis revealed that elderly male patients exhibited a higher mortality rate than non-elderly male patients (29.4% vs 21.3%, log-rank χ²=5.898, P=0.015), while no difference was observed between the elderly female patients and non-elderly female patients. In the Cox analysis, neither age nor sex was a significant independent predictor of all-cause mortality in patients with DCM.

Conclusion

In conclusion, no significant difference in mortality between male and female patients or between the elderly and non-elderly patients was observed. Only among males was a difference in mortality observed; elderly male patients experienced greater mortality than that of non-elderly male patients. No effect of age or sex on all-cause mortality was observed in patients with DCM.

Sex differences in device therapy for heart failure: utilization, outcomes, and adverse events

BACKGROUND

Multiple studies of heart failure patients demonstrated significant improvement in exercise capacity, quality of life, cardiac left ventricular function, and survival from cardiac resynchronization therapy (CRT), but the underenrollment of women in these studies is notable. Etiological and pathophysiological differences may result in different outcomes in response to this treatment by sex. The observed disproportionate representation of women suggests that many women with heart failure either do not meet current clinical criteria to receive CRT in trials or are not properly recruited and maintained in these studies.

METHODS

We performed a systematic literature review through May 2014 of clinical trials and registries of CRT use that stratified outcomes by sex or reported percent women included. One-hundred eighty-three studies contained sex-specific information.

RESULTS

Ninety percent of the studies evaluated included ≤ 35% women. Fifty-six articles included effectiveness data that reported response with regard to specific outcome parameters. When compared with men, women exhibited more dramatic improvement in specific parameters. In the studies reporting hazard ratios for hospitalization or death, women generally had greater benefit from CRT.

CONCLUSIONS

Our review confirms women are markedly underrepresented in CRT trials, and when a CRT device is implanted, women have a therapeutic response that is equivalent to or better than in men, while there is no difference in adverse events reported by sex.

Gender aspects in clinical presentation and prognostication of chronic heart failure according to NT-proBNP and the Heart Failure Survival Score

AIMS

We performed a prospective multi-center study to assess gender-specific differences in the predictive value of the measured level of NT-proBNP and the calculated Heart Failure Survival Score (HFSS).

METHODS

Baseline characteristics and follow-up data up to 5 years from 2,019 men and 530 women diagnosed with chronic heart failure (CHF) due to ischemic heart disease or dilated cardiomyopathy were prospectively compared. Death from any cause constituted the endpoint of the study. NT-proBNP was measured and HFSS calculated according to standard methods. Survival of men and women according to level of NT-proBNP and HFSS was analyzed in logistic regression models.

RESULTS

Median NT-proBNP level in men was 1,394 ng/l (IQR 516-3,406 ng/l) and 1,168 ng/l (IQR 444-2,830 ng/l) in women (p = n.s.). Median HFSS value was 8.4 (IQR 7.7-9.1) and 8.5 (8.0-9.1) in men and women, respectively. NT-proBNP levels and HFSS score correlated well with survival rates in both genders (p for interaction = 0.22 for NT-proBNP and 0.93 for HFSS). The all-cause death rates were similar in men and women.

CONCLUSION

Despite a number of gender-specific differences in CHF and the general predominance of men measured levels of NT-proBNP and HFSS score can be utilized for risk stratification with similar informative value in men and women.

Women with nonischemic cardiomyopathy have a favorable prognosis and a better left ventricular remodeling than men after cardiac resynchronization therapy

AIMS

Cardiac resynchronization therapy (CRT) is a well established therapy in heart failure patients who are on optimal medical therapy and have reduced left ventricular ejection fraction (LVEF) and wide QRS complexes. Although women and patients with nonischemic cardiomyopathy are under-represented in CRT trials and registries, there is evidence that these two groups of patients can benefit more from CRT. The aim of our analysis was to investigate the impact of female sex on mortality in a population that included a high percentage of patients (61%) with nonischemic cardiomyopathy.

METHODS

We analyzed data on 507 consecutive patients (20% women) who received CRT at two Italian Heart Transplant centers and were followed up for a maximum of 48 months.

RESULTS

After multivariate adjustment, women showed a trend toward better survival with regard to all-cause mortality [hazard ratio (HR) 0.32, confidence interval (CI) 0.10-1.04; P = 0.059]. However, this benefit was limited to nonischemic patients with regard to all-cause mortality (HR 0.20, CI 0.05-0.87, P = 0.032) and cardiovascular mortality (HR 0.14, CI 0.02-1.05, P = 0.056).

CONCLUSION

Female CRT recipients, at mid-term, have a favorable prognosis than male patients and this benefit appears to be more evident in nonischemic patients. Thus, we strongly believe that the apparent under-utilization of CRT in females is an anomaly that should be corrected.

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.

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

AIM AND METHODS

Gender-related differences in clinical phenotype, in-hospital management and prognosis of acute heart failure (AHF) patients have been previously reported in European and US registries. The ALARM-HF survey is the first to include a cohort of 4953 patients hospitalized for AHF in 666 hospitals in 6 European countries, Mexico and Australia.

RESULTS

Women accounted for 37% of the study population, were older and had higher rates of de novo heart failure (45% vs 36%, p<0.001) than men. An acute coronary syndrome (ACS) was the predominant precipitating factor in both genders, but to a lesser extent in females (30% vs 42%, p<0.001). Between genders comparison showed higher incidence of atrial fibrillation, valvular heart disease, diabetes, obesity, anemia and depression in women (p<0.05). Similarly, women had higher left ventricular ejection fraction (LVEF) on admission (42 ± 15% vs 36 ± 13%, p<0.001) and systolic blood pressure (135 ± 40 mm Hg vs 131 ± 39 mm Hg, p=0.001) than men. On the other hand, men had more often coronary artery disease, renal failure and chronic obstructive pulmonary disease (p<0.05). Importantly, in-hospital mortality was similar in both genders (11.1% in females vs 10.5% in males, p=0.475), and its common predictors were: systolic blood pressure at admission, creatinine>1.5mg/dL and diabetes. Furthermore, recent ACS, valvular heart disease and dementia contributed to prognosis in women, while LVEF, hypertension and anemia were independent predictors in men.

CONCLUSION

Among patients with AHF, there are significant differences in co-morbidities, precipitating factors and predictors of in-hospital mortality between genders. Nevertheless, in-hospital mortality remains similar between genders.

Comparison of women versus men hospitalized with heart failure (from a 20-year registry in a middle-eastern country 1991-2010)

The aim of the present study was to compare the clinical characteristics, treatment, and outcomes of women and men hospitalized with heart failure (HF) in a Middle-Eastern country. A retrospective analysis of all patients hospitalized with HF in the State of Qatar from 1991 through 2010 was made. The clinical characteristics, management, and outcomes of the patients with HF were compared according to gender. A subset analysis according to ethnicity was also done (Middle Eastern Arabs vs South Asians). During the 20-year period, 2,379 women and 4,689 men were hospitalized for HF. The women were older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment compared to the male patients. The women were less likely to be current smokers and to have ischemic heart disease compared to the men. Impaired left ventricular function was more common among men. The in-hospital mortality rates were comparable between the 2 groups (7.7% in women vs 8.2% in men; p = 0.4) and significantly improved with time in the 2 groups (p = 0.001). The mortality rates were comparable among the women, regardless of the ethnicity. In conclusion, overall improvement occurred in survival in patients hospitalized with HF in a Middle-Eastern country, regardless of gender. Women hospitalized with HF had mortality rates comparable to those of men.

Influence of gender on long-term prognosis of patients with chronic heart failure seen in heart failure clinics

BACKGROUND

Controversy exists concerning the influence of gender in the prognosis of patients with heart failure and no evidence is available from specific heart failure clinics.

HYPOTHESIS

Women with ambulatory heart failure are managed differently than men, although their prognosis might be better than men.

METHODS AND RESULTS

We analyzed the clinical characteristics, complementary test results, treatment, and prognosis in 4720 patients with chronic heart failure seen in 62 specialized clinics forming part of a multicenter registry during a mean follow-up of 40 months. The mean age was 65 +/- 12 years and 71% were men. The men were younger than the women and more often had a history of hyperlipidemia and ischemic heart disease. The men had a more advanced heart failure New York Heart Association (NYHA) functional class (III-IV) than the women and a greater frequency of systolic ventricular dysfunction. The men more often received treatment with beta-blockers, vasodilators, and antiplatelet aggregators as well as higher mean doses as compared with the women. The overall survival after the follow-up was similar for both genders, although the women had lower rates of survival free of admission for heart failure.

CONCLUSIONS

Despite the mortality of women and men with heart failure being similar, the rate of readmission for heart failure is greater in women in specialized heart failure clinics. These results may be associated with the pharmacological treatment differences observed.

Influence of sex on treatment and outcome in chronic heart failure

The population is aging, the prevalence of heart failure increases with age, and on average women live longer than men. There is evidence for sex-specific effects of individual, guideline-recommended drugs used for treatment of chronic heart failure. Women are underrepresented in most clinical trials and only a minority of drug applications to regulatory authorities have included sex analyses. The present review focuses on the potential female survival benefit in heart failure, the influence of sex on medical treatment in a broader sense, and the potential benefit to be derived from guideline recommended treatment and common adjunctive heart failure medication.

Clinical outcomes in medical outliers admitted to hospital with heart failure

BACKGROUND

Due to the lack of beds in medical wards, many patients are placed in other departments' wards (usually in surgical wards). These patients are called "medical outliers". This is a common problem in countries with public national health services. We determined whether location influences progress and prognosis of patients.

METHODS

This was a retrospective cohort study in a public university hospital in Madrid, Spain. 243 patients discharged from the Department of Internal Medicine during 2006 with the same diagnosis-related group (DRG) (congestive heart failure and cardiac arrhythmia with major complications or comorbidity) were studied. Patients admitted to departments other than the Internal Medicine department or Intensive Care Unit were excluded. "Medical outlier" was defined as a patient admitted to a ward different from the Internal Medicine ward. Medical outliers transferred to the Internal Medicine ward were not excluded.

RESULTS

109 (45%) patients were medical outliers. They had a longer stay in hospital (mean difference 2.6 days, 95% confidence interval 0.6-4.7) but with no statistically significant differences in mortality, readmission, or intra-hospital morbidity. These patterns persisted after control for confounding in multivariate analysis.

CONCLUSION

Patients admitted to the Department of Internal Medicine with heart failure had a longer stay if they initially start in other departments' wards. Significant differences were not seen in this group of patients with respect to mortality, readmission, or intra-hospital morbidity.

Elevated risk profile of women in secondary prevention of coronary artery disease: a 6-year survey of 117,913 patients

BACKGROUND AND AIMS

The prognosis of female patients after acute coronary syndrome (ACS) has been shown to be inferior to that of male patients. Little is known about gender differences during the secondary prevention phase.

METHODS

After ACS, 117,913 patients (30.7% female) were enrolled in two large-scale German registries from 2000 to 2005 during phase II cardiac rehabilitation (CR). Demographic parameters, reperfusion strategies, cardiovascular risk factors, exercise capacity, and medication use at admission and discharge were assessed. Temporary changes (trends) and gender-specific differences were determined.

RESULTS

Compared to 2000, patients in 2005 were significantly older (females: 66.4 vs. 68.0 years; males: 62.3 vs. 63.3 years; p = 0.001) and had a higher body mass index (BMI) (females: 27.7 vs. 28.6 kg/m(2); males: 27.6 vs. 28.1 kg/m(2), in 2000 and 2005, respectively, p < 0.001). Target blood pressure <140/90 mm Hg at discharge was obtained in a smaller proportion of women than men (81.0 vs. 83.0%, p < 0.001). Low-density lipoprotein cholesterol (LDL-C) levels at discharge were significantly higher in female patients (95.0 vs. 93.2 mg/dL, p < 0.001); 80.9% of female vs. 83.8% of male patients achieved a target fasting glucose <126 mg/dL during the CR (p < 0.001). Large between-center variability was noted for age, total cholesterol at entry, and exercise capacity at entry and discharge.

CONCLUSIONS

Although control of cardiovascular risk factors has improved in both genders, over a recent 6-year period, female patients compared with males were less likely to achieve target values for blood pressure, fasting glucose, and lipid values in the early period after acute coronary events.

Does heart failure therapy differ according to patient sex?

OBJECTIVES

To assess differences in clinical characteristics, treatment and outcome between men and women with heart failure (HF) treated at a multidisciplinary HF unit. All patients had their first unit visit between August 2001 and April 2004.

PATIENTS

We studied 350 patients, 256 men, with a mean age of 65 +/- 10.6 years. In order to assess the pharmacological intervention more homogeneously, the analysis was made at one year of follow-up.

RESULTS

Women were significantly older than men (69 +/- 8.8 years vs. 63.6 +/- 10.9 years, p < 0.001). Significant differences were found in the HF etiology and in co-morbidities. A higher proportion of men were treated with ACEI (83% vs. 68%, p < 0.001) while more women received ARB (18% vs. 8%, p = 0.006), resulting in a similar percentage of patients receiving either of these two drugs (men 91% vs. women 87%). No significant differences were observed in the percentage of patients receiving beta-blockers, loop diuretics, spironolactone, anticoagulants, amiodarone, nitrates or statins. More women received digoxin (39% vs. 22%, p = 0.001) and more men aspirin (41% vs. 31%, p = 0.004). Carvedilol doses were higher in men (29.4 +/- 18.6 vs. 23.8 +/- 16.4, p = 0.03), ACEI doses were similar between sexes, and furosemide doses were higher in women (66 mg +/- 26.2 vs. 56 mg +/- 26.2, p < 0.05). Mortality at 1 year after treatment analysis was similar between sexes (10.4% men vs. 10.5% women).

CONCLUSIONS

Despite significant differences in age, etiology and co-morbidities, differences in treatment between men and women treated at a multidisciplinary HF unit were small. Mortality at 1 year after treatment analysis was similar for both sexes.

The effectiveness of beta-blockers in women with congestive heart failure

BACKGROUND

Beta-blockers have been shown to improve survival in patients with congestive heart failure (CHF). However, few studies have looked at the effects of these medications specifically in women.

OBJECTIVE

To determine the effectiveness of beta-blockers in women with CHF.

PATIENTS

We conducted a retrospective cohort study that used administrative databases of all patients >65 years of age discharged with a diagnosis of CHF between January 1998 and March 2003 in Quebec, Canada. Follow-up information was available until March 31, 2004.

METHOD

The cohort included 27,837 patients. Subjects with filled prescription for a beta-blocker (14,083 users) were compared with those who never filled such prescription (12,254 nonusers). The primary outcome was survival in women and men by beta-blocker use.

RESULTS

There were 14,693 women (52% were prescribed beta-blockers) and 13,144 men (49% were prescribed beta-blockers). Women were older and had more hypertension, whereas men had more myocardial infarction. There was a significant survival benefit with beta-blockers use in both sexes (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.75-0.83 in women, and 0.76, 95% CI 0.72-0.80 in men). Sensitivity analyses adjusting for selection bias showed similar survival benefits in both sexes. Overall, men had a worse survival than women (HR 1.2, 95% CI 1.2-1.3 in men).

CONCLUSIONS

Beta-blockers appear to improve survival from CHF as much in women as in men. Clinical trials involving large numbers of women are necessary to demonstrate potential treatment benefits.

Angiotensin-converting enzyme inhibitors and survival in women and men with heart failure

BACKGROUND

Several randomized controlled trials demonstrate that angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure (CHF). However, whether ACE inhibitors benefit both sexes is not adequately addressed.

PURPOSE

Our objective was to determine the effectiveness of ACE inhibitors in women with CHF.

METHODS

The Quebec hospital discharge database was linked with the physician and drug claims database to identify a cohort with a discharge diagnosis of CHF between January 1998 and March 2003. In this retrospective cohort study, subjects who filled a prescription for ACE inhibitors (19,220 exposed) were compared to those who never filled such prescription (8617 non-exposed). The primary outcome was survival by exposure to ACE inhibitors.

MAIN FINDINGS

There were 14,693 women (67% exposed) and 13,144 men (72% exposed). The 1 year mortality was 19.5% and 30% in those exposed and non-exposed, respectively. A significant survival benefit was demonstrated in both sexes exposed to ACE inhibitors [adjusted hazard ratio (95% confidence interval): women 0.80 (0.76-0.85); men 0.71 (0.67-0.75)].

PRINCIPAL CONCLUSIONS

ACE inhibitors improve survival in both sexes with CHF, but the protective effect appears to be greater in men. Our results support the current recommendations for the management of women with CHF.

Self-care practices in women with diastolic heart failure

BACKGROUND

For many patients with heart failure (HF), performing self-care is complicated by the complex medication regimen, symptom monitoring, and required decision-making. Women with HF are typically older and more physically debilitated, have more comorbidities, and may be at higher risk for poor self-care practices. Previous studies have largely excluded patients with diastolic heart failure (DHF), however, so little is known about their self-care practices.

OBJECTIVES

The purposes of the study were to describe the (a) performance of self-care behaviors and (b) demographic and clinical characteristics that affected self-care practices in women with DHF.

METHODS

Thirty-two women who were 50 years of age or older and diagnosed with DHF were recruited through cardiologist referral from an outpatient HF clinic in an academic health care setting. Data were collected using a semistructured interview guide. Descriptive statistics were used to analyze participant demographic and clinical characteristics. The responses were tabulated in order of frequency and then coded into categories.

RESULTS

The mean age of the women was 68 +/- 11 years; 81% had annual incomes at or below the poverty level, 41% lived alone, and the majority had three or more comorbidities. Although most perceived their HF knowledge to be fair to good, and 62% had received HF educational information, only six (19%) weighed daily, few followed the recommended sodium restrictions, and 91% were sedentary at the time of the interview. The only self-care behavior that was consistently practiced (72%) was taking prescribed medications. Exertional intolerance often interfered with household chores and was cited most often as the reason for poorer quality of life. Decision-making about self-care activities such as taking diuretics was typically based on daily plans and social outings. Medical attention was sought only when acute or life-threatening symptoms occurred. Few women actively participated in ongoing symptom monitoring, and confusion over symptom recognition was a recurrent problem.

CONCLUSIONS

Lower socioeconomic status and advancing age increase vulnerability for poor self-care and negative clinical outcomes in women with DHF. Recommendations to improve self-care practices among economically disadvantaged women with HF such as prescribing routine activities as exercise, screening for depression, and home visits to increase socialization are discussed along with areas for future research.

Effect of gender on treatment, resource utilization, and outcomes in congestive heart failure in Quebec, Canada

This study assessed whether a gender gap exists in therapy, procedure use, and outcomes in patients who have a new diagnosis of congestive heart failure (CHF) at the population level. The Quebec hospital discharge database was linked with the physician and drug claims databases to identify a cohort of patients who had a diagnosis of CHF (code 428 in the International Classification of Diseases, Ninth Revision) between January 1998 and December 2002. There were 16,017 men and 16,622 women. Women who had CHF were older (78 +/- 11 vs 73 +/- 11 years, p <0.001), had more hypertension (41% vs 28%, p <0.001) and hyperlipidemia (18% vs 14%, p <0.001) but less frequent myocardial infarction (19% vs 25%, p <0.001). Women were less likely to see a cardiologist (30% vs 34%, p <0.001) and required a longer hospital stay (12.0 +/- 14.8 vs 10.6 +/- 13.3 days, p <0.001). During the first year after a first CHF hospitalization, women were less like to have an assessment of left ventricular function (61% vs 65%, p <0.001), diagnostic cardiac catheterization (11% vs 15%, p <0.001), and revascularization procedure (4% vs 6%, p <0.001). Women were less likely to be prescribed an angiotensin-converting enzyme inhibitor (60% vs 66%) and more likely to be prescribed a beta blocker (38% vs 34%). Women and men had similar yearly numbers of rehospitalizations for CHF (1.4 +/- 1.0 vs 1.5 +/- 1.0) and emergency room visits (1.7 +/- 1.2 vs 1.8 +/- 1.3). The adjusted risk of death was minimally higher in men than in women (hazard ratio 1.06, 95% confidence interval 1.03 to 1.1, p <0.01). Thus, despite less frequent cardiologist assessment, fewer cardiac-related procedures, and less frequent use of standard medical therapy, clinical outcomes in women and men who had CHF were similar.