Sex Differences in Heart Failure

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.

Endothelin type A receptor blockade increases renoprotection in congestive heart failure combined with chronic kidney disease: Studies in 5/6 nephrectomized rats with aorto-caval fistula

BACKGROUND

Association of congestive heart failure (CHF) and chronic kidney disease (CKD) worsens the patient's prognosis and results in poor survival rate. The aim of this study was to examine if addition of endothelin type A (ET_A) receptor antagonist to the angiotensin-converting enzyme inhibitor (ACEi) will bring additional beneficial effects in experimental rats.

METHODS

CKD was induced by 5/6 renal mass reduction (5/6 NX) and CHF was elicited by volume overload achieved by creation of aorto-caval fistula (ACF). The follow-up was 24 weeks after the first intervention (5/6 NX). The treatment regimens were initiated 6 weeks after 5/6 NX and 2 weeks after ACF creation.

RESULTS

The final survival in untreated group was 15%. The treatment with ET_A receptor antagonist alone or ACEi alone and the combined treatment improved the survival rate to 64%, 71% and 75%, respectively, however, the difference between the combination and either single treatment regimen was not significant. The combined treatment exerted best renoprotection, causing additional reduction in albuminuria and reducing renal glomerular and tubulointerstitial injury as compared with ACE inhibition alone.

CONCLUSIONS

Our results show that treatment with ET_A receptor antagonist attenuates the CKD- and CHF-related mortality, and addition of ET_A receptor antagonist to the standard blockade of RAS by ACEi exhibits additional renoprotective actions.

Remote Patient Monitoring for Patients with Heart Failure: Sex- and Race-based Disparities and Opportunities

Remote patient monitoring (RPM), within the larger context of telehealth expansion, has been established as an effective and safe means of care for patients with heart failure (HF) during the recent pandemic. Of the demographic groups, female patients and black patients are underenrolled relative to disease distribution in clinical trials and are under-referred for RPM, including remote haemodynamic monitoring, cardiac implantable electronic devices (CIEDs), wearables and telehealth interventions. The sex- and race-based disparities are multifactorial: stringent clinical trial inclusion criteria, distrust of the medical establishment, poor access to healthcare, socioeconomic inequities, and lack of diversity in clinical trial leadership. Notwithstanding addressing the above factors, RPM has the unique potential to reduce disparities through a combination of implicit bias mitigation and earlier detection and intervention for HF disease progression in disadvantaged groups. This review describes the uptake of remote haemodynamic monitoring, CIEDs and telehealth in female patients and black patients with HF, and discusses aetiologies that may contribute to inequities and strategies to promote health equity.

Cardiac Structure and Function Phenogroups and Risk of Incident Heart Failure (from the Multi-ethnic Study of Atherosclerosis)

Indices of cardiac structure and function, such as left ventricular (LV) mass and ejection fraction, have been associated with risk of incident heart failure (HF), but the clinical relevance of data-driven grouping of a comprehensive set of cardiac parameters is unclear. In Multi-Ethnic Study of Atherosclerosis participants, latent class analysis was applied in the sample stratified by gender to define phenogroups on the basis of cardiovascular magnetic resonance imaging parameters of right ventricular and LV structure and function at baseline. Cox proportional hazard models in gender-stratified analyses were used to assess the association between phenogroup membership and risk of HF subtypes adjusting for potential confounders. In the 4,204 participants (mean age 61 ± 10 years, 53% women), the mean follow-up time was 14 ± 4 years for men and 15 ± 4 years for women. For both genders, 4 distinct phenogroups were identified: (1) ideal cardiac mechanics; (2) higher output/hypertrophied LV; (3) impaired ejection fraction/dilated LV; and (4) higher output/hyperdynamic (LV). Men in phenogroups 4 (hazard ratio [HR] 2.91, 95% confidence interval [CI] 1.60 to 5.31, p = 0.0005), 3 (HR 3.52, 95% CI 1.90 to 6.53, p <0.0001), and 2 (HR 3.49, 95% CI 1.94 to 6.28, p <0.0001) had higher rates of incident HF than did men in phenogroup 1, in fully adjusted models. No significant associations were found between phenogroup membership and incident HF in women. In conclusion, phenogroup membership based on cardiac structure and function in men was significantly associated with incident HF. Integration of cardiac magnetic resonance imaging variables may help identify differential risk for HF in men.

Sex differences in left ventricular stroke work and cardiac power output per unit myocardium relate to blood pressure in apparently healthy adults

BACKGROUND

Left ventricular stroke work per unit myocardium (LVSWM) and cardiac power output per unit myocardium (CPOM) are important measures of myocardial workload. The sex differences in the myocardial workload and its correlation with blood pressure remain largely unclear.

OBJECTIVES

The purpose of this study is to investigate the sex differences in LVSWM and CPOM, and to relate them to blood pressure in a cohort of apparently healthy adults.

METHODS

The LVSWM and CPOM were estimated in 596 age- and heart rate-matched apparently healthy adults (298 men) using transthoracic echocardiography combined with cuff-measured brachial blood pressure. The data were compared between sexes, and the sex differences in LVSWM and CPOM were related to blood pressure.

RESULTS

After adjustment for the blood pressure, the LVSWM and CPOM were higher in women than in men [75.0 (73.7-76.4) vs 64.9 (63.5-66.2) cJ/100g for LVSWM, and 912.4 (894.1-930.6) vs 780.2 (762.0-798.5) milliwatt/100g for CPOM, respectively; all P<0.001]. After adjustment for the LVSWM and CPOM, the mean systolic and diastolic blood pressure were 7.4 mm Hg and 5.2 mm Hg higher in men than in women, respectively (all P<0.001).

CONCLUSIONS

For any given blood pressure, the workload per unit myocardium is higher in apparently healthy women than in their male counterparts. A sex-specific definition of normal blood pressure with a relatively lower threshold for women can minimize the sex differences in the myocardial workload, which might reduce the potentially comparatively higher risk of heart failure in women.

Biomarkers and the quadriceps femoris muscle architecture assessed by ultrasound in older adults with heart failure with preserved ejection fraction: a cross-sectional study

BACKGROUND

Sarcopenia is an important comorbidity in patients with heart failure with preserved ejection fraction (HFpEF). The ultrasound (US) assessment has all the advantages of being used in primary care to assess muscle quantity and quality. Some biomarkers could be indicative of muscle mass loss.

AIMS

To describe the quantitative and qualitative characteristics of the quadriceps femoris assessed by US in older adults with HFpEF and to assess the relationship of the blood and urinary biomarkers, the polypharmacy and comorbidities with US outcomes in older adults with HFpEF.

METHODS

A cross-sectional study was conducted. 76 older adults with HFpEF were included. The quadriceps femoris muscle thickness (MT, cm), the subcutaneous fat tissue thickness (FT, cm), the muscle echo intensity (MEI) and the subcutaneous fat tissue echo intensity (FEI) were assessed by US in a non-contraction (non-con) and contraction (con) situations. Polypharmacy, comorbidities, blood and urine biomarkers were also collected.

RESULTS

The carbohydrate antigen 125 (CA-125), the folic acid and the urine creatinine shared the 86.6% variance in the non-con MT, adjusted by age, sex and body mass index (BMI). The folic acid shared the 38.5% of the variance in the con MT, adjusted by age, sex and BMI. The glycosylated haemoglobin explained the 39.6% variance in the non-con MEI, adjusted by age, sex and BMI. The chlorine (Cl-) explained the 40.2% of the variance in the non-con FT, adjusted by age, sex and BMI. The polypharmacy and the folic acid explained the 37.9% of variance in the non-con FEI, while the polypharmacy and the thyrotropin (TSH) shared the 44.4% of variance in the con FEI, both adjusted by age, sex and BMI. No comorbidities, polypharmacy, or blood and urinary biomarkers could explain the con MEI and the con FT variance.

CONCLUSIONS

Blood and urinary biomarkers obtained in routine analyses could help clinicians detect US outcome changes in older adults with HFpEF and identify a worsening of sarcopenia.

TRIAL REGISTRATION

NCT03909919. April 10, 2019. Retrospectively registered.

A retrospective cohort study on the association between early coagulation disorder and short-term all-cause mortality of critically ill patients with congestive heart failure

Purpose

Coagulation disorder in congestive heart failure (CHF) has been well-documented. The prognostic value of a composite coagulation disorder score, which combines the absolute platelet count, international normalized ratio (INR), and activated partial thromboplastin time (APTT), has not been assessed in CHF. The present study endeavored to explore the association between the coagulation disorder score and adverse outcomes of critically ill patients with CHF.

Methods

Patients diagnosed with CHF in the Medical Information Mart for Intensive Care III (MIMIC-III) database were included in the present retrospective cohort study. The coagulation disorder score was calculated according to the abnormalities of the absolute platelet count, INR, and APTT within 24 h after intensive care unit admission. The primary outcomes were the short-term all-cause mortality, including 30-, 90-day and in-hospital mortalities. The Kaplan-Meier (K-M) survival curve and the Cox proportional hazard model were performed to assess the correlation between coagulation disorder score and outcome events.

Results

A total of 6,895 patients were enrolled in this study and divided into four groups according to the coagulation disorder score. K-M survival curve preliminarily indicated that subjects with higher coagulation disorder score presented lower survival rate and shorter survival time. After adjustment for potential confounders, the multivariate Cox analysis further illustrated that elevated coagulation disorder score as a quartile variable was significantly associated with increased all-cause mortality (quartile 4 vs. quartile 1, 30-day: HR [95% CI], 1.98 [1.50, 2.62], 90-day: HR [95% CI], 1.88 [1.49, 2.37], in-hospital: HR [95%CI], 1.93 [1.42, 2.61]).

Conclusion

In critically ill patients with CHF, ones with high coagulation disorder score tend to be worse clinical prognosis, which would be a promising biomarker and helpful for the management of CHF patients.

Sex differences in the impact of frailty in elderly outpatients with heart failure

Introduction

Frailty is common among patients with heart failure (HF). Our aim was to address the role of frailty in the management and prognosis of elderly men and women with HF.

Methods and results

Prospective multicenter registry that included 499 HF outpatients ≥75 years old. Mean age was 81.4 ± 4.3 years, and 193 (38%) were women. Compared with men, women were older (81.9 ± 4.3 vs. 81.0 ± 4.2 years, p = 0.03) and had higher left ventricular ejection fraction (46 vs. 40%, p < 0.001) and less ischemic heart disease (30 vs. 57%, p < 0.001). Women had a higher prevalence of frailty (22 vs. 10% with Clinical Frailty Scale, 34 vs. 15% with FRAIL, and 67% vs. 46% with the mobility visual scale, all p-values < 0.001) and other geriatric conditions (Barthel index ≤90: 14.9 vs. 6.2%, p = 0.003; malnutrition according to Mini Nutritional Assessment Short Formulary ≤11: 55% vs. 42%, p = 0.007; Pfeiffer cognitive test's errors: 1.6 ± 1.7 vs. 1.0 ± 1.6, p < 0.001; depression according to Yesavage test; p < 0.001) and lower comorbidity (Charlson index ≥4: 14.1% vs. 22.1%, p = 0.038). Women also showed worse self-reported quality of life (6.5 ± 2.1 vs. 6.9 ± 1.9, on a scale from 0 to 10, p = 0.012). In the univariate analysis, frailty was an independent predictor of mortality in men [Hazard ratio (HR) 3.18, 95% confidence interval (CI) 1.29–7.83, p = 0.012; HR 4.53, 95% CI 2.08–9.89, p < 0.001; and HR 2.61, 95% CI 1.23–5.43, p = 0.010, according to FRAIL, Clinical Frailty Scale, and visual mobility scale, respectively], but not in women. In the multivariable analysis, frailty identified by the visual mobility scale was an independent predictor of mortality (HR 1.95, 95% CI 1.04–3.67, p = 0.03) and mortality/readmission (HR 2.06, 95% CI 1.05–4.04, p = 0.03) in men.

Conclusions

In elderly outpatients with HF frailty is more common in women than in men. However, frailty is only associated with mortality in men.

Noninvasive Assessment of Sex Differences in Arterial Load in Healthy Adults

Background

Women have higher risk of heart failure than their male counterparts. Although the mechanical inefficiency of myocardium against an excessive afterload is an important reason of heart failure, little attention has been paid to the sex differences in arterial load and its clinical relevance.

Results

The effective arterial elastance index (EaI), total arterial compliance index (TACI), and systemic vascular resistance index (SVRI) were determined using transthoracic echocardiography combined with cuff-measured brachial blood pressure in 460 healthy adults (230 men). The sex differences in these arterial load indexes were analyzed. No statistical difference was found in the age, heart rate, and stroke volume index (all P < 0.05). After adjustment for the cuff-measured blood pressure; the estimated marginal means (95% CIs) of the EaI was higher in women than in men [0.972 (0.952–0.991) vs 0.743 (0.724–0.763) mmHg m2/mL, P < 0.001], the TACI was lower in women than in men [0.924 (0.905–0.944) vs 1.055 (1.036–1.075) mL/mm Hg m2, P < 0.001], and no statistical difference was found in the SVRI between sexes (P > 0.05).

Conclusions

For any given cuff-measured blood pressure, greater integrated and pulsatile arterial load are imposed on left ventricle in women than in men, which is a piece of evidence that women have higher risk of heart failure than their counterparts.

Role of sex on the efficacy of pharmacological and non-pharmacological treatment of heart failure with reduced ejection fraction: A systematic review

Background

Heart Failure (HF) is a growing epidemic with a similar prevalence in men and women. However, women have historically been underrepresented in clinical trials, leading to uneven evidence regarding the benefit of guideline-directed medical therapy (GDMT). This review aims to outline the sex differences in the efficacy of pharmacological and non-pharmacological treatment of HF with reduced ejection fraction (HFrEF).

Methods and results

We conducted a systematic review via Medline from inception to 31 January 2022, including all randomized clinical trials published in English including adult patients suffering HFrEF that reported data on the efficacy of each drug. Baseline clinical characteristics, primary outcomes, and sex-specific effects are summarized in tables. The systemic review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. In total, 29 articles were included in the systematic review. We observed that the proportion of women enrolled in clinical trials was generally low, the absence of a prespecified analysis of efficacy by sex was frequent, and the level of quality of evidence on the efficacy of GDMT and implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT-) in women was relatively poor.

Conclusions

Sex influences the response to treatment of patients suffering from HFrEF. All the results from the landmark randomized clinical trials are based on study populations composed mainly of men. Further studies specifically designed considering sex differences are warranted to elucidate if GDMT and new devices are equally effective in both sexes.

Special Considerations in the Care of Women With Advanced Heart Failure

Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.

It Takes a Village: Expanding Women's Cardiovascular Care to Include the Community as well as Cardiovascular and Primary Care Teams

PURPOSE OF REVIEW

Our aim is to highlight some of the current issues that prevent women from getting sex-specific and gender-specific cardiovascular care and provide recommendations for new approaches and delivery models to improve cardiovascular care for all women.

RECENT FINDINGS

Cardiovascular disease remains the number one cause of death for women in the US. Many women remain unaware of cardiovascular risk factors and many healthcare providers who care for women are also poorly informed and feel ill prepared to assess women for cardiovascular risk. Women's Heart Centers have tried to bridge the gaps in women's care between primary care and cardiology. Many of the impediments to care in the current models are lack of comprehensive care and socioeconomic societal limitations. New models of care and delivery are essential to change cardiovascular outcomes for all women, especially women at high risk.

The spectrum of comorbidities at the initial diagnosis of heart failure a case control study

The prognosis of heart failure (HF) patients is determined to a decisive extent by comorbidities. The present study investigates the association between a broad spectrum of diseases and the occurrence of HF in a large collective of outpatients. This retrospective case control study assessed the prevalence of 37 cardiac and extracardiac diseases in patients with an initial diagnosis of heart failure (ICD-10: I50) in 1,274 general practices in Germany between January 2005 and December 2019. The study is based on the Disease Analyzer database (IQVIA), which contains drug prescriptions, diagnoses, and basic medical and demographic data. Patients with and without heart failure were matched by sex, age, and index year. Hazard regression models were conducted to evaluate the association between different disease entities and heart failure. The present study included 162,246 patients with heart failure and 162,246 patients without heart failure. Mean age [SD] was 73.7 [12.1] years; 52.6% were women. Out of 37 predefined diagnoses, 36 were more prevalent in HF patients. The highest prevalence was primary hypertension (63.4% in HF patients vs. 53.3% in controls, p < 0.001) followed by lipid metabolism disorders (34.6% in HF patients vs. 29.1% in HF patients p < 0.001) and diabetes mellitus type II (32.2% in HF patients vs. 25.2% in controls, p < 0.001). In the regression analysis, 19 diseases were significantly associated with heart failure. Non-cardiovascular diagnoses strongly associated with HF were obesity (HR = 1.46), chronic bronchitis and COPD (HR = 1.41), gout (HR: 1.41), and chronic kidney disease (HR = 1.27). In the present study, we identified a variety of cardiac and extracardiac diseases associated with heart failure. Our data underscore the immense importance of comorbidities, even as early as at the stage of initial diagnosis of heart failure.

A Primer on Incorporating Sex as a Biological Variable into the Conduct and Reporting of Basic and Clinical Research Studies

The recent move to require sex as a biological variable (SABV), which includes gender, into the reporting of research published by the American Journal of Physiology - Heart and Circulatory Physiology follows a growing, and much-needed, trend by journals. Understandably, there is concern over how to do this without adding considerable work, especially if one's primary research focus is not on elucidating sex/gender differences. The purpose of this article is to provide additional guidance and examples on how to incorporate SABV into the conduct and reporting of basic and clinical research. Using examples from our research, which includes both studies focused and not focused on sex/gender differences, we offer suggestions for how to incorporate SABV into basic and clinical research studies.