Differential Impact of Heart Failure With Reduced Ejection Fraction on Men and Women

Do PRO Measures Function the Same Way for all Individuals With Heart Failure?

Women diagnosed with heart failure report worse quality of life than men on patient-reported outcome (PRO) measures. An inherent assumption of PRO measures in heart failure is that women and men interpret questions about quality of life the same way. If this is not the case, the risk then becomes that the PRO scores cannot be used for valid comparison or to combine outcomes by subgroups of the population. Inability to compare subgroups validly is a broad issue and has implications for clinical trials, and it also has specific and important implications for identifying and beginning to address health inequities. We describe this threat to validity (the psychometric term is differential item functioning), why it is so important in heart-failure outcomes, the research that has been conducted thus far in this area, the gaps that remain, and what we can do to avoid this threat to validity. PROs bring unique information to clinical decision making, and the validity of PRO measures is key to interpreting differences in heart failure outcomes.

Gender and CVD- Does It Really Matters?

Cardiovascular disease is leading cause of morbidity and mortality worldwide. Although women generally have a lower prevalence of CVD than men. Number of studies has shown that after an acute cardiovascular (CV) event, women have a greater death rate and a worse prognosis. Gender differences between men and women in terms of epidemiology, pathophysiology and remedial issues are of due to differences in gene expression from the sex chromosomes and posterior differences in sex hormones. According to western societies, majority of ischemic heart disease occurs 7-10 times later in women than in men. Men are more likely, around 3-4 times than women to suffer from ST - elevated myocardial infaction (STEMI) or non-STEMI. In this review, we summarized the gender differences of several typical cardiovascular diseases including coronary artery disease, heart failure, LBBB, atrial fibrillation, effect of drugs and risk factors. Cardiovascular death in women is major concern which is still under-recognition and untreated. Consideration of gender differences is important for prevention, diagnosis, treatment and management of CVD.

Sex-related Differences in Left Ventricular Deformation in Patients With Hypertensive Heart Failure With Reduced Ejection Fraction: Assessment by Cardiac Magnetic Resonance Tissue Tracking

We aimed to investigate sex-related differences in left ventricular (LV) deformation in heart failure with reduced ejection fraction (HFrEF) patients with comorbid hypertension (HTN) by cardiac MRI. A total of 281 patients with HFrEF who underwent cardiac MRI were enrolled in this study. Sex-related differences in LV structure, function and strains derived from cardiac cine MRI in the context of HTN were measured and compared. The clinical variables associated with LV strains in HFrEF patients with comorbid HTN and determinants of impaired LV strains were investigated for both sexes. The prevalence of HTN did not differ between the sexes (P > 0.05). Despite having a similar LVEF, hypertensive men displayed decreased LV deformation in all 3 directions compared with hypertensive women (all P < 0.05). Male sex and its interaction with HTN were associated with higher LV mass index, reduced LV GCPS and GLPS compared with hypertensive women (all P < 0.05). Male sex was associated with LV deformation impairment in hypertensive HFrEF patients (all P < 0.05). After adjustment for covariates in HFrEF patients, HTN was found to be an independent determinant of impaired LV GCPS [β = 0.17; P = 0.022] and GLPS [β = 0.25; P < 0.001]) in men but not in women (all P > 0.05). Sex had a modifying effect on LV deformation in hypertensive HFrEF patients, with greater adverse effects on LV strains in men than in women. Sex-tailored treatment approaches may be considered in the future for HFrEF patients with comorbid HTN.

Vericiguat: A New Hope for Heart Failure Patients

Heart failure with reduced ejection fraction (HFrEF) is the inability of the heart to adequately contract or eject blood. This heart is unable to produce adequate cardiac output to perfuse vital tissues. At a fundamental level, it is known that the cardioprotective pathway of nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate is impaired in heart failure patients. Vericiguat is a novel, orally used, small molecule, and direct stimulator of the soluble guanylate cyclase, and thus, it enhances the production of cyclic guanosine monophosphate. Vericiguat was approved by the FDA in January of 2021 to reduce the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient IV diuretics, in adults with symptomatic chronic heart failure and ejection fraction less than 45%. In this review, we describe the chemical and mechanistic aspects, pharmacokinetics, adverse effects, and contraindications of vericiguat so as to facilitate its optimal therapeutic use.

Change in Depressive Symptoms During the First Month of Discharge and 1-Year Clinical Outcomes in Patients Hospitalized for Heart Failure

Background The patterns of depressive symptom change during the first month after discharge, as well as their prognostic implications, and predictors of persistent or new-onset depressive symptoms are not well characterized. Methods and Results We included patients hospitalized for heart failure undergoing Patient Health Questionnaire-2 before discharge and at 1 month after discharge in a multicenter prospective cohort. We characterized 4 patterns of change in depressive symptoms-persistent, new-onset, remitted depressive symptoms, and no depressive symptom-and examined the associations between the 4 patterns and 1-year clinical outcomes. We analyzed the factors associated with persistent or new-onset depressive symptoms. A total of 4130 patients were included. Among 1175 (28.5%) symptomatic patients and 2955 (71.5%) symptom-free patients before discharge, 817 (69.5%) had remission, and 366 (12.2%) had new-onset depressive symptoms, respectively. Compared with no depressive symptom, persistent depressive symptoms were associated with an increased risk of cardiovascular death (hazard ratio [HR], 2.10 [95% CI, 1.59-2.79]) and heart failure rehospitalization (HR, 1.56 [95% CI, 1.30-1.87]); new-onset depressive symptoms were associated with an increased risk of cardiovascular death (HR, 1.78 [95%CI, 1.32-2.40]) and heart failure rehospitalization (HR, 1.54 [95% CI, 1.29-1.83]). Remitted depressive symptoms were associated with a slightly increased risk of cardiovascular death but had no significant association with heart failure rehospitalization. Patients who were female or had poor socioeconomic status, stroke history, renal dysfunction, or poor health status had a higher risk of persistent or new-onset depressive symptoms. Conclusions Sex, socioeconomic status, clinical characteristics, and health status help identify patients with high risks of depressive symptoms at 1 month after discharge. Dynamic capture of depressive symptom change during this period informs long-term risk stratifications and targets patients who require psychological interventions and social support to improve clinical outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier (NCT02878811).

Sex Differences in Heart Failure Mortality with Preserved, Mildly Reduced and Reduced Ejection Fraction: A Retrospective, Single-Center, Large-Cohort Study

BACKGROUND

Heart failure (HF) is one of the leading causes of death worldwide. Studies show that women have better survival rates than men despite higher hospitalizations. However, little is known about differences in mortality and predictors of death in women and men with HF with preserved (HFpEF), mildly reduced (HFmrEF), and reduced ejection fraction (HFrEF).

METHODS

From February 2017 to September 2020, mortality and predictors of death were analyzed in women and men with HF. Baseline data included clinical characteristics and echocardiographic findings.

RESULTS

A total of 11,282 patients, 63.9 ± 14.4 years, including 6256 (55.4%) males, were studied. Females were older, had a higher baseline mean left ventricular ejection fraction (LVEF) and lower left ventricular diastolic diameter. During follow-ups, 1375 (22%) men and 925 (18.4%) women died. Cumulative incidence of death was higher in men with HFrEF but similar for HFmrEF and HFpEF. Cox regression for death showed renal dysfunction, stroke, diabetes, atrial fibrillation, age, LVEF, valve disease, MI, and hypertensive CMP as independent death predictors for all HF patients.

CONCLUSIONS

Women had a better prognosis than men in HFrEF and similar mortality for HFmrEF and HFpEF, but sex was not an independent predictor of death for all HF subtypes.

Sex related differences in the characteristics and outcomes of heart failure: A sub analysis of heart failure disease management study

Aims

This is a sub-analysis of a randomized controlled trial on heart failure (HF) disease management (DM) in which patients with HF (N = 1,360; 27.5% women) were assigned randomly to DM (N = 682) or usual care (UC) (N = 678). Study intervention did not significantly affect the rate of hospital admissions or mortality. This study evaluates sex-related differences in baseline characteristics, clinical manifestations, adherence to treatment and outcomes among the study cohort.

Methods

Association between sex and hospital admissions and mortality was tested in multivariable models adjusted for the patients’ baseline characteristics. The primary composite outcome of the study included time to first HF hospitalization or all-cause mortality. Secondary composite outcome included number of hospital admissions and days of hospitalization, for HF and all other causes.

Results

Compared to males, females recruited in the study were on average 3 years older [median age 72 (62, 78) vs. 75 (65, 82), p = 0.001], with higher prevalence of preserved left ventricular function (LVEF ≥50%) and lower frequency of ischemic heart disease (IHD) (p ≤ 0.001). Females had shorter 6-min walking distance and worse quality of life and depression scores at baseline (p &lt; 0.001). The proportion of patients receiving HF recommended medical treatment was similar among females and males. During a median follow-up of 2.7 years (range: 0–5), there were no significant differences between females and males with respect to the time elapsed until the study primary endpoint and its components in univariate analysis [557 (56.5%) males and 218 (58.3%) females were hospitalized for HF or died for any cause; p &gt; 0.05]. Multivariable analysis showed that females were significantly less likely than males to experience the primary outcome [adjusted hazard ratio (HR) = 0.835, 95% CI: 0.699, 0.998] or to die from any cause [adjusted HR = 0.712; 95%CI: 0.560, 0.901]. The sex-related mortality differences were especially significant among patients with non-preserved EF, with IHD or with recent HF hospitalization. Females also had lower rates of all-cause hospital admissions [adjusted rate ratio = 0.798; 95%CI: 0.705, 0.904] and were more likely to adhere to HF medical therapy compared to males.

Conclusion

Females with HF fare better than men. Sex related differences were not explained by baseline and morbidity-related characteristics or adherence to medical treatment.

Sex differences in arterial hypertension

There is strong evidence that sex chromosomes and sex hormones influence blood pressure (BP) regulation, distribution of cardiovascular (CV) risk factors and co-morbidities differentially in females and males with essential arterial hypertension. The risk for CV disease increases at a lower BP level in females than in males, suggesting that sex-specific thresholds for diagnosis of hypertension may be reasonable. However, due to paucity of data, in particularly from specifically designed clinical trials, it is not yet known whether hypertension should be differently managed in females and males, including treatment goals and choice and dosages of antihypertensive drugs. Accordingly, this consensus document was conceived to provide a comprehensive overview of current knowledge on sex differences in essential hypertension including BP development over the life course, development of hypertension, pathophysiologic mechanisms regulating BP, interaction of BP with CV risk factors and co-morbidities, hypertension-mediated organ damage in the heart and the arteries, impact on incident CV disease, and differences in the effect of antihypertensive treatment. The consensus document also highlights areas where focused research is needed to advance sex-specific prevention and management of hypertension.

Old and new equations for maximal heart rate prediction in patients with heart failure and reduced ejection fraction on beta-blockers treatment: results from the MECKI score data set

AIMS

Predicting maximal heart rate (MHR) in heart failure with reduced ejection fraction (HFrEF) still remains a major concern. In such a context, the Keteyian equation is the only one derived in a HFrEF cohort on optimized β-blockers treatment. Therefore, using the Metabolic Exercise combined with Cardiac and Kidney Indexes (MECKI) data set, we looked for a possible MHR equation, for an external validation of Keteyien formula and, contextually, for accuracy of the historical MHR formulas and their relationship with the HR measured at the anaerobic threshold (AT).

METHODS AND RESULTS

Data from 3487 HFrEF outpatients on optimized β-blockers treatment from the MECKI data set were analyzed. Besides excluding all possible confounders, the new equation was derived by using HR data coming from maximal cardiopulmonary exercise test. The simplified derived equation was [109-(0.5*age) + (0.5*HR rest) + (0.2*LVEF)-(5 if haemoglobin <11 g/dL)]. The R2 and the standard error of the estimate were 0.24 and 17.5 beats min-1 with a mean absolute percentage error (MAPE) = 11.9%. The Keteyian equation had a slightly higher MAPE = 12.3%. Conversely, the Fox and Tanaka equations showed extremely higher MAPE values. The range 75-80% of MHR according to the new and the Keteyian equations was the most accurate in identifying the HR at the AT (MAPEs = 11.3-11.6%).

CONCLUSION

The derived equation to estimate the MHR in HFrEF patients, by accounting also for the systolic dysfunction degree and anaemia, improved slightly the Keteyian formula. Both formulas might be helpful in identifying the true maximal effort during an exercise test and the intensity domain during a rehabilitation programme.

Efficacy of Implantable Cardioverter Defibrillator in Nonischemic Systolic Heart Failure According to Sex: Extended Follow-Up Study of the DANISH Trial

BACKGROUND

Men and women may respond differently to certain therapies for heart failure with reduced ejection fraction, including implantable cardioverter defibrillators (ICD). In an extended follow-up study of the DANISH trial (Danish Study to Assess the Efficacy of ICDs in Patients With Non-Ischemic Systolic Heart Failure on Mortality), adding 4 years of additional follow-up, we examined the effect of ICD implantation according to sex.

METHODS

In the DANISH trial, 1116 patients with nonischemic systolic heart failure were randomized to receive an ICD (N=556) or usual clinical care (N=550). The primary outcome was all-cause mortality.

RESULTS

Of the 1116 patients randomized in the DANISH trial, 307 (27.5%) were women. During a median follow-up of 9.5 years, women had a lower associated rate of all-cause mortality (hazard ratio [HR], 0.60 [95% CI, 0.47-0.78]) cardiovascular death (HR, 0.62 [95% CI, 0.46-0.84]), nonsudden cardiovascular death (HR, 0.59 [95% CI, 0.42-0.85]), and a numerically lower rate of sudden cardiovascular death (HR, 0.70 [95% CI, 0.40-1.25]), compared with men. Compared with usual clinical care, ICD implantation did not reduce the rate of all-cause mortality, irrespective of sex (men, HR, 0.85 [95% CI, 0.69-1.06]; women, HR, 0.98 [95% CI, 0.64-1.50]; Pinteraction=0.51). In addition, sex did not modify the effect of ICD implantation on sudden cardiovascular death (men, HR, 0.57 [95% CI, 0.36-0.92]; women, HR, 0.68 [95% CI, 0.26-1.77]; Pinteraction=0.76).

CONCLUSIONS

In patients with nonischemic systolic heart failure, ICD implantation did not provide an overall survival benefit, but reduced sudden cardiovascular death, irrespective of sex.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT00542945.

What have we learned so far from the sex/gender issue in heart failure? An overview of current evidence

There are important differences in epidemiology, pathophysiology, HF patterns, prognosis, and treatment. Women have a higher incidence of HFpEF due to sex-specific factors (such as anthropometry, role of estrogens, pregnancy-related cardiomyopathies), increased incidence of comorbidities, and gender-specific conditions. Men instead present a predisposition to the development of HFrEF due to a higher incidence of coronary artery disease and myocardial infarction. However, there are still gaps in the management of women with HF. The poor inclusion of women in clinical trials may have contributed to a lesser understanding of disease behavior than in men. In addition, a full understanding of gender-specific factors that are studied in small populations is lacking in the literature, and only in recent years, studies have increased their focus on this issue. Understanding how society, family, and environment affect the prognosis of HF patients may help clinicians provide more appropriate levels of care. In this overview, we aimed at summarizing all the key available evidence regarding sex/gender differences in heart failure.

Frontiers and Hotspots Evolution in Psycho-cardiology: A Bibliometric Analysis From 2004 to 2022

In the last 20 years, research on the topic of psycho-cardiology has gradually entered the public eye, with more innovations and applications of evidence-based medical research, biological mechanism research, and guideline consensus in the field of psycho-cardiology. This study uses a bibliometric approach to visualize and analyze the literature within the field of psycho-cardiology over the last 20 years to visualize the development process, research hotspots, and cutting-edge trends in clinical practice, mechanisms, and management strategies related to psycho-cardiology. Quantitative description and evaluation of 409 articles published in the field from 2004-2022 were conducted using CiteSpace and VOSviewer, to provide a theoretical reference for the development of psycho-cardiology.

Gender differences in drug titration among heart failure patients with reduced ejection fraction in the ETIFIC trial

INTRODUCTION AND OBJECTIVES

Optimal medical therapy decreases mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. Women have been underrepresented in clinical trials and not specifically evaluated. This study aimed to compare the safety and effectiveness of drug titration in women vs men.

METHODS

This post hoc gender study of the ETIFIC multicenter randomized trial included hospitalized patients with new-onset HF with reduced ejection fraction and New York Heart Association II-III and no contraindications to beta-blockers. A structured 4-month titration process was implemented in HF clinics. The primary endpoint was the mean relative dose (% of target dose) of beta-blockers achieved by women vs men. Secondary endpoints included the mean relative doses of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists, adverse events, and other clinical outcomes at 6 months.

RESULTS

A total of 320 patients were included, 83 (25.93%) women and 237 (74.06%) men (76 vs 213 analyzed). The mean±standard deviation of the relative doses achieved by women vs men were as follows: beta-blockers 62.08%±30.72% vs 64.4%±32.77%, with a difference of-2.32% (95%CI,-10.58-5.94), P = .580; and mineralocorticoid receptor antagonists 79.85%±27.72% vs 67.29%±31.43%, P =.003. No other differences in drug dosage were found. Multivariate analysis showed nonsignificant differences. CV mortality was 1 (1.20%) vs 3 (1.26%), P=1, and HF hospitalizations 0 (0.00%) vs 10 (4.22%), P=.125.

CONCLUSIONS

In a post hoc analysis from the HF-titration ETIFIC trial, we found nonsignificant gender differences in drug dosage, cardiovascular mortality, and HF hospitalizations. Trial registry number: NCT02546856.

Building from Patient Experiences to Deliver Patient-Focused Healthcare Systems in Collaboration with Patients: A Call to Action

Patients’ experiences of their diagnosis, condition, and treatment (including the impact on their lives), and their experiences surrounding expectations of care, are becoming increasingly important in shaping healthcare systems that meet the evolving needs and priorities of different patient communities over time; this is an ongoing goal of all healthcare stakeholders. Current approaches that capture patient experiences with data are fragmented, resulting in duplication of effort, numerous requests for information, and increased patient burden. Application of patient experience data to inform healthcare decisions is still emerging and there remains an opportunity to align diverse stakeholders on the value of these data to strengthen healthcare systems. Given the collective value of understanding patient experiences across multiple stakeholder groups, we propose a more aligned approach to the collection of patient experience data. This approach is built on the principle that the patients’ experiences are the starting point, and not just something to be considered at the end of the process. It must also be based on meaningful patient engagement, where patients are collaborators and decision makers at each step, thereby ensuring their needs and priorities are accurately reflected. The resulting data and evidence should be made available for all stakeholders, to inform their decision making and healthcare strategies in ways that meet patient priorities. We call for multi-stakeholder collaboration that will deliver healthcare systems and interventions that are better centered around and tailored to patient experiences, and that will help address patients’ unmet needs.

A prospective study on sex differences in functional capacity, quality of life and prognosis in patients with heart failure

BACKGROUND

Due to the lack of evidence and inconsistency of sex differences in Heart failure (HF) in the Chinese population, this study aimed to compare sex differences in functional capacity and quality of life (QoL) between women and men after standard HF medications therapies, and analyze whether sex differences were associated with the composite endpoints of all-cause mortality or HF-related hospitalization and cardiac event-free survival rate in Chinese patients with HF.

METHODS

This was a 1-year longitudinal study. Participants included patients with HF from March 2017 to December 2018. At baseline and followed up at 1, 6, and 12 months later, functional capacity was assessed by 6-minute walk testing (6MWT), QoL was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQoL five dimensions (EQ-5D). The Cox proportional hazards model and Kaplan-Meier curves were used to determine sex differences in subsequent outcomes. The Cox proportional hazards model was used to identify the risk factors for composite endpoints. Kaplan-Meier curves were used to compare survival.

RESULTS

All patients were assigned to either men group (n = 94) or women group (n = 60). Longitudinal follow-ups showed a continuously increasing in 6MWT, Kansas City Cardiomyopathy Questionnaire overall score, EQ-5D visual analogue scale, and EQ-5D Index score in both groups (all P < 0.001); however, women reported a lower level of all parameters at the 1, 6, and 12 months follow-ups (all P < 0.05). In addition, women had a higher risk of all-cause mortality or HF-related hospitalization and a lower cardiac event-free survival rate than men (log-rank test, P = 0.027).

CONCLUSION

Women reported worse functional capacity, QoL, and prognosis than men in a sample of Chinese patients with HF. Our findings highlight the importance of paying attention to sex differences in HF.

Non-invasive Imaging in Women With Heart Failure - Diagnosis and Insights Into Disease Mechanisms

PURPOSE OF REVIEW

To summarise the role of different imaging techniques for diagnosis and investigation of heart failure in women.

RECENT FINDINGS

Although sex differences in heart failure are well recognised, and the scope of imaging techniques is expanding, there are currently no specific guidelines for imaging of heart failure in women. Diagnosis and stratification of heart failure is generally performed first line using transthoracic echocardiography. Understanding the aetiology of heart failure is central to ongoing management, and with non-ischaemic causes more common in women, a multimodality approach is generally required using advanced imaging techniques including cardiovascular magnetic resonance imaging, nuclear imaging techniques, and cardiac computed tomography. There are specific considerations for imaging in women including radiation risks and challenges during pregnancy, highlighting the clear unmet need for cardiology and imaging societies to provide imaging guidelines specifically for women with heart failure.

Evaluation of the Interaction of Sex Hormones and Cardiovascular Function and Health

Purpose of Review

Sex hormones drive development and function of reproductive organs or the development of secondary sex characteristics but their effects on the cardiovascular system are poorly understood. In this review, we identify the gaps in our understanding of the interaction between sex hormones and the cardiovascular system.

Recent Findings

Studies are progressively elucidating molecular functions of sex hormones in specific cell types in parallel with the initiation of crucial large randomized controlled trials aimed at improving therapies for cardiovascular diseases (CVDs) associated with aberrant levels of sex hormones.

Summary

In contrast with historical assumptions, we now understand that men and women show different symptoms and progression of CVDs. Abnormal levels of sex hormones pose an independent risk for CVD, which is apparent in conditions like Klinefelter syndrome, androgen insensitivity syndrome, and menopause. Moreover, sex hormone–based therapies remain understudied and may not be beneficial for cardiovascular health.

Circulating levels and prognostic cut-offs of sST2, hs-cTnT, and NT-proBNP in women vs. men with chronic heart failure

Aims

To define plasma concentrations, determinants, and optimal prognostic cut‐offs of soluble suppression of tumorigenesis‐2 (sST2), high‐sensitivity cardiac troponin T (hs‐cTnT), and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in women and men with chronic heart failure (HF).

Methods and results

Individual data of patients from the Biomarkers In Heart Failure Outpatient Study (BIOS) Consortium with sST2, hs‐cTnT, and NT‐proBNP measured were analysed. The primary endpoint was a composite of 1 year cardiovascular death and HF hospitalization. The secondary endpoints were 5 year cardiovascular and all‐cause death. The cohort included 4540 patients (age 67 ± 12 years, left ventricular ejection fraction 33 ± 13%, 1111 women, 25%). Women showed lower sST2 (24 vs. 27 ng/mL, P < 0.001) and hs‐cTnT level (15 vs. 20 ng/L, P < 0.001), and similar concentrations of NT‐proBNP (1540 vs. 1505 ng/L, P = 0.408). Although the three biomarkers were confirmed as independent predictors of outcome in both sexes, the optimal prognostic cut‐off was lower in women for sST2 (28 vs. 31 ng/mL) and hs‐cTnT (22 vs. 25 ng/L), while NT‐proBNP cut‐off was higher in women (2339 ng/L vs. 2145 ng/L). The use of sex‐specific cut‐offs improved risk prediction compared with the use of previously standardized prognostic cut‐offs and allowed to reclassify the risk of many patients, to a greater extent in women than men, and for hs‐cTnT than sST2 or NT‐proBNP. Specifically, up to 18% men and up to 57% women were reclassified, by using the sex‐specific cut‐off of hs‐cTnT for the endpoint of 5 year cardiovascular death.

Conclusions

In patients with chronic HF, concentrations of sST2 and hs‐cTnT, but not of NT‐proBNP, are lower in women. Lower sST2 and hs‐cTnT and higher NT‐proBNP cut‐offs for risk stratification could be used in women.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Baseline characteristics of 547 new onset heart failure patients in the PREFERS heart failure study

Aim

Methods and results

Conclusions

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Sex Differences in Therapies for Heart Failure

Heart failure (HF) is a common cause of morbimortality with different etiopathogenesis and prognosis between men and women. This review provides a brief overview of gender-based differences in response to pharmacological therapies of heart failure with or without reduced ejection fraction (EF). It focuses on the differences in therapy outcomes with angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), angiotensin neprilysin inhibitors (ARNI), beta-adrenergic blockers, mineralocorticoid/aldosterone receptor antagonists, diuretics, ivabradine and digoxin. The baseline data originates from randomised controlled trials (RCTs) and large registries. We conclude that current guidelines recommending similar therapeutic approaches for both men and women are appropriate, while additional consideration should be given for different approaches regarding the use of ARBs, ACEi, and digoxin. Based on the available data, the ARBs might be considered a first-line therapy of HR for women instead of ACEi. Moreover, female patients should have stricter digoxin monitoring due to higher sensitivity and increased risk of complications. Finally, women are underrepresented in current clinical trials, and therefore future trials should aim to balance the gender recruitment disparity allowing sub-group analysis and comparisons between genders to guide individualised therapeutic strategies and appropriately targeted preventative steps.

Heart-brain interactions in cardiac and brain diseases: why sex matters

Cardiovascular disease and brain disorders, such as depression and cognitive dysfunction, are highly prevalent conditions and are among the leading causes limiting patient's quality of life. A growing body of evidence has shown an intimate crosstalk between the heart and the brain, resulting from a complex network of several physiological and neurohumoral circuits. From a pathophysiological perspective, both organs share common risk factors, such as hypertension, diabetes, smoking or dyslipidaemia, and are similarly affected by systemic inflammation, atherosclerosis, and dysfunction of the neuroendocrine system. In addition, there is an increasing awareness that physiological interactions between the two organs play important roles in potentiating disease and that sex- and gender-related differences modify those interactions between the heart and the brain over the entire lifespan. The present review summarizes contemporary evidence of the effect of sex on heart-brain interactions and how these influence pathogenesis, clinical manifestation, and treatment responses of specific heart and brain diseases.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Heart Failure Subtypes and Cardiomyopathies in Women

Heart failure affects over 2.6 million women and 3.4 million men in the United States with known sex differences in epidemiology, management, response to treatment, and outcomes across a wide spectrum of cardiomyopathies that include peripartum cardiomyopathy, hypertrophic cardiomyopathy, stress cardiomyopathy, cardiac amyloidosis, and sarcoidosis. Some of these sex-specific considerations are driven by the cellular effects of sex hormones on the renin-angiotensin-aldosterone system, endothelial response to injury, vascular aging, and left ventricular remodeling. Other sex differences are perpetuated by implicit bias leading to undertreatment and underrepresentation in clinical trials. The goal of this narrative review is to comprehensively examine the existing literature over the last decade regarding sex differences in various heart failure syndromes from pathophysiological insights to clinical practice.

Background and Design of the Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure (BIOMES-HF) Study

BACKGROUND

Symptoms, which often cluster together, are a significant problem in heart failure (HF). There is considerable heterogeneity in symptom burden, particularly in the vulnerable transition period after a hospitalization for HF, and the biological underpinnings of symptom during transitions are unclear. The purpose of this paper is to describe the background and design of a study that addresses these knowledge gaps, entitled "Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure" (BIOMES-HF).

STUDY DESIGN AND METHODS

BIOMES-HF is a prospective gender- and age-balanced longitudinal study of 240 adults during the 6-month transition period after a HF hospitalization. The aims are to: 1) identify clusters of change in physical symptoms, 2) quantify longitudinal associations between biomarkers and physical symptoms, and 3) quantify longitudinal associations between physical frailty and physical symptoms among adults with heart failure. We will measure multiple symptoms, biomarkers, and physical frailty at discharge and then at 1 week and 1, 3, and 6 months post-hospitalization. We will use growth mixture modeling and longitudinal mediation modeling to examine changes in symptoms, biomarkers, and physical frailty post-HF hospitalization and associations therein.

CONCLUSIONS

This innovative study will advance HF symptom science by utilizing a multi-biomarker panel and the physical frailty phenotype to capture the multifaceted nature of HF. Using advanced quantitative modeling, we will characterize heterogeneity and identify potential mechanisms of symptoms in HF. As a result, this research will pinpoint amenable targets for intervention to provide better, individualized treatment to improve symptom burden in HF.

BRIEF LAY SUMMARY

Adults with heart failure may have significant symptom burden. This study is designed to shed light on our understanding of the role of biological and physiological mechanisms in explaining heart failure symptoms, particularly groups of co-occurring symptoms, over time. We will explore how symptoms, biomarkers, and physical frailty changes after a heart failure hospitalization. The knowledge generated from this study will be used to guide the management and self-care for adults with heart failure.

Primary Disease, Sex, and Racial Differences in Health-Related Quality of Life in Adolescents and Young Adults with Heart Failure

Health-related quality of life (HRQOL) is an important clinical and research trial endpoint in adult heart failure and has been shown to predict mortality and hospitalizations in adult heart failure populations. HRQOL has not been adequately studied in the growing pediatric and young adult heart failure population. This study described HRQOL in adolescents and young adults (AYAs) with heart failure and examined primary disease, sex, race, and other correlates of HRQOL in this sample. Participants in this cross-sectional, single-center study included adolescent and young adults with heart failure and a parent/guardian. Patients and their parent/proxies completed the PedsQL, a well-established measure of HRQOL in pediatric chronic illness populations. HRQOL is impaired in AYAs with heart failure resulting from dilated, hypertrophic, or other cardiomyopathy, congenital heart disease, or post-transplant with rejection/complications. Patients identifying as white endorsed poorer total HRQOL than non-white patients (p = 0.002). Subscale analysis revealed significant correlations between female sex (p = 0.01) and white race (p = 0.01) with poorer self-reported physical functioning. Family income was unrelated to HRQOL. Functional status was strongly associated with total (p = 0.0003) and physical HRQOL (p < 0.0001). Sociodemographic and disease-specific risk and resilience factors specific to HRQOL in AYAs with heart failure include primary cardiac disease, race, sex, and functional status. Building upon extensive work in adult heart failure, utilization, and study of HRQOL as a clinical and research trial outcome is necessary in pediatric heart failure. Developing targeted interventions for those at greatest risk of impaired HRQOL is an important next step.

Sex-Related Differences in Mortality Following Admission for Acute Heart Failure Across the Left Ventricular Ejection Fraction Spectrum

Background

Following a heart failure (HF)‐decompensation, there is scarce data about sex‐related prognostic differences across left ventricular ejection fraction (LVEF) status. We sought to evaluate sex‐related differences in 6‐month mortality risk across LVEF following admission for acute HF.

Methods and Results

We retrospectively evaluated 4812 patients consecutively admitted for acute HF in a multicenter registry from 3 hospitals. Study end points were all‐cause, cardiovascular, and HF‐related mortality at 6‐month follow‐up. Multivariable Cox regression models were fitted to investigate sex‐related differences across LVEF. A total of 2243 (46.6%) patients were women, 2569 (53.4%) were men, and 2608 (54.2%) showed LVEF≥50%. At 6‐month follow‐up, 645 patients died (13.4%), being 544 (11.3%) and 416 (8.6%) cardiovascular and HF‐related deaths, respectively. LVEF was not independently associated with mortality (HR, 1.02; 95% CI 0.99–1.05; P=0.135). After multivariable adjustment, we found no sex‐related differences in all‐cause mortality (P value for interaction=0.168). However, a significant interaction between sex and cardiovascular and HF mortality risks was found across LVEF (P value for interaction=0.030 and 0.007, respectively). Compared with men, women had a significantly lower risk of cardiovascular and HF‐mortality at LVEF<25% and <43%, respectively. On the contrary, women showed a higher risk of HF‐mortality at the upper extreme of LVEF (>80%).

Conclusions

Following an admission for acute HF, no sex‐related differences were found in all‐cause mortality risk. However, when compared with men, women showed a lower risk of cardiovascular and HF‐mortality at the lower extreme of LVEF. On the contrary, they showed a higher risk of HF death at the upper extreme.

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.

Extrahepatic causes of death in cirrhosis compared to other chronic conditions in the United States, 1999-2017

INTRODUCTION AND OBJECTIVES

Cirrhosis-related mortality is underestimated and is increasing; extrahepatic factors may contribute. We examined trends in cirrhosis mortality from 1999-2017 in the United States attributed to liver-related (varices, peritonitis, hepatorenal syndrome, hepatic encephalopathy, hepatocellular carcinoma, sepsis) or extrahepatic (cardiovascular disease, influenza and pneumonia, diabetes, malignancy) causes, and compared mortality trends with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) populations.

MATERIALS AND METHODS

A national mortality database was used. Changes in age-standardized mortality over time were determined by joinpoint analysis. Average annual percentage change (AAPC) was estimated.

RESULTS

Cirrhosis cohort: From 1999-2017, both liver-related (AAPC 1.3%; 95% confidence interval [CI] 0.7-1.9) and extrahepatic mortality (AAPC 1.0%; 95% CI 0.7-1.2) increased. Cirrhosis vs other chronic disease cohorts: changes in all-cause mortality were higher in cirrhosis (AAPC 1.0%; 95% CI 0.7-1.4) than CHF (AAPC 0.1%; 95% CI -0.5- 0.8) or COPD (AAPC -0.4%; 95% CI -0.6- -0.2). Sepsis mortality was highest in cirrhosis (AAPC 3.6%, 95% 3.2- 4.1) compared to CHF (AAPC 0.6%, 95% CI -0.5- 1.7) or COPD (AAPC 0.8%, 95% CI 0.5- 1.2). Cardiovascular mortality increased in cirrhosis (AAPC 1.3%, 95% CI 1.1- 1.5), declined in CHF (AAPC -2.0%, 95% CI -5.3- 1.3) and remained unchanged in COPD (AAPC 0.1%, 95% CI -0.2- 0.4). Extrahepatic mortality was higher among women, rural populations, and individuals >65 years with cirrhosis.

CONCLUSIONS

Extrahepatic causes of death are important drivers of mortality and differentially impact cirrhosis compared to other chronic diseases.

The Impact of Clinical, Biochemical, and Echocardiographic Parameters on the Quality of Life in Patients with Heart Failure with Reduced Ejection Fraction

Despite significant advances in HF diagnosis and treatment over the recent decades, patients still characterize poor long-term prognosis with many recurrent hospitalizations and reduced health-related quality of life (HRQoL). We aimed to check the potential relationship between clinical, biochemical, or echocardiographic parameters and HRQoL in patients with HF with reduced ejection fraction (HFrEF). We included 152 adult patients hospitalized due to chronic HFrEF. We used the WHOQoL-BREF questionnaire to assess HRQoL and GNRI to evaluate nutritional status. We also analyzed several biochemical parameters and left ventricle ejection fraction. Forty (26.3%) patients were hospitalized due to HF exacerbation and 112 (73.7%) due to planned HF evaluation. The median age was 57 (48–62) years. Patients with low somatic HRQoL score had lower transferrin saturation (23.7 ± 11.1 vs. 29.7 ± 12.5%; p = 0.01), LDL (2.40 (1.80–2.92) vs. 2.99 (2.38–3.60) mmol/L; p = 0.001), triglycerides (1.18 (0.91–1.57) vs. 1.48 (1.27–2.13) mmol/L; p = 0.006) and LVEF (20 (15–25) vs. 25 (20–30)%; p = 0.003). TIBC (64.9 (58.5–68.2) vs. 57.7 (52.7–68.6); p = 0.02) was significantly higher in this group. We observed no associations between HRQoL and age or gender. The somatic domain of WHOQoL-BREF in patients with HFrEF correlated with the clinical status as well as biochemical and echocardiographic parameters. Assessment of HRQoL in HFrEF seems important in everyday practice and can identify patients requiring a special intervention

Sex disparities in the current era of pediatric heart transplantation in the United States

BACKGROUND

While sex-related differences in transplant outcomes have been well characterized amongst adults, there are no sex-specific pediatric heart transplant studies over the last decade and none evaluating waitlist outcomes. In a contemporary cohort of children undergoing heart transplantation in the United States, this analysis was performed to determine if there were sex disparities in waitlist and/or post-transplant outcomes.

METHODS

Retrospective review of Scientific Registry of Transplant Recipients database from December 16, 2011 to February 28, 2019 to compare male and female children after listing and after transplant. Demographic, clinical characteristics and outcomes were compared unadjusted and after 1:1 propensity matching for selected covariates.

RESULTS

Of 4089 patients, 2299 (56%) were males. At listing, males were more likely to be older, have congenital heart disease (58% vs 48%), renal dysfunction (49% vs 44%) and implantable cardioverter defibrillator (9% vs 7%). At transplant, males were more likely to have renal (42 % vs 35%) and liver dysfunction (13% vs 10%), PRA >10% (29% vs 22%) and ischemic time >3.5 hours (p < 0.05 for all). There were no significant sex differences found in unadjusted rates of transplant or mortality. After propensity matching, females had increased waitlist mortality (HR 1.3, 95%CI 1.04-1.5; p =0.019) compared to males. There were no significant differences in post-transplant morbidity or mortality (HR 1.2, 95% CI 0.93-1.5; p = 0.18) between groups.

CONCLUSION

In a contemporary pediatric cohort, females have inferior heart transplant waitlist survival compared to propensity-matched males despite lower acuity of illness at listing and similar rates of transplantation. There were no sex-disparities noted in post-transplant outcomes.

Presentation, Management, and In-Hospital Outcomes of Patients with Acute Heart Failure in South India by Sex: A Secondary Analysis of a Prospective, Interrupted Time Series Study

Background

Sex differences in presentation, management, and outcomes of heart failure (HF) have been observed, but it is uncertain whether these differences exist in South India.

Objective

We describe sex differences in presentation, management, and in-hospital outcomes in patients hospitalized with HF in South India and explore sex-based differences in the effect of the quality improvement intervention in a secondary analysis of a prospective, interrupted time series study.

Methods

The Heart Failure Quality Improvement in Kerala (HF QUIK) study evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized with HF in eight hospitals in Kerala using an interrupted time series design from February 2018 to August 2018. The primary outcome was guideline-directed medical therapy (GDMT) at hospital discharge for patients with HF with reduced ejection fraction (HFrEF). We performed sex-stratified analyses using mixed effect logistic regression models.

Results

Among 1,400 patients, 536 (38.3%) were female. Female patients were older (69.6 vs. 65 years, p < 0.001), were less likely to have an ischemic etiology of HF (control period: 78.2% vs. 87.5%; intervention period: 83.6% vs. 91.5%; p < 0.05 for both) and were less likely to undergo coronary angiography or percutaneous coronary intervention. The quality improvement intervention had similar effects on the odds of GDMT at discharge in females with HFrEF (adjusted OR 1.79, 95% CI 0.92, 3.47) and males with HFrEF (adjusted OR 1.68, 95% CI 1.07, 2.64, pinteraction = 0.69).

Conclusions

We observed sex-specific differences in presentation and procedural management of patients with HF but no differences in the effect of the quality improvement intervention on discharge GDMT rates. Both male and female patients with HFrEF remained undertreated in the study intervention period, demonstrating the need for implementation strategies to close the HFrEF treatment gap in South India.

[Study of the factors contributing to poor quality of life in chronic heart failure with reduced ejection fraction]

BACKGROUND

The increasing prevalence and poor prognosis associated with chronic heart failure (CHF) have made the improvement of quality of life (QoL) one of the main goals in the treatment of CHF patients. Since little is known about the QoL in Tunisian patients with heart failure (HF), the current study was performed to assess QoL in a sample of Tunisian patients hospitalized with HF and to identify factors related to QoL.

METHODS

In this prospective study, we evaluated patients with CHF attending the cardiology department of Habib Thameur University Hospital in a four-month period. Echocardiography was performed and patients with left ventricular ejection fraction of 45% or less were selected. QoL assessment was performed with a disease-specific instrument: the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in a sample of 100 selected patients. Relationships between health-related QoL and the studied variables were examined with bivariate correlations and binary logistic regression analysis.

RESULTS

In the total sample (n = 100), mean age was 62.7 years. The majority were male (77%), married (76%), with a mean of 2.5 comorbidities, and in a New York Heart Association (NYHA) functional class III to IV (61%). Mean LVEF was 36%. Half of the patients had poor QoL on the total MLHFQ scale (median = 41.5) as well as on its physical (median = 17.5) and emotional (median = 11.25) domains. In univariate analysis, the following variables were related to poor QoL with p < 0.005: not being employed, suffering from hypertension, renal failure, anemia, being under a low-salt diet, having no regular physical activity, having the physical symptoms of HF, higher NYHA class and longer QRS duration. In multiple regression analysis, the main independent predictors of poor QoL on the total scale were higher NYHA functional class and renal dysfunction,. The data provided no evidence of an association between LVEF and QoL.

CONCLUSION

This study has found that higher NHYA functional class and chronic kidney disease are risk factors for impaired QoL, independently of disease severity among patients with heart failure.

Gender differences in characteristics and outcomes in heart failure patients referred for end-stage treatment

Aims

Despite signals from clinical trials and mechanistic studies implying different resilience to heart failure (HF) depending on gender, the impact of gender on presentation and outcomes in patients with HF remains unclear. This study assessed the impact of gender on clinical presentation and outcomes in patients with HF referred to a specialised tertiary HF service.

Methods and results

Consecutive patients with HF referred to a specialised tertiary HF service offering advanced therapy options including left ventricular assist devices (LVAD) and heart transplantation were prospectively enrolled from August 2015 until March 2018. We assessed clinical characteristics at baseline and performed survival analyses and age‐adjusted Cox regression analyses in men vs. women for all‐cause death and a combined disease‐related endpoint comprising death, heart transplantation, and LVAD implantation. Analyses were performed for the overall study population and for patients with HF with reduced ejection fraction (HFrEF). Of 356 patients included, 283 (79.5%) were male. The median age was 58 years (interquartile range 50–67). Two hundred and fifty‐one (74.5%) patients had HFrEF. HF aetiology, ejection fraction, functional status measures, and most of the cardiac and non‐cardiac comorbidities did not differ between men and women. In a median follow‐up of 3.2 years, 50 patients died (45 men, 5 women), 15 patients underwent LVAD implantation, and 8 patients heart transplantation. While all‐cause death was not significantly different between both genders in the overall population [16.9 vs. 6.0%, P = 0.065, hazard ratio (HR) 2.29 (95% confidence interval 0.91–5.78), P = 0.078], in the HFrEF subgroup, a significant difference between men and women was observed [20.7% vs. 3.9%, P = 0.017, HR 3.67 (95% confidence interval 1.13–11.91), P = 0.031]. The combined endpoint was more often reached in men than in women in both the overall population [21.6% vs. 9.0%, P = 0.053, HR 2.51 (1.08–5.82), P = 0.032] and the HFrEF subgroup [27.1% vs. 7.7%, P = 0.015, HR 3.58 (1.29–9.94), P = 0.014].

Conclusions

Patients referred to a specialised tertiary HF service showed a similar clinical profile without relevant gender differences. In the mid‐term follow‐up, more male than female patients died or underwent heart transplantation and LVAD implantation. These findings call for independent validation and for further research into gender‐specific drivers of HF progression.

Psychometric Evaluation of the Kansas City Cardiomyopathy Questionnaire in Men and Women With Heart Failure

BACKGROUND

The Kansas City Cardiomyopathy Questionnaire (KCCQ) has been psychometrically evaluated in multiple heart failure (HF) populations, but the comparability of its psychometric properties between men and women is unknown.

METHODS

Data from 3 clinical trials (1 in stable HF with preserved ejection fraction, 1 each in stable and acute HF with reduced ejection fraction) and 1 prospective cohort study (stable HF with reduced ejection fraction), incorporating 6773 men and 3612 women with HF, were used to compare the construct validity, internal and test-retest reliability, ability to detect change, predict mortality and hospitalizations and minimally important differences between the 2 sexes. Interactions of the KCCQ overall summary and subdomain scores by sex were independently examined.

RESULTS

The KCCQ-Overall Summary score correlated well with New York Heart Association functional class in both sexes across patients with stable (correlation coefficient: -0.40 in men versus -0.49 in women) and acute (-0.37 in men versus -0.34 in women) HF. All KCCQ subdomains demonstrated concordant relationships with relevant comparison standards with no significant interactions by sex in 19 of 21 of these construct validity analyses. All KCCQ scores were equally predictive and other psychometric evaluations showed similar results by sex: test-retest reliability (intraclass correlation coefficient 0.94 in men versus 0.92 in women), responsive to change (standardized response mean 1.01 in both sexes), as were the minimally important differences and internal reliability.

CONCLUSIONS

The psychometric properties of the KCCQ, in terms of validity, prognosis, reliability, and sensitivity to change, are comparable in men and women with HF with preserved ejection fraction and HF with reduced ejection fraction.

Sex-Specific Outcomes of Transcatheter Mitral-Valve Repair and Medical Therapy for Mitral Regurgitation in Heart Failure

OBJECTIVES

This study sought to assess the sex-specific outcomes in patients with heart failure (HF) with 3+ and 4+ secondary mitral regurgitation (SMR) treated with transcatheter mitral valve repair (TMVr) plus guideline-directed medical therapy (GDMT) versus GDMT alone in the COAPT trial.

BACKGROUND

The impact of sex in patients with HF and severe SMR treated with TMVr with the MitraClip compared with GDMT alone is unknown.

METHODS

Patients were randomized 1:1 to TMVr versus GDMT alone. Two-year outcomes were examined according to sex.

RESULTS

Among 614 patients, 221 (36.0%) were women. Women were younger than men and had fewer comorbidities, but reduced quality of life and functional capacity at baseline. In a joint frailty model accounting for the competing risk of death, the 2-year cumulative incidence of the primary endpoint of all HF hospitalizations (HFH) was higher in men compared with women treated with GDMT alone. However, the relative reduction in HFHs with TMVr was greater in men (HR: 0.43; 95% CI: 0.34-0.54) than women (HR: 0.78; 95% CI: 0.57-1.05) (P_interaction = 0.002). A significant interaction between TMVr versus GDMT alone treatment and time was present for all HFHs in women (HR: 0.57; 95% CI: 0.39-0.84, and HR: 1.39; 95% CI: 0.83-2.33 between 0-1 year and 1-2 years after randomization, respectively, P_interaction = 0.007) but not in men (HR: 0.48; 95% CI: 0.36-0.64, and HR: 0.33; 95% CI: 0.21-0.51; P_interaction = 0.16). Female sex was independently associated with a lower adjusted risk of death at 2 years (HR: 0.64; 95% CI: 0.46-0.90; P = 0.011). TMVr consistently reduced 2-year mortality compared with GDMT alone, irrespective of sex (P_interaction = 0.99).

CONCLUSIONS

In the COAPT trial, TMVr with the MitraClip resulted in improved clinical outcomes compared with GDMT alone, irrespective of sex. However, the impact of TMVr in reducing HFH was less pronounced in women compared with men beyond the first year after treatment. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Tria] [COAPT]; NCT01626079).

Systolic blood pressure at admission and long-term clinical outcomes in patients hospitalized for heart failure

Aims

The study sought to investigate the association between admission systolic blood pressure (SBP) and 1‐year clinical outcomes in patients hospitalized for heart failure (HF) and in subgroups.

Methods

This study was based on the China Patient‐centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study, which prospectively enrolled patients hospitalized for HF in 52 hospitals from 20 provinces in China between August 2016 and May 2018. Patients were divided into four groups according to the quartiles of SBP at admission. The multivariable Cox proportional hazards regression models were fitted to examine the association between admission SBP and all‐cause death and HF readmission within 1 year after the index hospitalization. Restricted cubic splines were used to explore the non‐linear association between SBP and the clinical outcomes.

Results

Among 4896 patients, those with lower admission SBP were younger, more likely to be male, have left ventricular ejection fraction <40%, and receive β‐blockers, aldosterone antagonists, and diuretics. After adjustment for potential confounders, lower admission SBP was significantly associated with higher all‐cause death and there is no threshold, while we only observed such an association with HF readmission when admission SBP was lower than 120 mmHg. Compared with the 4th SBP quartile, patients in the 1st SBP quartile had higher risk of all‐cause death (hazard ratio, 1.85; 95% confidence interval 1.48–2.33; P < 0.001) and HF readmission (hazard ratio, 1.40; 95% confidence interval 1.19–1.65, P < 0.001). These associations were consistent in most subgroups, such as age, sex, and left ventricular ejection fraction.

Conclusions

In patients hospitalized for HF, lower admission SBP portends an increased risk of 1 year all‐cause death and HF readmission, and these associations were consistent among subgroups.

Effect of patient-centered transitional care services on patient-reported outcomes in heart failure: sex-specific analysis of the PACT-HF randomized controlled trial

AIMS

We assessed the effect of transitional care on patient-reported outcomes (PROs) in women and men hospitalized for heart failure.

METHODS AND RESULTS

In this sex-specific analysis of a stepped wedge cluster randomized trial in Canada, the effect of a patient-centered transitional care model was tested on pre-specified PROs of discharge preparedness (B-PREPARED score, range 0-22), quality of transition [Care Transitions Measure-3 (CTM-3) score, range 0-100], and health-related quality of life (HRQOL) (EQ-5D-5L, range 0-1). Among 986 patients (47.4% women), B-PREPARED at 6 weeks was greater with the intervention than usual care [mean difference (MD) 4.01 (95% confidence interval-CI 2.90-5.12); P < 0.001], with no sex differences (P sex-interaction = 0.24). CTM-3 at 6 weeks was greater with the intervention than usual care [MD 10.52 (95% CI 6.00-15.04); P < 0.001], with no sex differences (P sex-interaction = 0.69). EQ-5D-5L was greater with intervention than usual care at discharge [MD 0.17 (95% CI 0.12-0.22); P < 0.001], 6 weeks [MD 0.06 (95% CI 0.01-0.12); P = 0.02], and 6 months [MD 0.05 (95% CI -0.01 to 0.12); P = 0.09], although the 6-month difference was not statistically significant. At discharge, women reported lower EQ-5D-5L but experienced significantly greater treatment benefit than men (P sex-interaction = 0.02). Treatment effect on EQ-5D-5L was numerically greater in women than men at 6 weeks and 6 months, but there were no significant sex differences (P sex-interaction 0.18 and 0.19, respectively).

CONCLUSION

A patient-centered transitional care model improved discharge preparedness, transition quality, and HRQOL in the weeks following heart failure hospitalization, with effects largely consistent in women and men. However, women reported lower HRQOL and experienced greater treatment benefit in this endpoint than men at hospital discharge.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02112227.

Guideline-Directed Medical Therapy in Females with Heart Failure with Reduced Ejection Fraction

PURPOSE OF REVIEW

This narrative review synthesizes sex differences in guideline-directed medical therapy (GDMT) use and response among female patients with heart failure with reduced ejection fraction (HFrEF), discusses female representation in HFrEF clinical trials, and outlines future areas of investigation to reduce sex disparities in HFrEF care globally.

RECENT FINDINGS

Observational registries suggest sex-specific disparities persist in GDMT rates, and there may be key sex-specific differences in optimal dosing of GDMT in HFrEF patients. Underrepresentation of female patients in HF clinical trials is a key barrier, and sex disparities in HF clinical trial leadership may influence sex-specific knowledge generation of medical management of HFrEF patients. There are important sex-specific differences in GDMT use and response among female HFrEF patients that warrant further study. Increasing female representation in HFrEF clinical trials, diversifying HF trial leadership, and embedding sex-specific approaches in the lifecycle of research from conception to reporting are essential to decreasing sex disparities in clinical care of all HFrEF patients.

Exploring gender differences in trajectories of clinical markers and symptoms after left ventricular assist device implantation

AIMS

Despite well-known gender differences in heart failure, it is unknown if clinical markers and symptoms differ between women and men after left ventricular assist device (LVAD) implantation. Our aim was to examine gender differences in trajectories of clinical markers (echocardiographic markers and plasma biomarkers) and symptoms from pre- to post-LVAD implantation.

METHODS AND RESULTS

This was a secondary analysis of data collected from a study of patients from pre- to 1, 3, and 6 months post-LVAD implantation. Data were collected on left ventricular internal end-diastolic diameter (LVIDd) and ejection fraction (LVEF), plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP), and soluble suppressor of tumorigenicity (sST2). Physical and depressive symptoms were measured using the Heart Failure Somatic Perception Scale and Patient Health Questionnaire-9, respectively. Latent growth curve modelling was used to compare trajectories between women and men. The average age of the sample (n = 98) was 53.3 ± 13.8 years, and most were male (80.6%) and had non-ischaemic aetiology (65.3%). Pre-implantation, women had significantly narrower LVIDd (P < 0.001) and worse physical symptoms (P = 0.041) compared with men. Between pre- and 6 months post-implantation, women had an increase in plasma sST2 followed by a decrease, whereas men had an overall decrease (slope: P = 0.014; quadratic: P = 0.011). Between 1 and 6 months post-implantation, women had a significantly greater increase in LVEF (P = 0.045) but lesser decline in plasmoa NT-proBNP compared with men (P = 0.025).

CONCLUSION

Trajectories of clinical markers differed somewhat between women and men, but trajectories of symptoms were similar, indicating some physiologic but not symptomatic gender differences in response to LVAD.

Efficacy and Safety of Dapagliflozin in Men and Women With Heart Failure With Reduced Ejection Fraction: A Prespecified Analysis of the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure Trial

Importance

Women may respond differently to certain treatments for heart failure (HF) with reduced ejection fraction (HFrEF) than men.

Objective

To investigate the efficacy and safety of dapagliflozin compared with placebo in men and women with HFrEF enrolled in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF).

Design, Setting, and Participants

Prespecified subgroup analysis of a phase 3 randomized clinical trial conducted at 410 sites in 20 countries. Patients with New York Heart Association functional class II through IV with an ejection fraction of 40% or less and elevated N-terminal pro-B-type natriuretic peptide were eligible. Data were analyzed between June 2020 and January 2021.

Interventions

Addition of once-daily 10 mg of dapagliflozin or placebo to guideline-recommended therapy.

Main Outcomes and Measures

The primary outcome was the composite of an episode of worsening HF (HF hospitalization or urgent HF visit requiring intravenous therapy) or cardiovascular death.

Results

A total of 4744 patients were randomized in DAPA-HF, of whom 1109 were women (23.4%). Compared with placebo, dapagliflozin reduced the risk of worsening HF events or cardiovascular death to a similar extent in both men and women (hazard ratios, 0.73 [95% CI, 0.63-0.85] and 0.79 [95% CI, 0.59-1.06], respectively; P for interaction = .67). Consistent benefits were observed for the components of the primary outcome and all-cause mortality. Compared with placebo, dapagliflozin increased the proportion of patients with a meaningful improvement in symptoms (Kansas City Cardiomyopathy Questionnaire total symptom score of ≥5 points; men, 59% vs 50%; women, 57% vs 54%; P for interaction = .14) and decreased the proportion with worsening symptoms (Kansas City Cardiomyopathy Questionnaire total symptom score decrease of ≥5 points; men, 25% vs 34%; women, 27% vs 31%; P for interaction = .15), irrespective of sex. Results were consistent for the Kansas City Cardiomyopathy Questionnaire clinical summary score and overall summary score. Study drug discontinuation and serious adverse events were not more frequent in the dapagliflozin group than in the placebo group in either men or women.

Conclusions and Relevance

Dapagliflozin reduced the risk of worsening HF, cardiovascular death, and all-cause death and improved symptoms, physical function, and health-related quality of life similarly in men and women with heart failure and reduced ejection fraction. In addition, dapagliflozin was safe and well-tolerated irrespective of sex.

Trial Registration

ClinicalTrials.gov Identifier: NCT03036124.

Dosing of losartan in men versus women with heart failure with reduced ejection fraction: the HEAAL trial

AIMS

In heart failure with reduced ejection fraction (HFrEF), guidelines recommend up-titration of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptors blockers (ARBs) to the maximum tolerated dose. However, some studies suggest that women might need lower doses of ACEi/ARBs than men to achieve similar treatment benefit.

METHODS AND RESULTS

The HEAAL trial compared low vs. high dose of losartan. We reassessed the efficacy and safety of high- vs. low-dose in men vs. women using Cox models and machine learning algorithms. The mean age was 66 years and 30% of patients were women. Men appeared to have benefited more from high-dose than from low-dose losartan, whereas women appeared to have responded similarly to low and high doses [hazard ratio (95% confidence interval) comparing high- vs. low-dose losartan for the composite outcome of all-cause death or all-cause hospitalization: 0.89 (0.81-0.98) in men and 1.10 (0.95-1.28) in women; interaction P = 0.018]. Female sex clustered along with older age, ischaemic heart failure, New York Heart Association class III/IV, and estimated glomerular filtration rate <60 mL/min. Patients with these features had a poorer response to high-dose losartan. Subgroup analyses supported no benefit from high-dose losartan in patients with poorer kidney function and severe heart failure symptoms.

CONCLUSIONS

Compared with men, women might need lower doses of losartan to achieve similar treatment benefit. However, beyond sex, other factors (e.g. kidney function, age, and symptoms) may influence the response to high-dose losartan, suggesting that sex-based subgroup findings may be biased by other confounders.