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Del Pilar Falcón Fleytas R, Centurión OA, Figueredo JG, Saldivar HG, Martínez JE. Profile and Prognostic Impact of Multimorbidity in Elderly Patients with Heart Failure: Are there Differences between Men and Women? Curr Heart Fail Rep 2024:10.1007/s11897-024-00673-x. [PMID: 38958891 DOI: 10.1007/s11897-024-00673-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) represents a pathology in constant growth, but, despite the fact that a significant proportion of its population is comprised of elderly patients, they are not adequately represented in clinical trials or registries. They constitute a heterogeneous population with their particularities and interaction of the multiple comorbidities that characterize this age group, which makes the clinical course, prognosis and outcomes of the disease different. RECENT FINDINGS Compared to men, women with HF tend to be older, with a greater burden of non-cardiovascular comorbidities, less ischemic heart disease and preserved ventricular function in most cases. This fact translates into worse self-perceived quality of life, with lower hospitalization and mortality rates. Moreover, paradoxically, women are less likely to receive treatment recommended by clinical practice guidelines, including revascularization and device placement. As there are not enough representative studies of this population, the reasons for these results with better prognosis and relatively benign impact in the elderly female population are unknown, which is why it is necessary to continue with research in order to obtain greater evidence of the exposed gaps.
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Affiliation(s)
- Rocío Del Pilar Falcón Fleytas
- Division of Cardiovascular Medicine. Clinical Hospital. School of Medical Science, Asuncion National University (UNA), Av. Mariscal Lopez y Coronel Cazal, San Lorenzo, Paraguay.
| | - Osmar Antonio Centurión
- Division of Cardiovascular Medicine. Clinical Hospital. School of Medical Science, Asuncion National University (UNA), Av. Mariscal Lopez y Coronel Cazal, San Lorenzo, Paraguay
- Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de La Mora, Paraguay
| | - Javier Galeano Figueredo
- Division of Cardiovascular Medicine. Clinical Hospital. School of Medical Science, Asuncion National University (UNA), Av. Mariscal Lopez y Coronel Cazal, San Lorenzo, Paraguay
| | - Hugo González Saldivar
- Division of Cardiovascular Medicine. Clinical Hospital. School of Medical Science, Asuncion National University (UNA), Av. Mariscal Lopez y Coronel Cazal, San Lorenzo, Paraguay
| | - Jorge E Martínez
- Division of Cardiovascular Medicine. Clinical Hospital. School of Medical Science, Asuncion National University (UNA), Av. Mariscal Lopez y Coronel Cazal, San Lorenzo, Paraguay
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Chyou JY, Qin H, Butler J, Voors AA, Lam CSP. Sex-related similarities and differences in responses to heart failure therapies. Nat Rev Cardiol 2024; 21:498-516. [PMID: 38459252 DOI: 10.1038/s41569-024-00996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Abstract
Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.
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Affiliation(s)
- Janice Y Chyou
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hailun Qin
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-NUS Medical School, Singapore, Singapore.
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Chen CC, Chiu CC, Hao WR, Hsu MH, Liu JC, Lin JL. Sex differences in clinical characteristics and long-term clinical outcomes in Asian hospitalized heart failure patients. ESC Heart Fail 2024. [PMID: 38863210 DOI: 10.1002/ehf2.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/28/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024] Open
Abstract
AIMS Sex differences in long-term post-discharge clinical outcomes in Asian patients hospitalized for acute decompensated heart failure (HF) persist despite the world-wide implementation of guideline-directed medical therapy for decades. The present study aims to elucidate the puzzling dilemma and to depict the directions of solution. METHODS AND RESULTS Between 2011 and 2020, a total of 12 428 patients (6518 men and 5910 women, mean age 73.50 ± 14.85) hospitalized for acute decompensated HF were retrospectively enrolled from a university HF cohort. Compared with men, women hospitalized for acute decompensated HF were older in age (76.40 ± 13.43 vs. 71.20 ± 15.67 years old, P < 0.0001) with more coexisting hypertension, diabetes, hyperlipidaemia and moderate to severe chronic kidney disease, but less with ischaemic heart disease, cerebrovascular disease and chronic obstructive pulmonary disease (P < 0.0001). In echocardiography measurement parameters, women had smaller left ventricular and left atrial dimensions, higher left ventricular mass index, higher left ventricular ejection fraction (LVEF) and more in HF with preserved ejection fraction (EF) category (LVEF > 50%) than men (P < 0.0001). In HF therapy, women compared with men received more guideline-directed medical HF therapies including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors, but similar beta-blockers and mineralocorticoid receptor antagonists (P < 0.0001). Post-discharge long-term clinical outcomes after multivariate-adjusted analysis revealed that women compared with men had lower all-cause mortality [adjusted hazard ratio (aHR): 0.89, 95% confidence interval (CI): 0.84-0.93], lower cardiovascular mortality (aHR: 0.89, 95% CI: 0.80-0.99) and lower 1 year mortality (aHR: 0.91, 95% CI: 0.84-0.99) but similar HF rehospitalization rate (aHR: 1.02, 95% CI: 0.95-1.09) over 8 years of follow-up. The superiority of women over men in all-cause mortality was shown in HF with preserved EF (>50%) and HF with mildly reduced EF (40%-50%), but not in HF with reduced EF (<40%) category. Subgroup forest plot analysis showed body mass index, coexisting hypertension and chronic obstructive pulmonary disease as significant interacting factors. CONCLUSIONS With more coronary risk factors and medical comorbidities, less cardiac remodelling and better adherence to guideline-directed HF therapy, women hospitalized for acute decompensated HF demonstrated superiority over men in long-term post-discharge clinical outcomes, including all-cause mortality, cardiovascular mortality and 1 year mortality, and mainly in HF with preserved and mid-range EF categories, in the Asian HF cohort.
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Affiliation(s)
- Chun-Chao Chen
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Chun-Chih Chiu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Wen-Rui Hao
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Min-Huei Hsu
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Department of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ju-Chi Liu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
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Romiti GF, Nabrdalik K, Corica B, Bucci T, Proietti M, Qian M, Chen Y, Thompson JLP, Homma S, Lip GYH. Diabetes mellitus in patients with heart failure and reduced ejection fraction: a post hoc analysis from the WARCEF trial. Intern Emerg Med 2024; 19:931-939. [PMID: 38393500 PMCID: PMC11186946 DOI: 10.1007/s11739-024-03544-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) and diabetes mellitus (DM) have an increased risk of adverse events, including thromboembolism. In this analysis, we aimed to explore the association between DM and HFrEF using data from the "Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction" (WARCEF) trial. We analyzed factors associated with DM using multiple logistic regression models and evaluated the effect of DM on long-term prognosis, through adjusted Cox regressions. The primary outcome was the composite of all-cause death, ischemic stroke, or intracerebral hemorrhage; we explored individual components as the secondary outcomes and the interaction between treatment (warfarin or aspirin) and DM on the risk of the primary outcome, stratified by relevant characteristics. Of 2294 patients (mean age 60.8 (SD 11.3) years, 19.9% females) included in this analysis, 722 (31.5%) had DM. On logistic regression, cardiovascular comorbidities, symptoms and ethnicity were associated with DM at baseline, while age and body mass index showed a nonlinear association. Patients with DM had a higher risk of the primary composite outcome (Hazard Ratio [HR] and 95% Confidence Intervals [CI]: 1.48 [1.24-1.77]), as well as all-cause death (HR [95%CI]: 1.52 [1.25-1.84]). As in prior analyses, no statistically significant interaction was observed between DM and effect of Warfarin on the risk of the primary outcome, in any of the subgroups explored. In conclusion, we found that DM is common in HFrEF patients, and is associated with other cardiovascular comorbidities and risk factors, and with a worse prognosis.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Min Qian
- Mailman School of Public Health, Columbia University, New York, USA
| | - Yineng Chen
- Center for Preventive Ophthalmology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Shunichi Homma
- Cardiology Division, Columbia University Medical Center, New York, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Razaghizad A, Aziz H, Zhang GK, Ferreira JP, White WB, Mehta CR, Bakris GL, Zannad F, Sharma A. Pathophysiological Sex Differences in Heart Failure Progression After Acute Coronary Syndrome: Insights From the EXAMINE Trial. J Card Fail 2024; 30:767-777. [PMID: 37939897 DOI: 10.1016/j.cardfail.2023.10.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Therapies can reduce the risk of heart failure (HF) development and progression in type 2 diabetes; nevertheless, the risk of these outcomes is greater in females than in males. METHODS AND RESULTS To investigate sex differences in HF development and progression, we compared baseline circulating proteins (Olink Cardiovascular II panel) in males and females with type 2 diabetes and recent acute coronary syndrome for the outcome of HF hospitalization. Data were from the placebo-controlled Examination of Cardiovascular Outcomes with Alogliptin vs Standard of Care (EXAMINE) trial. Pathophysiological sex-differences were interpreted with network and pathway over-representation analyses. The EXAMINE trial enrolled 5380 participants (32.1% females) with biomarker data available for 95.4% of individuals. Analyses revealed 43 biomarkers were differentially expressed in HF hospitalization, of which 18 were sex specific. Among these 43 biomarkers, interleukin-6 was identified as a central node for the pathogenesis of HF hospitalization in both females and in males. Additional pathway over-representation analyses demonstrated that biomarkers associated with inflammatory pathways related to endothelial dysfunction and cardiac fibrosis were more up-regulated in females than males with HF hospitalization. Differential expression of 3 biomarkers (pentraxin-related protein 3, hydroxyacid oxidase 1, and carbonic anhydrase 5A) was independently associated with an increased risk of HF hospitalization in females but not in males (interaction P < .05). CONCLUSIONS In males and females with type 2 diabetes and acute coronary syndrome, interleukin-6 seems to be central in the pathogenesis of HF. Females exhibit higher levels of circulating proteins related to immunological pathways, reflecting sex-specific differences underlying HF development and progression.
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Affiliation(s)
- Amir Razaghizad
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Haya Aziz
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Guang K Zhang
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - João Pedro Ferreira
- Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, Nancy, France; Department of Surgery and Physiology, Cardiovascular R&D Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - William B White
- Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Cyrus R Mehta
- Harvard School of Public Health, Boston, Massachusetts
| | | | - Faiez Zannad
- Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
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Agarwal S, Farhat K, Khan MS, DeSimone CV, Deshmukh A, Munir MB, Asad ZUA, Stavrakis S. Sex differences in atrial fibrillation ablation outcomes in patients with heart failure. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01833-8. [PMID: 38811501 DOI: 10.1007/s10840-024-01833-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND There is a lack of data on the impact of sex on the outcomes of patients with heart failure (HF) undergoing atrial fibrillation (AF) ablation. We aimed to analyze the association of sex with outcomes of atrial fibrillation ablation in patients with heart failure. METHODS The National Readmissions Database (NRD) was analyzed from 2016 to 2019 to identify patients ≥ 18 years old with heart failure (HF) undergoing AF ablation. The outcomes of interest included peri-procedural complications, in-hospital mortality, resource utilization, and unplanned 1-year readmissions. The final cohort was divided into patients with HFrEF and HFpEF and outcomes were compared between males and females in both cohorts. RESULTS A total of 23,277 patients with HF underwent AF ablation between 2016 and 2019, of which 14,480 had HFrEF and 8,797 had HFpEF. Among patients with HFrEF, 61.6% were males and 38.4% were females whereas, among patients with HFpEF, 35.4% were males and 64.6% were females. On a multivariable-adjusted analysis, in patients with HFrEF, there was no difference in the odds of in-hospital mortality, peri-procedural complications, or 1-year HF-related/AF-related/all-cause readmissions between males and females. In patients with HFpEF, females had a higher risk 1-year HF-related readmissions (adjusted hazards ratio: 1.46; 95% CI: 1.13-1.87; p = 0.01), without any difference in the 1-year AF-related/all-cause readmissions, in-hospital mortality, or peri-procedural complications. CONCLUSION Our results show that females with HFrEF undergoing AF ablation have similar outcomes whereas females with HFpEF have higher 1-year HF readmissions with no difference in the other outcomes, compared to males.
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Affiliation(s)
- Siddharth Agarwal
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kassem Farhat
- Department of Internal Medicine, Yale School of Medicine, Waterbury, CT, USA
| | - Muhammad Salman Khan
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | | | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, CA, USA
| | - Zain Ul Abideen Asad
- Department of Cardiology, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK, 73104, USA
| | - Stavros Stavrakis
- Department of Cardiology, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK, 73104, USA.
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Pabon MA, Vaduganathan M, Lam CSP. Is the optimal dose of heart failure medical therapy different in women and men? Eur J Heart Fail 2024. [PMID: 38800983 DOI: 10.1002/ejhf.3320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024] Open
Affiliation(s)
- Maria A Pabon
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
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Rosano GMC, Stolfo D, Anderson L, Abdelhamid M, Adamo M, Bauersachs J, Bayes-Genis A, Böhm M, Chioncel O, Filippatos G, Hill L, Lainscak M, Lambrinou E, Maas AHEM, Massouh AR, Moura B, Petrie MC, Rakisheva A, Ray R, Savarese G, Skouri H, Van Linthout S, Vitale C, Volterrani M, Metra M, Coats AJS. Differences in presentation, diagnosis and management of heart failure in women. A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024. [PMID: 38783694 DOI: 10.1002/ejhf.3284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/11/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
Despite the progress in the care of individuals with heart failure (HF), important sex disparities in knowledge and management remain, covering all the aspects of the syndrome, from aetiology and pathophysiology to treatment. Important distinctions in phenotypic presentation are widely known, but the mechanisms behind these differences are only partially defined. The impact of sex-specific conditions in the predisposition to HF has gained progressive interest in the HF community. Under-recruitment of women in large randomized clinical trials has continued in the more recent studies despite epidemiological data no longer reporting any substantial difference in the lifetime risk and prognosis between sexes. Target dose of medications and criteria for device eligibility are derived from studies with a large predominance of men, whereas specific information in women is lacking. The present scientific statement encompasses the whole scenario of available evidence on sex-disparities in HF and aims to define the most challenging and urgent residual gaps in the evidence for the scientific and clinical HF communities.
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Affiliation(s)
- Giuseppe M C Rosano
- Chair of Pharmacology, Department of Human Sciences and Promotion of Quality of Life, San Raffaele University of Rome, Rome, Italy
- Cardiology, San Raffaele Cassino Hospital, Cassino, Italy
| | - Davide Stolfo
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lisa Anderson
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London and St George's University Hospitals NHS Foundation Trust, London, UK
| | - Magdy Abdelhamid
- Department of Cardiovascular Medicine, Faculty of Medicine, Kasr Al Ainy, Cairo University, Giza, Egypt
| | - Marianna Adamo
- ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Poujol, CIBERCV, Badalona, Spain
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | - Gerasimos Filippatos
- National & Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Chaidari, Greece
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Rakičan, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela R Massouh
- Hariri School of Nursing, American University of Beirut, Beirut, Lebanon
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Amina Rakisheva
- City Cardiological Center, Almaty Kazakhstan Qonaev city hospital, Almaty Region, Kazakhstan
| | - Robin Ray
- Department of Cardiology, St George's Hospital, London, UK
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical city, Abu Dhabi, UAE
| | - Sophie Van Linthout
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | | | - Maurizio Volterrani
- Department of Human Science and Promotion of Quality of Life, San Raffaele Open University, Rome, Italy
- Cardio-Pulmonary Department, IRCCS San Raffaele, Rome, Italy
| | - Marco Metra
- ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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9
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Robles-Mezcua A, Aguado NG, de la Rosa APM, Cruzado-Álvarez C, Rubio CJ, Cabeza AIP, Gómez-Doblas JJ, Jiménez-Navarro MF, Pierri MM, García-Pinilla JM. Sex-based Differences in Heart Failure Biomarkers. Curr Heart Fail Rep 2024:10.1007/s11897-024-00665-x. [PMID: 38767760 DOI: 10.1007/s11897-024-00665-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE OF REVIEW Differences in HF biomarker levels by sex may be due to hormonal, genetic, and fat distribution differences. Knowledge of these differences is scarce, and it is not well established whether they may affect their usefulness in the management of HF. RECENT FINDINGS The different biomarker profiles in women and men have been confirmed in recent studies: in women, markers of cardiac stretch and fibrosis (NP and galectin-3) are higher, whereas in men, higher levels of markers of cardiac injury and inflammation (cTn and sST2) are found. The use of new biomarkers, together with growing evidence that a multimarker approach can provide better risk stratification, raises the question of building models that incorporate sex-specific diagnostic criteria. More and more research are being devoted to understanding sex-related differences in HF. The aim of this review is to review the dynamics of HF biomarkers according to sex and in different situations, to learn whether these sex differences may affect their use in the diagnosis and follow-up of HF patients.
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Affiliation(s)
- Ainhoa Robles-Mezcua
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Nelsa González Aguado
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
| | - Antonia Pilar Martin de la Rosa
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
| | - Concepción Cruzado-Álvarez
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
| | - Clara Jiménez Rubio
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
| | - Alejandro IPérez Cabeza
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan José Gómez-Doblas
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Medicina y Dermatología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain
| | - Manuel F Jiménez-Navarro
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Medicina y Dermatología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain
| | - Mora Murri Pierri
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.
- Endocrinology and Nutrition UGC, Hospital Universitario Virgen de La Victoria, Málaga, Spain.
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Hospital Clínico Virgen de La Victoria, Málaga, Spain.
- CIBER Fisiopatología de La Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Málaga, Spain.
| | - José M García-Pinilla
- Área del Corazón, Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Unidad de Insuficiencia Cardíaca y Cardiopatías Familiares, Cardiología. Hospital Universitario Virgen de La Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA Plataforma BIONAND), Málaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Endocrinology and Nutrition UGC, Hospital Universitario Virgen de La Victoria, Málaga, Spain
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10
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Álvarez-Zaballos S, Martínez-Sellés M. Impact of Sex and Diabetes in Patients with Heart Failure. Curr Heart Fail Rep 2024:10.1007/s11897-024-00666-w. [PMID: 38698294 DOI: 10.1007/s11897-024-00666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is a complex clinical syndrome with a growing global health burden. This review explores the intersection of HF, diabetes mellitus, and sex, highlighting epidemiological patterns, pathophysiological mechanisms, and treatment implications. RECENT FINDINGS Despite similar HF prevalence in men and women, diabetes mellitus (DM) appears to exert a more pronounced impact on HF outcomes in women. Pathophysiological differences involve cardiovascular risk factors, severe left ventricular dysfunction, and coronary artery disease, as well as hormonal influences and inflammatory markers. Diabetic cardiomyopathy introduces a sex-specific challenge, with women experiencing common adverse outcomes related to increased fibrosis and myocardial remodeling. Treatment strategies, particularly sodium-glucose cotransporter 2 inhibitors, exhibit cardiovascular benefits, but their response may differ in women. The link between HF and DM is bidirectional, with diabetes significantly increasing the risk of HF, and vice versa. Additionally, the impact of diabetes on mortality appears more pronounced in women than in men, leading to a modification of the traditional gender gap observed in HF outcomes. A personalized approach is crucial, and further research to improve outcomes in the complex interplay of HF, diabetes, and sex is needed.
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Affiliation(s)
- Sara Álvarez-Zaballos
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.
- Universidad Europea, Universidad Complutense, Madrid, Spain.
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11
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Bugiardini R, Gulati M. Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity. Atherosclerosis 2024; 392:117500. [PMID: 38503147 DOI: 10.1016/j.atherosclerosis.2024.117500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.
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Affiliation(s)
- Raffaele Bugiardini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.
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12
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Ferrari A, Stolfo D, Uijl A, Orsini N, Benson L, Sinagra G, Mol P, de Vries ST, Dahlström U, Rosano G, Lund LH, Savarese G. Sex differences in the prognostic role of achieving target doses of heart failure medications: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2024; 26:1101-1110. [PMID: 38695292 DOI: 10.1002/ejhf.3272] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/08/2024] [Accepted: 04/18/2024] [Indexed: 06/27/2024] Open
Abstract
AIMS Guidelines recommend target doses (TD) of heart failure (HF) with reduced ejection fraction (HFrEF) medications regardless of sex. Differences in pharmacokinetics and pharmacodynamics may explain heterogeneity in treatment response, adverse reactions, and tolerability issues across sexes. The aim of this study was to explore sex-based differences in the association between TD achievement and mortality/morbidity in HFrEF. METHODS AND RESULTS Patients with HFrEF and HF duration ≥6 months registered in the Swedish HF Registry between May 2000 and December 2020 (follow-up until December 2021) were analysed. Treatments of interest were renin-angiotensin system inhibitors (RASI) or angiotensin receptor-neprilysin inhibitors (ARNI), and beta-blockers. Multivariable Cox regression models were performed to explore the risk of cardiovascular mortality or hospitalization for HF across dose categories in females versus males. A total of 17 912 patients were analysed (median age 77.0 years, interquartile range [IQR] 70.0-83.0), 29% were female. Over a median follow-up of 1.33 years (IQR 0.29-3.22), for RASI/ARNI there was no significant difference in outcome for females achieving 50-99% versus 100% of TD (hazard ratio 0.92, 95% confidence interval 0.83-1.03), whereas males showed a gradual lowering in risk together with the achievement of higher % of TD (p-interaction = 0.030). For beta-blockers the achievement of TD was associated with the lowest risk of outcome regardless of sex. CONCLUSIONS Our findings suggest that females and males might differently benefit from the same dose of RASI/ARNI, and do represent a general call for randomized controlled trials to consider sex-specific up-titration schemes when testing HFrEF treatments in need of up-titration.
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Affiliation(s)
- Amerigo Ferrari
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- MeS (Management and Health) Laboratory, Institute of Management, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Alicia Uijl
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gianfranco Sinagra
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Peter Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sieta T de Vries
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. Georges, University of London, London, UK
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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13
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Garg P, Grafton-Clarke C, Matthews G, Swoboda P, Zhong L, Aung N, Thomson R, Alabed S, Demirkiran A, Vassiliou VS, Swift AJ. Sex-specific cardiac magnetic resonance pulmonary capillary wedge pressure. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae038. [PMID: 38751456 PMCID: PMC11095051 DOI: 10.1093/ehjopen/oeae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/18/2024]
Abstract
Aims Heart failure (HF) with preserved ejection fraction disproportionately affects women. There are no validated sex-specific tools for HF diagnosis despite widely reported differences in cardiac structure. This study investigates whether sex, as assigned at birth, influences cardiac magnetic resonance (CMR) assessment of left ventricular filling pressure (LVFP), a hallmark of HF agnostic to ejection fraction. Methods and results A derivation cohort of patients with suspected pulmonary hypertension and HF from the Sheffield centre underwent invasive right heart catheterization and CMR within 24 h of each other. A sex-specific CMR model to estimate LVFP, measured as pulmonary capillary wedge pressure (PCWP), was developed using multivariable regression. A validation cohort of patients with confirmed HF from the Leeds centre was used to evaluate for the primary endpoints of HF hospitalization and major adverse cardiovascular events (MACEs). Comparison between generic and sex-specific CMR-derived PCWP was undertaken. A total of 835 (60% female) and 454 (36% female) patients were recruited into the derivation and validation cohorts respectively. A sex-specific model incorporating left atrial volume and left ventricular mass was created. The generic CMR PCWP showed significant differences between males and females (14.7 ± 4 vs. 13 ± 3.0 mmHg, P > 0.001), not present with the sex-specific CMR PCWP (14.1 ± 3 vs. 13.8 mmHg, P = 0.3). The sex-specific, but not the generic, CMR PCWP was associated with HF hospitalization (hazard ratio 3.9, P = 0.0002) and MACE (hazard ratio 2.5, P = 0.001) over a mean follow-up period of 2.4 ± 1.2 years. Conclusion Accounting for sex improves precision and prognostic performance of CMR biomarkers for HF.
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Affiliation(s)
- Pankaj Garg
- Norwich Medical School, University of East Anglia, Norwich Research Park, Rosalind Franklin Road, Norwich NR4 7UQ, UK
- Department of Cardiology, Norfolk and Norwich University NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - Ciaran Grafton-Clarke
- Norwich Medical School, University of East Anglia, Norwich Research Park, Rosalind Franklin Road, Norwich NR4 7UQ, UK
- Department of Cardiology, Norfolk and Norwich University NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - Gareth Matthews
- Norwich Medical School, University of East Anglia, Norwich Research Park, Rosalind Franklin Road, Norwich NR4 7UQ, UK
- Department of Cardiology, Norfolk and Norwich University NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - Peter Swoboda
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Liang Zhong
- National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, Singapore
- Signature Programme of Cardiovascular Metabolic and Disorders, Duke-NUS Medical School, 8 College Road, Singapore
| | - Nay Aung
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Ross Thomson
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Samer Alabed
- National Institute for Health and Care Research, Sheffield Biomedical Research Centre, Sheffield, UK
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Cardiology, Kocaeli City Hospital, Kocaeli, Turkey
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Norwich Research Park, Rosalind Franklin Road, Norwich NR4 7UQ, UK
- Department of Cardiology, Norfolk and Norwich University NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - Andrew J Swift
- National Institute for Health and Care Research, Sheffield Biomedical Research Centre, Sheffield, UK
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
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14
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Núñez E, Santas E, Merenciano H, Lorenzo-Hernández M, Mollar A, Miñana G, Palau P, Fuertes L, Valero E, de la Espriella R, Bodí V, Sanchis J, Bayés-Genís A, Núñez J. Differential sex-related effect of left ventricular ejection fraction trajectory on the risk of mortality and heart failure readmission following hospitalization for acute heart failure: A longitudinal study. Eur J Heart Fail 2024. [PMID: 38679819 DOI: 10.1002/ejhf.3252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/18/2024] [Accepted: 04/08/2024] [Indexed: 05/01/2024] Open
Abstract
AIMS There is limited information on the sex-specific longitudinal changes of left ventricular ejection fraction (LVEF) after an acute heart failure (AHF) hospitalization. We aimed to investigate whether LVEF trajectories over time and their impact on mortality and AHF readmission rates differ between men and women. METHODS AND RESULTS We conducted a retrospective sex-specific analysis of longitudinal LVEF measurements (n = 9581) in 3383 patients with an index hospitalization for AHF in a single tertiary-level hospital. Statistical techniques suited for longitudinal data analysis were used. The mean age of the sample was 73.8 ± 11.2 years, and 47.9% were women. The mean LVEF was 49.4 ± 15.3%. At a median follow-up of 2.58 years (interquartile range 0.77-5.62), we registered 2197 deaths (64.9%) and 2597 AHF readmissions in 1302 (38.5%) patients. The longitudinal analysis showed that women had consistently higher LVEF values throughout the follow-up with both trajectories characterized by an early peak-approximately at 1 year-followed by decreasing values in men but a plateau in women. Multivariate between-sex comparisons across LVEF categories revealed that women had lower rates of AHF readmissions when LVEF ≤40%. On the contrary, women displayed an excess risk of AHF readmissions when LVEF >60%. A trend in the same direction was found for cardiovascular and all-cause mortality. CONCLUSION Sex was a significant factor in determining the follow-up trajectory of LVEF and predicting differences in outcomes after an AHF admission. The findings suggest that women have a higher risk of AHF readmissions at higher LVEF values, while men have a higher risk at lower LVEF values. For all-cause and cardiovascular mortality, the same direction of the association was inferred but they were not significant.
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Affiliation(s)
- Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Hector Merenciano
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Miguel Lorenzo-Hernández
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Patricia Palau
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Laura Fuertes
- Cardiology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Ernesto Valero
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Antoni Bayés-Genís
- CIBER Cardiovascular, Madrid, Spain
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Madrid, Spain
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15
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Martin CM. Cardiomyopathies in Women. Methodist Debakey Cardiovasc J 2024; 20:59-69. [PMID: 38495661 PMCID: PMC10941701 DOI: 10.14797/mdcvj.1368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Heart failure affects over 2.6 million people in the United States. While women have better overall survival rates, they also suffer from higher morbidity as shown by higher rates of hospitalization and worse quality of life. Several anatomical differences in women's hearts affect both systolic and diastolic cardiac physiology. Despite these findings, women are significantly underrepresented in clinical trials, necessitating extrapolation of data from males. Because women have sex-specific etiologies of heart failure and unique manifestations in genetic-related cardiomyopathies, meaningful sex-related differences affect heart failure outcomes as well as access to and outcomes in advanced heart failure therapies in women. This review explores these gender-specific differences and potential solutions to balance care between women and men.
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Affiliation(s)
- Cindy M. Martin
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
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16
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Walli-Attaei M, Joseph P, Johansson I, Sliwa K, Lonn E, Maggioni AP, Mielniczuk L, Ross H, Karaye K, Hage C, Pogosova N, Grinvalds A, McCready T, McMurray J, Yusuf S. Characteristics, management, and outcomes in women and men with congestive heart failure in 40 countries at different economic levels: an analysis from the Global Congestive Heart Failure (G-CHF) registry. Lancet Glob Health 2024; 12:e396-e405. [PMID: 38218197 DOI: 10.1016/s2214-109x(23)00557-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/21/2023] [Accepted: 11/24/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND There is a paucity of data on the clinical characteristics, management, and outcomes of women compared with men with heart failure in low-income and middle-income countries compared with high-income countries. We examined sex differences in risk factors, clinical characteristics, and treatments, and prospectively assessed the risk of heart failure hospitalisation and mortality in patients with heart failure in 40 high-income, middle-income, and low-income countries. METHODS Participants aged 18 years or older with heart failure were enrolled from Dec 20, 2016, to Sept 9, 2020 in the prospective Global Congestive Heart Failure (G-CHF) study from 257 centres in 40 high-income, middle-income, and low-income countries. Participants were followed up until May 25, 2023. We recorded the demographic characteristics, medical history, and treatments of participants. We prospectively recorded data on heart failure hospitalisation and mortality by sex in the overall study, according to country economic status, and according to level of left ventricular ejection fraction (LVEF). FINDINGS 23 341 participants (9119 [39·1%] women and 14 222 [60·1%] men) were recruited and followed up for a mean of 2·6 years (SD 1·4). The mean age of women in the study was 62 years (SD 17) compared with 64 years (14) in men. Fewer women than men had an LVEF of 40% or lower (51·7% women vs 66·2% men). By contrast, more women than men had an LVEF of 50% or higher (33·2% women vs 18·6% men). Hypertensive heart failure was the most common aetiology in women (25·5% women vs 16·8% men), whereas ischaemic heart failure was the most common aetiology in men (45·6% men vs 26·6% women). Signs and symptoms of congestion were more common in women than men: 42·6% of women had a New York Heart Association functional class of III or IV compared with 37·9% of men. The use of heart failure medications and cardiac tests did not differ systematically between the sexes, although implantable cardioverter defibrillator (ICD) implantation was lower among women than men (8·7% women vs 17·2% men). The adjusted risk of heart failure hospitalisation was similar in women and men (women-to-men adjusted hazard ratio [HR] 0·99 [95% CI 0·92-1·05]). This pattern was consistent within groups of countries categorised by economic status, geographical region, and by LVEF level. However, women had a lower adjusted risk of mortality (women-to-men adjusted HR 0·79 [95% CI 0·75-0·84]) despite adjustments for prognostic factors-a pattern which was consistently observed across groups of countries irrespective of economic status, geography, and LVEF levels of patients. INTERPRETATION The underlying cause of heart failure and ejection fraction phenotype differ between women and men, as do the severity of symptoms. Heart failure treatments (except ICD use) were not consistently in favour of one sex. Paradoxically, while the rates of hospitalisations were similar among women and men, the risk of death was lower among women. These patterns were consistent regardless of the economic status of the countries. The higher mortality among men is unexplained and warrants further study. FUNDING Bayer.
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Affiliation(s)
- Marjan Walli-Attaei
- Population Health Research Institute and Hamilton Health Sciences, Hamilton, ON, Canada; Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Philip Joseph
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Isabelle Johansson
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Karen Sliwa
- Cape Heart Institute, University of Cape Town, Cape Town, South Africa
| | - Eva Lonn
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Aldo P Maggioni
- ANMCO Research Center-Heart Care Foundation, Florence, Italy
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, Ted Rogers Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Kamilu Karaye
- Department of Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Camilla Hage
- Karolinska Institutet, Department of Medicine, Cardiology Unit, Stockholm, Sweden
| | - Nana Pogosova
- Medical Research Center of Cardiology named after E.I. Chazov, Moscow, Russia
| | - Alex Grinvalds
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Tara McCready
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - John McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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17
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Sumarsono A, Xie L, Keshvani N, Zhang C, Patel L, Alonso W, Thibodeau J, Fonarow GC, Van Spall HGC, Messiah SE, Pandey A. Sex Disparities in Longitudinal Use and Intensification of Guideline-Directed Medical Therapy Among Patients With Newly Diagnosed Heart Failure With Reduced Ejection Fraction. Circulation 2024; 149:510-520. [PMID: 38258605 PMCID: PMC11069415 DOI: 10.1161/circulationaha.123.067489] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Guideline-directed medical therapies (GDMTs) are the mainstay of treatment for heart failure with reduced ejection fraction (HFrEF), but they are underused. Whether sex differences exist in the initiation and intensification of GDMT for newly diagnosed HFrEF is not well established. METHODS Patients with incident HFrEF were identified from the 2016 to 2020 Optum deidentified Clinformatics Data Mart Database, which is derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The primary outcome was the use of optimal GDMT within 12 months of HFrEF diagnosis. Consistent with the guideline recommendations during the time period of the study, optimal GDMT was defined as ≥50% of the target dose of evidence-based beta-blocker plus ≥50% of the target dose of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, or any dose of angiotensin receptor neprilysin inhibitor plus any dose of mineralocorticoid receptor antagonist. The probability of achieving optimal GDMT on follow-up and predictors of optimal GDMT were evaluated with time-to-event analysis with adjusted Cox proportional hazard models. RESULTS The study cohort included 63 759 patients (mean age, 71.3 years; 15.2% non-Hispanic Black race; 56.6% male). Optimal GDMT use was achieved by 6.2% of patients at 12 months after diagnosis. Female (compared with male) patients with HFrEF had lower use across every GDMT class and lower use of optimal GDMT at each time point at follow-up. In an adjusted Cox model, female sex was associated with a 23% lower probability of achieving optimal GDMT after diagnosis (hazard ratio [HR], 0.77 [95% CI, 0.71-0.83]; P<0.001). The sex disparities in GDMT use after HFrEF diagnosis were most pronounced among patients with commercial insurance (females compared with males; HR, 0.66 [95% CI, 0.58-0.76]) compared with Medicare (HR, 0.85 [95% CI, 0.77-0.92]); Pinteraction sex×insurance status=0.005) and for younger patients (age <65 years: HR, 0.65 [95% CI, 0.58-0.74]) compared with older patients (age ≥65 years: HR, 87 [95% CI, 80-96]) Pinteraction sex×age=0.009). CONCLUSIONS Overall use of optimal GDMT after HFrEF diagnosis was low, with significantly lower use among female (compared with male) patients. These findings highlight the need for implementation efforts directed at improving GDMT initiation and titration.
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Affiliation(s)
- Andrew Sumarsono
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Luyu Xie
- School of Public Health, University of Texas Health Science Center at Houston, Dallas, TX
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Chenguang Zhang
- School of Public Health, University of Texas Health Science Center at Houston, Dallas, TX
| | - LajjaBen Patel
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Windy Alonso
- College of Nursing, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Thibodeau
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Gregg C. Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, CA
| | - Harriette GC Van Spall
- Population Health Research Institute, Hamilton, Ontario, CA
- McMaster University, Hamilton, Ontario, CA
- Research Institute of St. Joseph’s, Hamilton, Ontario, CA
| | - Sarah E. Messiah
- School of Public Health, University of Texas Health Science Center at Houston, Dallas, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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18
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Kawai A, Nagatomo Y, Yukino-Iwashita M, Nakazawa R, Yumita Y, Taruoka A, Takefuji A, Yasuda R, Toya T, Ikegami Y, Masaki N, Adachi T. Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure. J Pers Med 2024; 14:201. [PMID: 38392634 PMCID: PMC10890585 DOI: 10.3390/jpm14020201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/22/2024] [Accepted: 02/11/2024] [Indexed: 02/24/2024] Open
Abstract
Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.
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Affiliation(s)
- Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | | | - Ryota Nakazawa
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yusuke Yumita
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akira Taruoka
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Asako Takefuji
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Risako Yasuda
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Nobuyuki Masaki
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
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19
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Campesi I, Franconi F, Serra PA. The Appropriateness of Medical Devices Is Strongly Influenced by Sex and Gender. Life (Basel) 2024; 14:234. [PMID: 38398743 PMCID: PMC10890141 DOI: 10.3390/life14020234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Until now, research has been performed mainly in men, with a low recruitment of women; consequentially, biological, physiological, and physio-pathological mechanisms are less understood in women. Obviously, without data obtained on women, it is impossible to apply the results of research appropriately to women. This issue also applies to medical devices (MDs), and numerous problems linked to scarce pre-market research and clinical trials on MDs were evidenced after their introduction to the market. Globally, some MDs are less efficient in women than in men and sometimes MDs are less safe for women than men, although recently there has been a small but significant decrease in the sex and gender gap. As an example, cardiac resynchronization defibrillators seem to produce more beneficial effects in women than in men. It is also important to remember that MDs can impact the health of healthcare providers and this could occur in a sex- and gender-dependent manner. Recently, MDs' complexity is rising, and to ensure their appropriate use they must have a sex-gender-sensitive approach. Unfortunately, the majority of physicians, healthcare providers, and developers of MDs still believe that the human population is only constituted by men. Therefore, to overcome the gender gap, a real collaboration between the inventors of MDs, health researchers, and health providers should be established to test MDs in female and male tissues, animals, and women.
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Affiliation(s)
- Ilaria Campesi
- Dipartimento di Scienze Biomediche, Università degli Studi di Sassari, 07100 Sassari, Italy
- Laboratorio Nazionale sulla Farmacologia e Medicina di Genere, Istituto Nazionale Biostrutture Biosistemi, 07100 Sassari, Italy;
| | - Flavia Franconi
- Laboratorio Nazionale sulla Farmacologia e Medicina di Genere, Istituto Nazionale Biostrutture Biosistemi, 07100 Sassari, Italy;
| | - Pier Andrea Serra
- Dipartimento di Medicina, Chirurgia e Farmacia, Università degli Studi di Sassari, 07100 Sassari, Italy;
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20
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Conde-Martel A, Trullàs JC, Morales-Rull JL, Casado J, Carrera-Izquierdo M, Sánchez-Marteles M, Llácer P, Salamanca-Bautista P, Manzano L, Formiga F. Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial. Rev Clin Esp 2024; 224:67-76. [PMID: 38215973 DOI: 10.1016/j.rceng.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/25/2023] [Indexed: 01/14/2024]
Abstract
AIMS The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex. METHODS This is a post-hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96 h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. The influence of sex on primary, secondary and safety outcomes was evaluated. RESULTS One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96 h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all p-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR [95%CI]: 8.68 [3.41-24.63]) than men (OR [95%CI]: 2.5 [0.99-4.87]), p = 0.027. There were no differences in mortality or rehospitalizations at 30/90 days. CONCLUSION Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov: NCT01647932; EudraCT Number: 2013-001852-36.
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Affiliation(s)
- A Conde-Martel
- Internal Medicine Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain; Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - J C Trullàs
- Internal Medicine Department, Hospital d'Olot i Comarcal de la Garrotxa, Girona, Spain; Tissue Repair and Regeneration Laboratory (TR2Lab), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IrisCC), Barcelona, Spain
| | - J L Morales-Rull
- Internal Medicine Department, Heart Failure Unit, Hospital Universitari Arnau de Villanova, Institut de Recerca Biomédica (IRBLleida), Lleida, Spain
| | - J Casado
- Internal Medicine Department, Hospital Universitario de Getafe, Madrid, Spain
| | - M Carrera-Izquierdo
- Internal Medicine Department, Complejo Hospitalario de Soria, Paseo Santa Bárbara, Soria, Spain
| | - M Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario 'Lozano Blesa', Aragón Research Health Institutte (IIS Aragon), Zaragoza, Spain
| | - P Llácer
- Internal Medicine Department, Hospital de Manises, Valencia, Spain
| | - P Salamanca-Bautista
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | - L Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - F Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
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21
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Spacht WA, Lau ES. A disease of her own? Unique features of heart failure in women. Climacteric 2024; 27:32-40. [PMID: 37768321 PMCID: PMC10843094 DOI: 10.1080/13697137.2023.2256673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
Heart failure (HF) is a significant and growing public health challenge for women. Compared with men, women tend to develop HF later in life and are more likely to experience HF with preserved ejection fraction. There are also significant sex differences in outcomes, with women reporting lower quality of life but overall better survival versus men. In this review, we summarize sex differences in traditional HF risk factors, such as hypertension, diabetes, obesity and coronary artery disease, as well as female-specific HF risk factors including menopause, pregnancy and adverse pregnancy outcomes, and breast cancer therapy. While our understanding of the sex-specific efficacy of HF therapy remains limited by the underrepresentation of women in major clinical trials, there is a suggestion of preferential benefit of specific agents for women. Further work is required to better understand the pathophysiology of HF in women uniquely and to increase representation of women in clinical trials.
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Affiliation(s)
| | - Emily S. Lau
- Cardiovascular Research Center and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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22
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Aydin D, Allach Y, Brugts JJ. Implications of Sex Differences on the Treatment Effectiveness in Heart Failure with Reduced Ejection Fraction Related to Clinical Endpoints and Quality of Life. Curr Heart Fail Rep 2024; 21:43-52. [PMID: 38060192 PMCID: PMC10827832 DOI: 10.1007/s11897-023-00638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF THE REVIEW This narrative review will emphasize the necessity for more female enrollment in heart failure (HF) trials and proposes future investigations regarding optimal dosages. Ultimately, a deeper understanding of the unique pathophysiology and medication responses in both men and women is crucial for effective HF management and may improve the quality of life in women. RECENT FINDINGS An analysis of 740 cardiovascular studies reveals that women make up only 38.2% of participants on average. Regarding to trials testing the effectiveness of HF medications, women's involvement are as low as 23.1%. While current guidelines lack sex-specific treatment recommendations, emerging research suggests differential medication dosages could be beneficial. Studies indicate that women may achieve comparable outcomes with lower doses of certain medications (angiotensin-receptor blockers) compared to men, signaling potential for more tailored dosing approaches. We advocate that the next step in HF research should prioritize the importance of tailoring treatment for HF patients by taking into account the variations in drug absorption and distribution among women.
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Affiliation(s)
- D Aydin
- Department of Cardiology, Erasmus University Medical Centre, 3015, Rotterdam, The Netherlands.
| | - Y Allach
- Department of Cardiology, Erasmus University Medical Centre, 3015, Rotterdam, The Netherlands
| | - J J Brugts
- Department of Cardiology, Erasmus University Medical Centre, 3015, Rotterdam, The Netherlands
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23
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Ventoulis I, Kamperidis V, Abraham MR, Abraham T, Boultadakis A, Tsioukras E, Katsiana A, Georgiou K, Parissis J, Polyzogopoulou E. Differences in Health-Related Quality of Life among Patients with Heart Failure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:109. [PMID: 38256370 PMCID: PMC10818915 DOI: 10.3390/medicina60010109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Heart failure (HF) is characterized by a progressive clinical course marked by frequent exacerbations and repeated hospitalizations, leading to considerably high morbidity and mortality rates. Patients with HF present with a constellation of bothersome symptoms, which range from physical to psychological and mental manifestations. With the transition to more advanced HF stages, symptoms become increasingly more debilitating, interfere with activities of daily living and disrupt multiple domains of life, including physical functioning, psychological status, emotional state, cognitive function, intimate relationships, lifestyle status, usual role activities, social contact and support. By inflicting profuse limitations in numerous aspects of life, HF exerts a profoundly negative impact on health-related quality of life (HRQOL). It is therefore not surprising that patients with HF display lower levels of HRQOL compared not only to the general healthy population but also to patients suffering from other chronic diseases. On top of this, poor HRQOL in patients with HF becomes an even greater concern considering that it has been associated with unfavorable long-term outcomes and poor prognosis. Nevertheless, HRQOL may differ significantly among patients with HF. Indeed, it has consistently been reported that women with HF display poorer HRQOL compared to men, while younger patients with HF tend to exhibit lower levels of HRQOL than their older counterparts. Moreover, patients presenting with higher New York Heart Association (NYHA) functional class (III-IV) have significantly more impaired HRQOL than those in a better NYHA class (I-II). Furthermore, most studies report worse levels of HRQOL in patients suffering from HF with preserved ejection fraction (HFpEF) compared to patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF). Last, but not least, differences in HRQOL have been noted depending on geographic location, with lower HRQOL levels having been recorded in Africa and Eastern Europe and higher in Western Europe in a recent large global study. Based on the observed disparities that have been invariably reported in the literature, this review article aims to provide insight into the underlying differences in HRQOL among patients with HF. Through an overview of currently existing evidence, fundamental differences in HRQOL among patients with HF are analyzed based on sex, age, NYHA functional class, ejection fraction and geographic location or ethnicity.
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Affiliation(s)
- Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, 50200 Ptolemaida, Greece; (E.T.); (A.K.); (K.G.)
| | - Vasileios Kamperidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St Kiriakidi 1, 54636 Thessaloniki, Greece;
| | - Maria Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, CA 94117, USA; (M.R.A.); (T.A.)
| | - Theodore Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, CA 94117, USA; (M.R.A.); (T.A.)
| | - Antonios Boultadakis
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece; (A.B.); (J.P.); (E.P.)
| | - Efthymios Tsioukras
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, 50200 Ptolemaida, Greece; (E.T.); (A.K.); (K.G.)
| | - Aikaterini Katsiana
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, 50200 Ptolemaida, Greece; (E.T.); (A.K.); (K.G.)
| | - Konstantinos Georgiou
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, 50200 Ptolemaida, Greece; (E.T.); (A.K.); (K.G.)
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece; (A.B.); (J.P.); (E.P.)
| | - Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece; (A.B.); (J.P.); (E.P.)
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24
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Kałużna-Oleksy M, Krysztofiak H, Sawczak F, Kukfisz A, Szczechla M, Soloch A, Cierzniak M, Szubarga A, Przytarska K, Dudek M, Uchmanowicz I, Straburzyńska-Migaj E. Sex differences in the nutritional status and its association with long-term prognosis in patients with heart failure with reduced ejection fraction: a prospective cohort study. Eur J Cardiovasc Nurs 2024:zvad105. [PMID: 38170824 DOI: 10.1093/eurjcn/zvad105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 01/05/2024]
Abstract
AIMS Many studies show the association between malnutrition and poor prognosis in heart failure (HF) patients. Our research aimed to analyse sex differences in patients with HF with reduced ejection fraction (HFrEF), emphasizing nutritional status and the influence of selected parameters on the prognosis. METHODS AND RESULTS We enrolled 276 consecutive patients diagnosed with HFrEF. Nutritional status was assessed using Mini Nutritional Assessment (MNA), geriatric nutritional risk index (GNRI), and body mass index (BMI). The mean follow-up period was 564.4 ± 346.3 days. The analysed group included 81.2% of men. The median age was 58, interquartile range (IQR) 49-64 years. Among all patients, almost 60% were classified as NYHA III or IV. Half of the participants were at risk of malnutrition, and 2.9% were malnourished. During follow-up, 72 (26.1%) patients died. The female sex was not associated with a higher occurrence of malnutrition (P = 0.99) or nutritional risk (P = 0.85), according to MNA. Coherently, GNRI scores did not differ significantly between the sexes (P = 0.29). In contrast, BMI was significantly higher in males (29.4 ± 5.3 vs. 25.9 ± 4.7; P < 0.001). Impaired nutritional status assessed with any method (MNA, GNRI, BMI) was not significantly associated with a worse prognosis. In multivariable analysis, NYHA class, lower estimated glomerular filtration rate, higher B-type natriuretic peptide (BNP), higher N-terminal fragment of proBNP, and higher uric acid were independent of sex and age predictors of all-cause mortality. CONCLUSION There were no sex differences in the nutritional status in the HFrEF patients, apart from lower BMI in females. Impaired nutritional status was not associated with mortality in both men and women.
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Affiliation(s)
- Marta Kałużna-Oleksy
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Helena Krysztofiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Filip Sawczak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Agata Kukfisz
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
- 3rd Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Curie-Sklodowska 9, 41-800 Zabrze, Poland
| | - Magdalena Szczechla
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Aleksandra Soloch
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Maria Cierzniak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Alicja Szubarga
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Katarzyna Przytarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Magdalena Dudek
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Wroclaw Medical University, Bartla 5, 51-618 Wroclaw, Poland
| | - Ewa Straburzyńska-Migaj
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
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25
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Ekpo E, Balla S, Ngo S, Witting C, Sarraju A, Furst A, Rodriguez F. Underrepresentation of Women in Reduced Ejection Heart Failure Clinical Trials With Improved Mortality or Hospitalization. JACC. ADVANCES 2024; 3:100743. [PMID: 38405270 PMCID: PMC10890822 DOI: 10.1016/j.jacadv.2023.100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND There are established sex-specific differences in heart failure with reduced ejection fraction (HFrEF) outcomes. Randomized clinical trials (RCTs) based on cardiovascular outcome benefits, typically either reduced cardiovascular mortality or hospitalization for heart failure (HHF), influence current guidelines for therapy. OBJECTIVES The authors evaluate the representation of women in HFrEF RCTs that observed reduced all-cause or cardiovascular mortality or HHF. METHODS We queried Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica dataBASE, Medical Literature Analysis and Retrieval System Online, and PubMed for HFrEF RCTs that reported a statistically significant benefit of intervention resulting in improved mortality or HHF published from 1980 to 2021. We estimated representation using the participation-to-prevalence ratio (PPR). A PPR of 0.8 to 1.2 was considered representative. RESULTS The final analysis included 33 RCTs. Women represented only 23.2% of all enrolled participants (n = 24,366/104,972), ranging from 11.4% to 40.1% per trial. Overall PPR was 0.58, with per-trial PPR estimates ranging from 0.29 to 1.00. Only 5 trials (15.2%) had a PPR of women representative of the disease population. Representation did not change significantly over time. The proportion of women in North American trials was significantly greater than trials conducted in Europe (P = 0.03). The proportion of women was greater in industry trials compared to government-funded trials (P = 0.05). CONCLUSIONS Women are underrepresented in HFrEF RCTs that have demonstrated mortality or HHF benefits and influence current guidelines. Representation is key to further delineation of sex-specific differences in major trial results. Sustained efforts are warranted to ensure equitable and appropriate inclusion of women in HFrEF trials.
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Affiliation(s)
- Eson Ekpo
- Department of Cardiovascular Medicine, Scripps Clinic, La Jolla, California, USA
| | - Sujana Balla
- Department of Internal Medicine, University of California-San Francisco, Fresno, California, USA
| | - Summer Ngo
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Celeste Witting
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ashish Sarraju
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adam Furst
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Palo Alto Veterans Institute for Research (PAVIR), Palo Alto, California, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
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Antwi-Amoabeng D, Neelam V, Ulanja MB, Beutler BD, Gbadebo TD, Sugathan P. Association between Psychiatric Disorders and the Incidence of Heart Failure in Women. J Cardiovasc Dev Dis 2023; 10:491. [PMID: 38132659 PMCID: PMC10743548 DOI: 10.3390/jcdd10120491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/18/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Depression and anxiety occur more frequently in women and are associated with an increased risk of cardiovascular disease. OBJECTIVES Data on the association between these psychiatric conditions and the incidence of acute heart failure (HF) and how they influence heart failure outcomes in women are lacking. We investigated this potential relationship using data from the National Inpatient Sample. METHODS We used ICD-10 codes to extract encounters for acute heart failure and/or the acute exacerbation of chronic heart failure, anxiety, and depression from the discharge data of the NIS from 2019 to 2020. We compared baseline characteristics and length of stay (LOS), cost of care (COC) and acute HF by depression/anxiety status for males and females and employed regression models to assess the influence of these psychiatric conditions on the outcomes. RESULTS There were 6,394,136 encounters involving females, which represented 56.6% of the sample. The prevalence of depression and anxiety were 15.7% and 16.8%, respectively. Among females, the occurrence of acute CHF did not differ by depression or anxiety status. However, Takostubo cardiomyopathy was more prevalent in those with depression (0.3% vs. 0.2%, p = 0.003) and anxiety (0.3% vs. 0.2%, p = 0.03) compared to those without these conditions. Among those with depression, LOS was significantly longer (3 days IQR: 2-6, vs. 3 days IQR:2-5 days, p < 0.001). The COC was USD 1481 more in patients with depression. On the contrary, LOS and COC were significantly lower in those without anxiety. CONCLUSIONS Depression was associated with an increased LOS among both men and women and an increased cost of care among women. Anxiety was associated with a decreased LOS and cost of care among women, which may be related to an increased rate of against medical advice (AMA) discharges among this population. Further research is necessary to identify optimal management strategies for depression and anxiety among patients hospitalized with HF.
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Affiliation(s)
- Daniel Antwi-Amoabeng
- Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70602, USA; (V.N.); (M.B.U.); (P.S.)
| | - Vijay Neelam
- Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70602, USA; (V.N.); (M.B.U.); (P.S.)
| | - Mark Bilinyi Ulanja
- Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70602, USA; (V.N.); (M.B.U.); (P.S.)
| | - Bryce David Beutler
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA;
| | | | - Prasanna Sugathan
- Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70602, USA; (V.N.); (M.B.U.); (P.S.)
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27
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Pabon M, Cunningham J, Claggett B, Felker GM, McMurray JJV, Metra M, Diaz R, Wang X, Arias-Mendoza A, Bonderman D, Crespo-Leiro M, Fonseca C, Goncalvesova E, Lund M, O'Meara E, Sliwa-Hahnle K, Malik FI, Solomon SD, Teerlink JR. Sex Differences in Heart Failure With Reduced Ejection Fraction in the GALACTIC-HF Trial. JACC. HEART FAILURE 2023; 11:1729-1738. [PMID: 37831045 DOI: 10.1016/j.jchf.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Women with heart failure with reduced ejection fraction (HFrEF) receive less guideline-recommended therapy and experience worse quality of life than men. OBJECTIVES The authors sought to assess differences in baseline characteristics, outcomes, efficacy, and safety of omecamtiv mecarbil between men and women enrolled in the GALACTIC-HF (Registrational Study With Omecamtiv Mecarbil [AMG 423] to Treat Chronic Heart Failure With Reduced Ejection Fraction) study. METHODS In GALACTIC-HF, patients with symptomatic heart failure with EF of 35% or less, recent heart failure event, and elevated natriuretic peptides were randomized to omecamtiv mecarbil or placebo. The current analysis investigated differences in baseline characteristics, clinical outcomes, and efficacy and safety of omecamtiv mecarbil between men and women. RESULTS Of 8,232 patients analyzed, 21.2% were women. Women more likely self-identified as being Black, had worse symptoms (lower Kansas City Cardiomyopathy Questionnaire Total Symptom Score [KCCQ-TSS]), and were less likely to be treated with angiotensin receptor/neprilysin inhibitor and devices at baseline. Compared with men, women had lower rates of the primary endpoint (adjusted HR: 0.80, 95% CI: 0.73-0.88). Sex did not significantly modify omecamtiv mecarbil's treatment effect (P interaction = 0.68). Women also had 20% less risk of cardiovascular death, heart failure event, and all-cause death. Women participants had lower rates of serious adverse events. CONCLUSIONS Women participants of the GALACTIC-HF trial had worse quality of life and were less likely to be treated with guideline-based therapies at baseline. Despite KCCQ-TSS being predictive of poor outcomes in this population, women had a 20% lower risk of an HF event or cardiovascular death compared with men. The beneficial effect of omecamtiv mecarbil did not significantly differ by sex. (Registrational Study With Omecamtiv Mecarbil [AMG 423] to Treat Chronic Heart Failure With Reduced Ejection Fraction [GALACTIC-HF]; NCT02929329).
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Affiliation(s)
- Maria Pabon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Cunningham
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian Claggett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Glasgow, United Kingdom
| | | | - Rafael Diaz
- Estudios Clínicos Latino América, Rosario, Argentina
| | - Xiaowen Wang
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Maria Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - Cândida Fonseca
- Department of Internal Medicine, Hospital São Francisco Xavier, Lisbon, Portugal
| | | | | | - Eileen O'Meara
- Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada
| | | | - Fady I Malik
- Cytokinetics Inc, South San Francisco, California, USA
| | - Scott D Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - John R Teerlink
- San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California, USA
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28
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Stempien-Otero A. HFrEF Progress for Women Remains Stagnant. JACC. HEART FAILURE 2023; 11:1739-1741. [PMID: 37921803 DOI: 10.1016/j.jchf.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 11/04/2023]
Affiliation(s)
- April Stempien-Otero
- Department of Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.
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29
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Dagan M, Dinh DT, Stehli J, Nan Tie E, Brennan A, Ajani AE, Clark DJ, Freeman M, Reid CM, Hiew C, Oqueli E, Kaye DM, Duffy SJ. Sex Differences in Pharmacotherapy and Long-Term Outcomes in Patients With Ischaemic Heart Disease and Comorbid Left Ventricular Dysfunction. Heart Lung Circ 2023; 32:1457-1464. [PMID: 37945426 DOI: 10.1016/j.hlc.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 06/07/2023] [Accepted: 09/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) are common among women. However, women tend to present later and are less likely to receive guideline-directed medical therapy (GDMT) compared with men. METHODS We analysed prospectively collected data (2005-2018) from a multicentre registry on GDMT 30 days after percutaneous coronary intervention in 13,015 patients with LV ejection fraction <50%. Guideline-directed medical therapy was defined as beta blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker±mineralocorticoid receptor antagonist. Long-term mortality was determined by linkage with the Australian National Death Index. RESULTS Women represented 20% (2,634) of the total cohort. Mean age was 65±12 years. Women were on average >5 years, with higher body mass index and higher rates of hypertension, diabetes, renal dysfunction, prior stroke, and rheumatoid arthritis. Guideline-directed medical therapy was similar between sexes (73% vs 72%; p=0.58), although women were less likely to be on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80% vs 82%; p=0.02). Women were less likely to be on statin therapy (p<0.001) or a second antiplatelet agent (p=0.007). Women had higher unadjusted long-term mortality (25% vs 19%; p<0.001); however, there were no differences in long-term mortality between sexes on adjusted analysis (hazard ratio 0.99; 95% confidence interval 0.87-1.14; p=0.94). CONCLUSIONS Rates of GDMT for LV dysfunction were high and similar between sexes; however, women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality in women was attenuated in adjusted analysis, which highlights the need for optimisation of baseline risk to improve long-term outcomes of women with IHD and comorbid LV dysfunction.
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Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia. http://www.twitter.com/misha_dagan
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Emilia Nan Tie
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Andrew E Ajani
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Population Health, Curtin University, Perth, WA, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia; School of Medicine, Deakin University, Melbourne, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Melbourne, Vic, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Vic, Australia.
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30
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Kittleson MM. Management of Heart Failure in Hospitalized Patients. Ann Intern Med 2023; 176:ITC177-ITC192. [PMID: 38079639 DOI: 10.7326/aitc202312190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Heart failure affects more than 6 million people in the United States, and hospitalizations for decompensated heart failure confer a heavy toll in morbidity, mortality, and health care costs. Clinical trials have demonstrated effective interventions; however, hospitalization and mortality rates remain high. Key components of effective hospital care include appropriate diagnostic evaluation, triage and risk stratification, early implementation of guideline-directed medical therapy, adequate diuresis, and appropriate discharge planning.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California (M.M.K.)
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31
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Seckin M, Johnston B, Petrie MC, Stewart S, Chan YK. Characteristics of symptoms and symptom change across different heart failure subtypes: a sex-stratified analysis. Eur J Cardiovasc Nurs 2023; 22:690-700. [PMID: 36288919 DOI: 10.1093/eurjcn/zvac099] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 10/12/2023]
Abstract
AIMS To examine sex-stratified differences in the association of left ventricular ejection fraction-based heart failure (HF) subtypes and the characteristics and correlates of self-reported changes in HF symptoms. METHODS AND RESULTS We report a secondary data analysis from 528 hospitalized individuals diagnosed with HF characterised by a reduced, mildly reduced, or preserved ejection fraction [HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), or HF with preserved ejection fraction (HFpEF)] who completed 12-month follow-up within a multicentre disease management trial. There were 302 men (71.1 ± 11.9 years, 58% with HFrEF) and 226 women (77.1 ± 10.6 years, 49% with HFpEF). The characteristics of self-reported symptoms measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12-month were analysed. At baseline, shortness of breath and fatigue predominated; with key differences according to HF subtypes in bilateral ankle oedema (both sexes), walking problems (women) and depressive symptoms (men). At 12-month follow-up, most KCCQ scores had not significantly changed. However, 25% of individuals reported worse symptom. In women, those with HFpEF had worse symptoms than those with HFmrEF/HFrEF (P = 0.025). On an adjusted basis, women [odds ratios (OR): 1.78, 95% confidence interval (CI): 1.00-3.16 vs. men], those with coronary artery disease (OR: 2.01, 95% CI: 1.21-3.31) and baseline acute pulmonary oedema (OR: 1.67, 95% CI: 1.02-2.75) were most likely to report worsening symptoms. Among men, worsening symptoms correlated with a history of hypertension (OR: 2.16, 95% CI: 1.07-4.35) and a non-English-speaking background (OR: 2.30, 95% CI: 1.02-5.20). CONCLUSION We found significant heterogeneity (with potential clinical implications) in the symptomatic characteristics and subsequent symptom trajectory according to the sex and HF subtype of those hospitalized with the syndrome. TRIAL REGISTRATION ANZCTR12613000921785.
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Affiliation(s)
- Muzeyyen Seckin
- School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
| | - Bridget Johnston
- School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
- NHS Greater Glasgow and Clyde, 1055 Great Western Rd, Glasgow, G12 0XH, UK
| | - Mark C Petrie
- NHS Greater Glasgow and Clyde, 1055 Great Western Rd, Glasgow, G12 0XH, UK
- School of Cardiovascular & Metabolic Health, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Simon Stewart
- School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
- Institute of Health Research, Notre Dame University of Australia, 32 Mouat St, Fremantle, WA 6160, Australia
| | - Yih-Kai Chan
- Mary MacKillop Institute for Health Research, Australia Catholic University, 215 Spring Street, Melbourne, VIC 3000, Australia
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32
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Oliveros E, Saldarriaga Giraldo CI, Hall J, Tinuoye E, Rodriguez MJ, Gallego C, Contreras JP. Addressing Barriers for Women with Advanced Heart Failure. Curr Cardiol Rep 2023; 25:1257-1267. [PMID: 37698818 DOI: 10.1007/s11886-023-01946-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE OF REVIEW Describe disparities in diagnosis and management between men and women with advanced heart failure (HF). Our goal is to identify barriers and suggest solutions. RECENT FINDINGS Women with advanced HF are less likely to undergo diagnostic testing and procedures (i.e., revascularization, implantable cardioverter defibrillators, cardiac resynchronization therapy, mechanical circulatory support, and orthotopic heart transplantation). Disparities related to gender create less favorable outcomes for women with advanced HF. The issues arise from access to care, paucity of knowledge, enrollment in clinical trials, and eligibility for advanced therapies. In this review, we propose a call to action to level the playing field in order to improve survival in women with advanced HF.
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Affiliation(s)
- Estefania Oliveros
- Heart and Vascular Institute, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA, 19444, USA.
| | | | - Jillian Hall
- Heart and Vascular Institute, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA, 19444, USA
| | - Elizabeth Tinuoye
- Department of Cardiology, Mount Sinai Hospital, Icahn School of Medicine, New York, NY, USA
| | | | - Catalina Gallego
- Pontificia Bolivariana, University of Antioquia, Cardiovid Clinic, Medellin, Colombia
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33
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Lam CSP, Docherty KF, Ho JE, McMurray JJV, Myhre PL, Omland T. Recent successes in heart failure treatment. Nat Med 2023; 29:2424-2437. [PMID: 37814060 DOI: 10.1038/s41591-023-02567-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/25/2023] [Indexed: 10/11/2023]
Abstract
Remarkable recent advances have revolutionized the field of heart failure. Survival has improved among individuals with heart failure and a reduced ejection fraction and for the first time, new therapies have been shown to improve outcomes across the entire ejection fraction spectrum of heart failure. Great strides have been taken in the treatment of specific cardiomyopathies such as cardiac amyloidosis and hypertrophic cardiomyopathy, whereby conditions once considered incurable can now be effectively managed with novel genetic and molecular approaches. Yet there remain substantial residual unmet needs in heart failure. The translation of successful clinical trials to improved patient outcomes is limited by large gaps in implementation of care, widespread lack of disease awareness and poor understanding of the socioeconomic determinants of outcomes and how to address disparities. Ongoing clinical trials, advances in phenotype segmentation for precision medicine and the rise in technology solutions all offer hope for the future.
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Affiliation(s)
- Carolyn S P Lam
- Duke-NUS Medical School, Singapore, Singapore.
- National Heart Centre Singapore, Singapore, Singapore.
- University Medical Center Groningen, Groningen, the Netherlands.
| | - Kieran F Docherty
- University of Glasgow, School of Cardiovascular and Metabolic Health, Glasgow, UK
| | - Jennifer E Ho
- CardioVascular Institute and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - John J V McMurray
- University of Glasgow, School of Cardiovascular and Metabolic Health, Glasgow, UK
| | - Peder L Myhre
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
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34
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Díez-Villanueva P, Jiménez-Méndez C, López-Lluva MT, Wasniewski S, Solís J, Fernández-Friera L, Martínez-Sellés M. Heart Failure in the Elderly: the Role of Biological and Sociocultural Aspects Related to Sex. Curr Heart Fail Rep 2023; 20:321-332. [PMID: 37498496 DOI: 10.1007/s11897-023-00619-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW Heart failure (HF) entails poor prognosis, with high morbidity and mortality burden, particularly in elderly patients. Notably, important sex differences have been described between men and women with HF. In this regard, some biological and sociocultural aspects related to sex may play a key role in the different development and prognosis of HF in elderly men and women. RECENT FINDINGS Important differences between men and women with HF, especially in the elderly population, have been specifically addressed in recent studies. Consequently, specific differences in biological and sociocultural aspects have been found to associate differences in pathophysiology, baseline clinical profile, and prognosis according to sex. Moreover, differences in comorbidities and frailty and other geriatric conditions, frequent in elderly population with HF, have also been described. Biological and sociocultural differences related to sex are key in the different clinical presentation and prognosis of heart failure in elderly women. Further studies will be required to better understand some other underlying reasons that may differently impact prognosis in elderly patients with HF.
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Affiliation(s)
- Pablo Díez-Villanueva
- Cardiology Department, Hospital Universitario de La Princesa, Calle Diego de León 62, 28006, Madrid, Spain.
| | | | | | - Samantha Wasniewski
- Cardiac Imaging Unit, Hospital Universitario HM Montepríncipe-CIEC, Madrid, Spain
- Universidad Camilo José Cela, Madrid, Spain
- Atria Clinic, Madrid, Spain
| | - Jorge Solís
- Atria Clinic, Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Leticia Fernández-Friera
- Cardiac Imaging Unit, Hospital Universitario HM Montepríncipe-CIEC, Madrid, Spain
- Universidad Camilo José Cela, Madrid, Spain
- Atria Clinic, Madrid, Spain
- Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
- Universidad Complutense and Universidad Europea de Madrid, Madrid, Spain
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35
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Qiu W, Cai A, Li L, Feng Y. Lagging behind the Western countries: the knowledge gaps of gender differences in heart failure in Asia. ESC Heart Fail 2023; 10:2797-2806. [PMID: 37652064 PMCID: PMC10567648 DOI: 10.1002/ehf2.14501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
Gender differences in heart failure (HF), ranging from epidemiological and pathophysiological factors to therapeutic response and prognosis, have been well documented in Western countries, especially in Europe and North America. The above gender differences in HF found in Westerners are rarely investigated in Asians. In this review, we explore the worrying knowledge gap on the gender differences in HF that existed in Asia in contrast with Western populations based on the following four aspects: epidemiology, risk factors, therapy, and prognosis. Finally, we conclude that investigations of gender differences in HF in Asia lag behind those in Europe and North America. Future work is required to establish and better use the high-level, population-based cohorts and develop our own high-quality, convincing clinical trials to deliver robust gender-specific conclusions in Asia.
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Affiliation(s)
- Weida Qiu
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular InstituteGuangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical UniversityNo. 106, Zhongshan 2nd Road, Yuexiu DistrictGuangzhou510080China
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
| | - Anping Cai
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular InstituteGuangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical UniversityNo. 106, Zhongshan 2nd Road, Yuexiu DistrictGuangzhou510080China
| | - Liwen Li
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular InstituteGuangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical UniversityNo. 106, Zhongshan 2nd Road, Yuexiu DistrictGuangzhou510080China
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
| | - Yingqing Feng
- Department of Cardiology, Hypertension Research Laboratory, Guangdong Cardiovascular InstituteGuangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical UniversityNo. 106, Zhongshan 2nd Road, Yuexiu DistrictGuangzhou510080China
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
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36
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Lam CSP, Piña IL, Zheng Y, Bonderman D, Pouleur AC, Saldarriaga C, Pieske B, Blaustein RO, Nkulikiyinka R, Westerhout CM, Armstrong PW. Age, Sex, and Outcomes in Heart Failure With Reduced EF: Insights From the VICTORIA Trial. JACC. HEART FAILURE 2023; 11:1246-1257. [PMID: 37565973 DOI: 10.1016/j.jchf.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Age and sex influence treatment and outcomes in patients with heart failure (HF). OBJECTIVES The authors examined the associations of age and sex with clinical characteristics, background therapies, outcomes, and response to vericiguat in this post hoc analysis of 5,050 VICTORIA (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) patients with HF and reduced ejection fraction; 1,568 (31%) were ≥75 years of age, of whom 445 (24%) were women. METHODS Clinical characteristics were compared across age (<65, 65 to <75, and ≥75 years) and sex. The treatment effect of vericiguat was estimated by age and sex on the primary composite outcome (time to first HF hospitalization or cardiovascular death) using Cox proportional hazards regression. RESULTS Compared with younger patients, those ≥75 years of age had more class III and IV symptoms, higher N-terminal pro-B-type natriuretic peptide levels, and worse kidney function but had the lowest use of triple therapy. No sex differences in triple therapy existed by age, but achieving target doses of triple therapy was less likely in older patients. Men ≥75 years of age were more than twice as likely to receive defibrillators and 65% more likely to undergo cardiac resynchronization than women. The primary composite outcome was nominally lower in women than men across all age groups. Vericiguat dosing did not differ between sexes in each age group, and its beneficial effect on the primary endpoint was not modified by age (continuous age, Pinteraction = 0.169; categorical age, Pinteraction = 0.189); and sex (3-way interaction; P = 0.847). CONCLUSIONS Although elderly women received less intense background HF therapy than men, their prognosis was nominally better. The benefit of vericiguat was independent of age and sex. (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction [HFrEF] [MK-1242-001] [VICTORIA]; NCT02861534).
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Affiliation(s)
- Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Ileana L Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Anne-Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Cardiovascular Division, Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
| | | | | | | | | | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Tromp J, Ezekowitz JA, Ouwerkerk W, Chandramouli C, Yiu KH, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Dickstein K, Collins SP, Filippatos G, Cleland JGF, Lam CSP. Global Variations According to Sex in Patients Hospitalized for Heart Failure in the REPORT-HF Registry. JACC. HEART FAILURE 2023; 11:1262-1271. [PMID: 37678961 DOI: 10.1016/j.jchf.2023.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Previous reports suggest that risk factors, management, and outcomes of acute heart failure (AHF) may differ by sex, but they rarely extended analysis to low- and middle-income countries. OBJECTIVES In this study, the authors sought to analyze sex differences in treatment and outcomes in patients hospitalized for AHF in 44 countries. METHODS The authors investigated differences between men and women in treatment and outcomes in 18,553 patients hospitalized for AHF in 44 countries in the REPORT-HF (Registry to Assess Medical Practice With Longitudinal Observation for the Treatment of Heart Failure) registry stratified by country income level, income disparity, and world region. The primary outcome was 1-year all-cause mortality. RESULTS Women (n = 7,181) were older than men (n = 11,372), were more likely to have heart failure with preserved left ventricular ejection fraction, had more comorbid conditions except for coronary artery disease, and had more severe signs and symptoms at admission. Coronary angiography, cardiac stress tests, and coronary revascularization were less frequently performed in women than in men. Women with AHF and reduced left ventricular ejection fraction were less likely to receive an implanted device, regardless of region or country income level. Women were more likely to receive treatments that could worsen HF than men (18% vs 13%; P < 0.0001). In countries with low-income disparity, women had better 1-year survival than men. This advantage was lost in countries with greater income disparity (Pinteraction < 0.001). CONCLUSIONS Women were less likely to have diagnostic testing or receive guideline-directed care than men. A survival advantage for women was observed only in countries with low income disparity, suggesting that equity of HF care between sexes remains an unmet goal worldwide.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Duke-NUS Medical School, Singapore.
| | - Justin A Ezekowitz
- The Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Wouter Ouwerkerk
- National Heart Centre, Singapore; Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | | | - Kai Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong, China; Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Ulf Dahlstrom
- Departments of Cardiology and Health, Medicine, and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Georg Ertl
- Comprehensive Heart Failure Center, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Mahmoud Hassanein
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sergio V Perrone
- Sanctuary of the Trinidad Miter, Lezica Cardiovascular Institute, El Cruce Hospital by Florencio Varela, Buenos Aires, Argentina
| | | | | | | | | | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus; Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-Being, University of Glasgow, Scotland, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Carolyn S P Lam
- Duke-NUS Medical School, Singapore; National Heart Centre, Singapore.
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Mansur AP, Pereira-Barretto AC, Del Carlo CH, Ianni BM, Avakian SD, Gonçalinho GHF, Nakagawa NK, César LAM, Bocchi EA. Sex Differences in Prognosis of Heart Failure Due to Chronic Chagas Cardiomyopathy. JACC. HEART FAILURE 2023; 11:1284-1286. [PMID: 37178080 DOI: 10.1016/j.jchf.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
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Stolfo D, Lund LH, Benson L, Lindberg F, Ferrannini G, Dahlström U, Sinagra G, Rosano GMC, Savarese G. Real-world use of sodium-glucose cotransporter 2 inhibitors in patients with heart failure and reduced ejection fraction: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1648-1658. [PMID: 37419495 DOI: 10.1002/ejhf.2971] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/09/2023] Open
Abstract
AIMS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce mortality/morbidity in heart failure (HF). We explored the implementation of SGLT2i over time, and patient characteristics associated with their use, in a large, nationwide population with HF with reduced ejection fraction (HFrEF). METHODS AND RESULTS Patients with HFrEF (ejection fraction <40%), no type 1 diabetes, estimated glomerular filtration rate (eGFR) <20 ml/min/1.73 m2 and/or on dialysis, registered in the Swedish HF Registry between 1 November 2020 and 5 August 2022 were included. Independent predictors of use were investigated by multivariable logistic regressions. Of 8192 patients, 37% received SGLT2i. Use increased overall from 20.5% to 59.0% over time, from 46.2% and 12.5% to 69.8% and 55.4% in patients with and without type 2 diabetes, from 14.7% and 22.3% to 58.0% and 59.8% in eGFR <60 versus ≥60 ml/min/1.73 m2 , from 21.0% and 18.9% to 61.6% and 52.0% in males versus females, from 24.2% and 18.0% to 60.8% and 57.7% in patients with versus without recent HF hospitalization, from 26.1% and 19.8% to 54.7% and 59.6% in inpatients versus outpatients, and from 20.2% and 21.2% to 59.2% and 58.7% in those with HF duration <6 versus ≥6 months, respectively. Important characteristics associated with SGLT2i use were male sex, recent HF hospitalization, specialized HF follow-up, lower ejection fraction, type 2 diabetes, higher education level, use of other HF/cardiovascular interventions. Older age, higher blood pressure, atrial fibrillation and anaemia were associated with less use. Discontinuation rate at 6 and 12 months was 13.1% and 20.0%, respectively. CONCLUSIONS Use of SGLT2i increased three-fold over 2 years. Although this indicates a more rapid translation of trial results and guidelines into clinical practice compared to previous HF drugs, further efforts are advocated to complete the implementation process while avoiding inequities across different patient subgroups and discontinuations.
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Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | | | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Mansur ADP, Pereira-Barretto AC, del Carlo CH, Avakian SD, Nakagawa NK, Cesar LAM, Bocchi EA. Sex Differences in Prognosis of Heart Failure Due to Ischemic and Nonischemic Cardiomyopathy. J Clin Med 2023; 12:5323. [PMID: 37629365 PMCID: PMC10456101 DOI: 10.3390/jcm12165323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/27/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Limited research has explored sex-specific differences in death predictors of HF patients with ischemic (iCMP) and nonischemic (niCMP) cardiomyopathy. This study assessed sex differences in niCMP and iCMP prognosis. METHODS We studied 7487 patients with HF between February 2017 and September 2020. Clinical features and echocardiographic findings were collected. We used Kaplan-Meier, Cox proportional hazard models, and chi-square scores of Cox regression to determine death predictors in women and men. RESULTS The mean age was 64.3 ± 14.2 years, with 4417 (59%) males. Women with iCMP and niCMP exhibited a significantly higher mean age, higher mean left ventricular ejection fraction, and smaller left ventricular diastolic diameter than men. Over 2.26 years of follow-up, 325 (14.7%) women and 420 (15.7%) men, and 211 women (24.5%) and 519 men (29.8%) with niCMP (p = NS) and iCMP (p = 0.004), respectively, died. The cumulative incidence of death was higher in men with iCMP (log-rank p < 0.0001) but similar with niCMP. Cox regression showed chronic kidney disease, diabetes, stroke, atrial fibrillation, age, and myocardial infarction as the main predictors of death for iCMP in women and men. CONCLUSIONS Women exhibited a better prognosis than men with iCMP, but similar for niCMP. Nevertheless, sex was not an independent predictor of death for both CMP.
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Affiliation(s)
- Antonio de Padua Mansur
- Serviço de Prevencao, Cardiopatia na Mulher e Reabilitação Cardiovascular, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Antonio Carlos Pereira-Barretto
- Serviço de Prevencao, Cardiopatia na Mulher e Reabilitação Cardiovascular, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Carlos Henrique del Carlo
- Hospital Dia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Solange Desirée Avakian
- Unidade Clinica de Valvopatias, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Naomi Kondo Nakagawa
- Departamento de Fisioterapia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 01246-903, SP, Brazil;
| | - Luiz Antonio Machado Cesar
- Unidade Clinica de Coronariopatias Crônicas, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Edimar Alcides Bocchi
- Unidade Clinica de Insuficiencia Cardiaca, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
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Arata A, Ricci F, Khanji MY, Mantini C, Angeli F, Aquilani R, Di Baldassarre A, Renda G, Mattioli AV, Nodari S, Gallina S. Sex Differences in Heart Failure: What Do We Know? J Cardiovasc Dev Dis 2023; 10:277. [PMID: 37504533 PMCID: PMC10380698 DOI: 10.3390/jcdd10070277] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Heart failure (HF) remains an important global health issue, substantially contributing to morbidity and mortality. According to epidemiological studies, men and women face nearly equivalent lifetime risks for HF. However, their experiences diverge significantly when it comes to HF subtypes: men tend to develop HF with reduced ejection fraction more frequently, whereas women are predominantly affected by HF with preserved ejection fraction. This divergence underlines the presence of numerous sex-based disparities across various facets of HF, encompassing aspects such as risk factors, clinical presentation, underlying pathophysiology, and response to therapy. Despite these apparent discrepancies, our understanding of them is far from complete, with key knowledge gaps still existing. Current guidelines from various professional societies acknowledge the existence of sex-based differences in HF management, yet they are lacking in providing explicit, actionable recommendations tailored to these differences. In this comprehensive review, we delve deeper into these sex-specific differences within the context of HF, critically examining associated definitions, risk factors, and therapeutic strategies. We provide a specific emphasis on aspects exclusive to women, such as the impact of pregnancy-induced hypertension and premature menopause, as these unique factors warrant greater attention in the broader HF discussion. Additionally, we aim to clarify ongoing controversies and knowledge gaps pertaining to the pharmacological treatment of HF and the sex-specific indications for cardiac implantable electronic devices. By shining a light on these issues, we hope to stimulate a more nuanced understanding and promote the development of more sex-responsive approaches in HF management.
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Affiliation(s)
- Allegra Arata
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London EC1M 6BQ, UK
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Mohammed Y Khanji
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London EC1M 6BQ, UK
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Angeli
- Department of Medical and Surgical Sciences, University of Bologna, Via Zamboni, 33-40126 Bologna, Italy
| | - Roberta Aquilani
- Cardiac Surgery Intensive Care Unit, Heart Department, SS Annunziata University Hospital, Via dei Vestini 5, 66100 Chieti, Italy
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, and Reprogramming and Cell Differentiation Lab, Center for Advanced Studies and Technology (CAST), "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Anna Vittoria Mattioli
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy
| | - Savina Nodari
- Department of Cardiology, University of Brescia and ASST "Spedali Civili" Hospital, 25123 Brescia, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
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Cobo Marcos M, de la Espriella R, Gayán Ordás J, Zegrí I, Pomares A, Llácer P, Fort A, Rodríguez Chavarri A, Méndez A, Blázquez Z, Caravaca Pérez P, Rubio Gracia J, Recio-Mayoral A, García Pinilla JM, Soler MJ, Garrido González R, Górriz JL, González Rico M, Castro A, Núñez J. Sex differences in Cardiorenal Syndrome: Insights from CARDIOREN Registry. Curr Heart Fail Rep 2023; 20:157-167. [PMID: 37222949 DOI: 10.1007/s11897-023-00598-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/25/2023]
Abstract
PURPOSE OF THE WORK Although sex-specific differences in heart failure (HF) or kidney disease (KD) have been analyzed separately, the predominant cardiorenal phenotype by sex has not been described. This study aims to explore the sex-related differences in cardiorenal syndrome (CRS) in a contemporary cohort of outpatients with HF. FINDINGS An analysis of the Cardiorenal Spanish registry (CARDIOREN) was performed. CARDIOREN Registry is a prospective multicenter observational registry including 1107 chronic ambulatory HF patients (37% females) from 13 Spanish HF clinics. Estimated Glomerular Filtration Rate (eGFR) < 60 ml/min/1.73 m2 was present in 59.1% of the overall HF population, being this prevalence higher in the female population (63.2% vs. 56.6%, p = 0.032, median age: 81 years old, IQR:74-86). Among those with kidney dysfunction, women displayed higher odds of showing HF with preserved ejection fraction (HFpEF) (odds ratio [OR] = 4.07; confidence interval [CI] 95%: 2.65-6.25, p < 0.001), prior valvular heart disease (OR = 1.76; CI 95%:1.13-2.75, p = 0.014), anemia (OR: 2.02; CI 95%:1.30-3.14, p = 0.002), more advanced kidney disease (OR for CKD stage 3: 1.81; CI 95%:1.04-3.13, p = 0.034; OR for CKD stage 4: 2.49, CI 95%:1.31-4.70, p = 0.004) and clinical features of congestion (OR:1.51; CI 95%: 1.02-2.25, p = 0.039). On the contrary, males with cardiorenal disease showed higher odds of presenting HF with reduced ejection fraction (HFrEF) (OR:3.13; CI 95%: 1.90-5.16, p < 0.005), ischemic cardiomyopathy (OR:2.17; CI 95%: 1.31-3.61, p = 0.003), hypertension (OR = 2.11; CI 95%:1.18-3.78, p = 0.009), atrial fibrillation (OR:1.71; CI 95%: 1.06-2.75, p = 0.025), and hyperkalemia (OR:2.43, CI 95%: 1.31-4.50, p = 0.005). In this contemporary registry of chronic ambulatory HF patients, we observed sex-related differences in patients with combined heart and kidney disease. The emerging cardiorenal phenotype characterized by advanced CKD, congestion, and HFpEF was predominantly observed in women, whereas HFrEF, ischemic etiology, hypertension, hyperkalemia, and atrial fibrillation were more frequently observed in men.
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Affiliation(s)
- Marta Cobo Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Rafael de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Jara Gayán Ordás
- Department of Cardiology, Hospital Universitario Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
| | - Isabel Zegrí
- Department of Cardiology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Antonia Pomares
- Department of Cardiology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Pau Llácer
- Internal Medicine Department, Hospital Universitario Ramón Y Cajal, IRYCIS, Madrid, Spain. Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Madrid, Spain
| | - Aleix Fort
- Department of Cardiology, Hospital Universitari Dr. Josep Trueta., Girona, Spain
| | | | - Ana Méndez
- Department of Cardiology, Hospital Universitario Vall d´Hebron, Barcelona, Spain
| | - Zorba Blázquez
- Department of Cardiology, Hospital Universtiario Gregorio Marañón, Madrid, Spain
| | | | - Jorge Rubio Gracia
- Department of Internal Medicine, Hospital Universitario Lozano Blesa, University of Zaragoza, Saragossa, Spain
| | | | | | - Maria Jose Soler
- Department of Nephrology, Hospital Universitario Vall d´Hebron, Barcelona, Spain
| | - Ramón Garrido González
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
| | - Jose Luis Górriz
- Department of Nephrology, Hospital Clínico Universitario Valencia (INCLIVA), University of Valencia, Valencia, Spain
| | - Miguel González Rico
- Department of Nephrology, Hospital Clínico Universitario Valencia (INCLIVA), University of Valencia, Valencia, Spain
| | - Almudena Castro
- Department of Cardiology, Hospital Universitario La Paz, Madrid, Spain
| | - Julio Núñez
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain.
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de Bakker M, Petersen TB, Akkerhuis KM, Harakalova M, Umans VA, Germans T, Caliskan K, Katsikis PD, van der Spek PJ, Suthahar N, de Boer RA, Rizopoulos D, Asselbergs FW, Boersma E, Kardys I. Sex-based differences in cardiovascular proteomic profiles and their associations with adverse outcomes in patients with chronic heart failure. Biol Sex Differ 2023; 14:29. [PMID: 37198662 DOI: 10.1186/s13293-023-00516-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/05/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Studies focusing on sex differences in circulating proteins in patients with heart failure with reduced ejection fraction (HFrEF) are scarce. Insight into sex-specific cardiovascular protein profiles and their associations with the risk of adverse outcomes may contribute to a better understanding of the pathophysiological processes involved in HFrEF. Moreover, it could provide a basis for the use of circulating protein measurements for prognostication in women and men, wherein the most relevant protein measurements are applied in each of the sexes. METHODS In 382 patients with HFrEF, we performed tri-monthly blood sampling (median follow-up: 25 [13-31] months). We selected all baseline samples and two samples closest to the primary endpoint (PEP: composite of cardiovascular death, heart transplantation, left ventricular assist device implantation, and HF hospitalization) or censoring. We then applied an aptamer-based multiplex proteomic assay identifying 1105 proteins previously associated with cardiovascular disease. We used linear regression models and gene-enrichment analysis to study sex-based differences in baseline levels. We used time-dependent Cox models to study differences in the prognostic value of serially measured proteins. All models were adjusted for the MAGGIC HF mortality risk score and p-values for multiple testing. RESULTS In 104 women and 278 men (mean age 62 and 64 years, respectively) cumulative PEP incidence at 30 months was 25% and 35%, respectively. At baseline, 55 (5%) out of the 1105 proteins were significantly different between women and men. The female protein profile was most strongly associated with extracellular matrix organization, while the male profile was dominated by regulation of cell death. The association of endothelin-1 (Pinteraction < 0.001) and somatostatin (Pinteraction = 0.040) with the PEP was modified by sex, independent of clinical characteristics. Endothelin-1 was more strongly associated with the PEP in men (HR 2.62 [95%CI, 1.98, 3.46], p < 0.001) compared to women (1.14 [1.01, 1.29], p = 0.036). Somatostatin was positively associated with the PEP in men (1.23 [1.10, 1.38], p < 0.001), but inversely associated in women (0.33 [0.12, 0.93], p = 0.036). CONCLUSION Baseline cardiovascular protein levels differ between women and men. However, the predictive value of repeatedly measured circulating proteins does not seem to differ except for endothelin-1 and somatostatin.
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Affiliation(s)
- Marie de Bakker
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun B Petersen
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K Martijn Akkerhuis
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Magdalena Harakalova
- Department of Cardiology, Division Heart and Lungs, Circulatory Health Research Center, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
- Regenerative Medicine Center Utrecht, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Victor A Umans
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Tjeerd Germans
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Peter D Katsikis
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter J van der Spek
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Navin Suthahar
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Folkert W Asselbergs
- Amsterdam University Medical Centers, Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
- Health Data Research UK and Institute of Health Informatics, University College London, London, UK
| | - Eric Boersma
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, Room Na-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Liu Z, Zhu Y, Chen S, Wu M, Huang H, Peng K, Zhang L, Zhao W, Peng X, Li N, Zhang H, Zhou Y, Peng Y, Fan J, Zeng J. Sex differences in patients with heart failure and mildly reduced left ventricular ejection fraction. Sci Rep 2023; 13:6832. [PMID: 37100821 PMCID: PMC10133291 DOI: 10.1038/s41598-023-33733-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
Clinical studies on heart failure with mildly reduced left ventricular ejection fraction (HFmrEF) have gradually increased. However, studies on the prognostic differences between men and women among patients with HFmrEF are few, and no evidence on sex differences in such patients exists. Therefore, we retrospectively assessed the data of patients with HFmrEF using propensity score-matched analysis (PSMA). A total of 1691 patients with HFmrEF were enrolled in the Outcome of Discharged HFmrEF Patients study (OUDI-HF study), which included 1095 men and 596 women. After propensity score matching, we compared the difference in cardiovascular (CV) events (cardiovascular death or heart failure readmission) and all-cause mortality at 90 days and 1 year after discharge between men and women using Kaplan-Meier analysis and Cox regression. After PSMA, men with HFmrEF were 2.2 times more likely to die at 90 days than women with HFmrEF [hazard ratio (HR) 1.88; 95% confidence interval (95% CI) 1.03-3.46; P = 0.041]. However, there was no difference in the 90-day CV events (HR 0.96; 95% CI 0.75-1.22; P = 0.718). Similarly, there was no difference in all-cause mortality (HR 1.16; 95% CI 0.81-1.65; P = 0.417) and CV events (HR 0.98; 95% CI 0.83-1.16; P = 0.817) between men and women after 1 year. Among the patients with HFmrEF, men had a higher 90-day risk of all-cause mortality than women after hospital discharge, and this risk disappeared after 1 year.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT05240118 (ESC Heart Failure. (2022). doi: https://doi.org/10.1002/ehf2.14044 ).
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Affiliation(s)
- Zhican Liu
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Yunlong Zhu
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Sihao Chen
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Mingxin Wu
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Haobo Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Ke Peng
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Lingling Zhang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Wenjiao Zhao
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Xin Peng
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Na Li
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Hui Zhang
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Yuying Zhou
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Yiqun Peng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Jie Fan
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China
| | - Jianping Zeng
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China.
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411100, China.
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Tamargo J, Caballero R, Mosquera ED. Sex and gender differences in the treatment of arterial hypertension. Expert Rev Clin Pharmacol 2023; 16:329-347. [PMID: 36891888 DOI: 10.1080/17512433.2023.2189585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Arterial hypertension represents the leading modifiable risk factor for all-cause death and early development of cardiovascular disease in women. Current clinical guidelines for the treatment of hypertension noted that women respond to antihypertensive drugs similarly to men and, therefore, treatment recommendations remain the same for both sexes. However, clinical evidence suggests the existence of sex- and gender-related differences (SGRD) in the prevalence, pathophysiology, pharmacodynamics (efficacy and safety) and pharmacokinetics of antihypertensive drugs. AREAS COVERED This review summarizes SGRD in the prevalence of hypertension, hypertension-mediated organ damage and blood pressure control, prescription patterns, and pharmacokinetics/ pharmacodynamics and doses of antihypertensive drugs. EXPERT OPINION There is limited information on SGRD in antihypertensive drug efficacy because of the underrepresentation of women in randomized clinical trials and, more important, because few trials reported results stratified by sex or performed sex-specific analyses. However, there are SGRD in hypertension-mediated organ damage, drug pharmacokinetics and, particularly, in drug safety. Prospective trials specifically designed to better understand the basis for SGRD in the pathophysiology of hypertension and in the efficacy and safety of antihypertensive drugs are needed to achieve a more personalized treatment of hypertension and hypertension-mediated organ damage in women.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| | - Eva Delpón Mosquera
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
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Coles TM, Lin L, Weinfurt K, Reeve BB, Spertus JA, Mentz RJ, Piña IL, Bocell FD, Tarver ME, Henke DM, Saha A, Caldwell B, Spring S. Do PRO Measures Function the Same Way for all Individuals With Heart Failure? J Card Fail 2023; 29:210-216. [PMID: 35691480 DOI: 10.1016/j.cardfail.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Theresa M Coles
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina.
| | - Li Lin
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Kevin Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Missouri
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Ileana L Piña
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Fraser D Bocell
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Michelle E Tarver
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Debra M Henke
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Anindita Saha
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Brittany Caldwell
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Silver Spring
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
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Suman S, Pravalika J, Manjula P, Farooq U. Gender and CVD- Does It Really Matters? Curr Probl Cardiol 2023; 48:101604. [PMID: 36690310 DOI: 10.1016/j.cpcardiol.2023.101604] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Satyam Suman
- Department of Pharmacy Practice, Care College of Pharmacy, Warangal, Telangana, India.
| | - Jakkula Pravalika
- Department of Pharmacy Practice, Care College of Pharmacy, Warangal, Telangana, India
| | - Pulluru Manjula
- Department of Pharmacology, Care College of Pharmacy, Warangal, Telangana, India
| | - Umar Farooq
- Department of Pharmaceutics, Care College of Pharmacy, Warangal, Telangana, India
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48
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Zhang G, Li Y, Li XM, Shen MT, Guo YK, Shi K, Yang ZG. Sex-related Differences in Left Ventricular Deformation in Patients With Hypertensive Heart Failure With Reduced Ejection Fraction: Assessment by Cardiac Magnetic Resonance Tissue Tracking. Curr Probl Cardiol 2023; 48:101601. [PMID: 36681211 DOI: 10.1016/j.cpcardiol.2023.101601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Ge Zhang
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yuan Li
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xue-Ming Li
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Meng-Ting Shen
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ke Shi
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Zhi-Gang Yang
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Vericiguat: A New Hope for Heart Failure Patients. Cardiovasc Ther 2022; 2022:1554875. [PMID: 36618548 PMCID: PMC9789902 DOI: 10.1155/2022/1554875] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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50
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Wang B, Lei L, Zhang H, Miao F, Zhang L, Tian A, Li J. Change in Depressive Symptoms During the First Month of Discharge and 1-Year Clinical Outcomes in Patients Hospitalized for Heart Failure. J Am Heart Assoc 2022; 11:e027438. [PMID: 36515248 PMCID: PMC9798811 DOI: 10.1161/jaha.122.027438] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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).
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Affiliation(s)
- Bin Wang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China,Fuwai Hospital, Chinese Academy of Medical SciencesShenzhenPeople’s Republic of China
| | - Lubi Lei
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China
| | - Haibo Zhang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China
| | - Fengyu Miao
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China
| | - Lihua Zhang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China
| | - Aoxi Tian
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China
| | - Jing Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular DiseaseFuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular DiseasesBeijingPeople’s Republic of China,Fuwai Hospital, Chinese Academy of Medical SciencesShenzhenPeople’s Republic of China,Central China Subcenter of the National Center for Cardiovascular DiseasesZhengzhouPeople’s Republic of China
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