1
|
Nicolaou PA. Sex differences in heart failure medications targeting the renin-angiotensin-aldosterone system. Eur J Pharmacol 2021; 897:173961. [PMID: 33617824 DOI: 10.1016/j.ejphar.2021.173961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/05/2021] [Accepted: 02/15/2021] [Indexed: 12/28/2022]
Abstract
Heart failure (HF) is a major healthcare problem. Sex-related differences in clinical manifestations, outcomes, risk factors and symptoms in HF have been described in the literature. Sex-related differences have also been described in the regulation of the renin-angiotensin-aldosterone system (RAAS), which is at the core of the pathophysiology of HF. Considering that drugs targeting RAAS are cornerstones in the treatment of HF, it is important to determine whether sex-related differences exist in the use of angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs) and ARB/neprilysin inhibitors (ARNIs). In regards to the relative efficacy of RAAS drugs in men vs. women in HF, there are conflicting results, which may stem from the fact that a lot of clinical trials were not specifically designed to investigate sex differences, with many of them having an underrepresentation of women. With respect to optimal dosage of RAAS drugs, even though, current HF guidelines, recommend up-titration to the same target dose in both men and women, evidence suggests that lower doses could be used in women. Furthermore, several studies have reported underutilization of guideline-directed medical therapy in women, including ACEIs, ARBs and MRAs, which may be at least partially attributed to increased prevalence of HF with a preserved ejection fraction and increased propensity for adverse effects in women. Overall, these investigations have shed some light on sex-related differences but there is scope for conducting further studies to determine the optimal use of RAAS drugs in men and women with failing hearts.
Collapse
Affiliation(s)
- Persoulla A Nicolaou
- Department of Basic and Clinical Sciences, Medical School, University of Nicosia, Cyprus; Honorary Senior Lecturer, St. George's, University of London, UK.
| |
Collapse
|
2
|
Differential Impact of Heart Failure With Reduced Ejection Fraction on Men and Women. J Am Coll Cardiol 2019; 73:29-40. [DOI: 10.1016/j.jacc.2018.09.081] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 11/20/2022]
|
3
|
Torpet LA, Kragelund C, Reibel J, Nauntofte B. Oral Adverse Drug Reactions to Cardiovascular Drugs. ACTA ACUST UNITED AC 2016; 15:28-46. [PMID: 14761898 DOI: 10.1177/154411130401500104] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A great many cardiovascular drugs (CVDs) have the potential to induce adverse reactions in the mouth. The prevalence of such reactions is not known, however, since many are asymptomatic and therefore are believed to go unreported. As more drugs are marketed and the population includes an increasing number of elderly, the number of drug prescriptions is also expected to increase. Accordingly, it can be predicted that the occurrence of adverse drug reactions (ADRs), including the oral ones (ODRs), will continue to increase. ODRs affect the oral mucous membrane, saliva production, and taste. The pathogenesis of these reactions, especially the mucosal ones, is largely unknown and appears to involve complex interactions among the drug in question, other medications, the patient’s underlying disease, genetics, and life-style factors. Along this line, there is a growing interest in the association between pharmacogenetic polymorphism and ADRs. Research focusing on polymorphism of the cytochrome P450 system (CYPs) has become increasingly important and has highlighted the intra- and inter-individual responses to drug exposure. This system has recently been suggested to be an underlying candidate regarding the pathogenesis of ADRs in the oral mucous membrane. This review focuses on those CVDs reported to induce ODRs. In addition, it will provide data on specific drugs or drug classes, and outline and discuss recent research on possible mechanisms linking ADRs to drug metabolism patterns. Abbreviations used will be as follows: ACEI, ACE inhibitor; ADR, adverse drug reaction; ANA, antinuclear antigen; ARB, angiotensin II receptor blocker; BAB, beta-adrenergic blocker; CCB, calcium-channel blocker; CDR, cutaneous drug reaction; CVD, cardiovascular drug; CYP, cytochrome P450 enzyme; EM, erythema multiforme; FDE, fixed drug eruption; I, inhibitor of CYP isoform activity; HMG-CoA, hydroxymethyl-glutaryl coenzyme A; NAT, N-acetyltransferase; ODR, oral drug reaction; RDM, reactive drug metabolite; S, substrate for CYP isoform; SJS, Stevens-Johnson syndrome; SLE, systemic lupus erythematosus; and TEN, toxic epidermal necrolysis.
Collapse
Affiliation(s)
- Lis Andersen Torpet
- Department of Oral Medicine, Clinical Oral Physiology, Oral Pathology & Anatomy, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, 20 Norre Allé, DK-2200 Copenhagen N, Denmark
| | | | | | | |
Collapse
|
4
|
Lam CSP, McEntegart M, Claggett B, Liu J, Skali H, Lewis E, Køber L, Rouleau J, Velazquez E, Califf R, McMurray JJ, Pfeffer M, Solomon S. Sex differences in clinical characteristics and outcomes after myocardial infarction: insights from the Valsartan in Acute Myocardial Infarction Trial (VALIANT). Eur J Heart Fail 2015; 17:301-12. [DOI: 10.1002/ejhf.238] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/11/2014] [Accepted: 11/14/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Carolyn S. P. Lam
- National University Health System; Tower Block Level 9, 1E Kent Ridge Road Singapore 119228
| | | | | | | | | | | | | | | | | | - Rob Califf
- Duke University Medical Center; Durham NC USA
| | - John J. McMurray
- Department of Cardiology; Western Infirmary; Glasgow Scotland UK
| | | | | |
Collapse
|
5
|
Effects of treatment with zofenopril in men and women with acute myocardial infarction: gender analysis of the SMILE Program. PLoS One 2014; 9:e111558. [PMID: 25364906 PMCID: PMC4218766 DOI: 10.1371/journal.pone.0111558] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/05/2014] [Indexed: 12/28/2022] Open
Abstract
Background the SMILE studies proved the prognostic benefit of zofenopril vs. placebo or other ACE-inhibitors (ACEIs) in post-acute myocardial infarction (AMI). In this retrospective pooled analysis of these studies we assessed whether the zofenopril effect is influenced by gender. Methods the four double-blind, randomized, parallel-group SMILE studies, compared the efficacy and safety of 6–48 week treatment with zofenopril 60 mg/day with that of placebo, lisinopril 10 mg/day or ramipril 10 mg/day in 3630 AMI patients. This pooled analysis compared treatment efficacy (1-year combined occurrence of death or hospitalization for CV causes) in 2733 men and 897 women. Results women were older than men, had a higher prevalence of diabetes and of other major CV risk factors. The risk of a major CV event was significantly larger for women (23% vs. 17% men, p<0.001). Between-gender risk difference was more marked for people living in Southern (+54%) than in Northern Europe (+12%). In both genders zofenopril similarly reduced the 1-year risk of CV morbidity and mortality vs. placebo (−39% men, p = 0.0001; −40% women, p = 0.005). The risk reduction was more marked with zofenopril than with the other ACEIs, particularly in men (−27%, p = 0.012; women: −14%, p = 0.479). The drug safety profile was similar between genders in zofenopril-treated patients, while it was worse in women treated with other ACEIs. Conclusions post-AMI women are at higher risk of CV complications than men, particularly when living in Mediterranean countries. Their response to ACE-inhibition varies according to the type of drug and is usually better in men.
Collapse
|
6
|
Franconi F, Campesi I. Pharmacogenomics, pharmacokinetics and pharmacodynamics: interaction with biological differences between men and women. Br J Pharmacol 2014; 171:580-94. [PMID: 23981051 PMCID: PMC3969074 DOI: 10.1111/bph.12362] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 08/05/2013] [Accepted: 08/16/2013] [Indexed: 12/16/2022] Open
Abstract
Pharmacological response depends on multiple factors and one of them is sex-gender. Data on the specific effects of sex-gender on pharmacokinetics, as well as the safety and efficacy of numerous medications, are beginning to emerge. Nevertheless, the recruitment of women for clinical research is inadequate, especially during the first phases. In general, pharmacokinetic differences between males and females are more numerous and consistent than disparities in pharmacodynamics. However, sex-gender pharmacodynamic differences are now increasingly being identified at the molecular level. It is now even becoming apparent that sex-gender influences pharmacogenomics and pharmacogenetics. Sex-related differences have been reported for several parameters, and it is consistently shown that women have a worse safety profile, with drug adverse reactions being more frequent and severe in women than in men. Overall, the pharmacological status of women is less well studied than that of men and deserves much more attention. The design of clinical and preclinical studies should have a sex-gender-based approach with the aim of tailoring therapies to an individual's needs and concerns.
Collapse
Affiliation(s)
- Flavia Franconi
- Department of Biomedical Sciences, University of SassariSassari, Italy
- Laboratory of Sex-Gender Medicine, National Institute of Biostructures and BiosystemsOsilo, Italy
| | - Ilaria Campesi
- Laboratory of Sex-Gender Medicine, National Institute of Biostructures and BiosystemsOsilo, Italy
- Department of Surgical, Microsurgical and Medical Sciences, University of SassariSassari, Italy
| |
Collapse
|
7
|
Jiménez-Navarro MF, Ramirez-Marrero MA, Anguita-Sánchez M, Castillo JC. Influence of gender on long-term prognosis of patients with chronic heart failure seen in heart failure clinics. Clin Cardiol 2011; 33:E13-8. [PMID: 20155855 DOI: 10.1002/clc.20476] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Controversy exists concerning the influence of gender in the prognosis of patients with heart failure and no evidence is available from specific heart failure clinics. HYPOTHESIS Women with ambulatory heart failure are managed differently than men, although their prognosis might be better than men. METHODS AND RESULTS We analyzed the clinical characteristics, complementary test results, treatment, and prognosis in 4720 patients with chronic heart failure seen in 62 specialized clinics forming part of a multicenter registry during a mean follow-up of 40 months. The mean age was 65 +/- 12 years and 71% were men. The men were younger than the women and more often had a history of hyperlipidemia and ischemic heart disease. The men had a more advanced heart failure New York Heart Association (NYHA) functional class (III-IV) than the women and a greater frequency of systolic ventricular dysfunction. The men more often received treatment with beta-blockers, vasodilators, and antiplatelet aggregators as well as higher mean doses as compared with the women. The overall survival after the follow-up was similar for both genders, although the women had lower rates of survival free of admission for heart failure. CONCLUSIONS Despite the mortality of women and men with heart failure being similar, the rate of readmission for heart failure is greater in women in specialized heart failure clinics. These results may be associated with the pharmacological treatment differences observed.
Collapse
Affiliation(s)
- Manuel F Jiménez-Navarro
- Servicio de Cardiologia, Hospital Clínico Universitario Virgen de la Victoria de Málaga, Campus de Teatinos, Málaga, Spain.
| | | | | | | | | |
Collapse
|
8
|
Frankenstein L, Clark AL, Ribeiro JP. Influence of sex on treatment and outcome in chronic heart failure. Cardiovasc Ther 2011; 30:182-92. [PMID: 21599874 DOI: 10.1111/j.1755-5922.2010.00253.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The population is aging, the prevalence of heart failure increases with age, and on average women live longer than men. There is evidence for sex-specific effects of individual, guideline-recommended drugs used for treatment of chronic heart failure. Women are underrepresented in most clinical trials and only a minority of drug applications to regulatory authorities have included sex analyses. The present review focuses on the potential female survival benefit in heart failure, the influence of sex on medical treatment in a broader sense, and the potential benefit to be derived from guideline recommended treatment and common adjunctive heart failure medication.
Collapse
Affiliation(s)
- Lutz Frankenstein
- Department of Cardiology, Angiology, Pulmonology, University of Heidelberg, Germany.
| | | | | |
Collapse
|
9
|
Equitable Improvement for Women and Men in the Use of Guideline-Recommended Therapies for Heart Failure: Findings From IMPROVE HF. J Card Fail 2010; 16:940-9. [DOI: 10.1016/j.cardfail.2010.07.250] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 07/20/2010] [Accepted: 07/22/2010] [Indexed: 11/21/2022]
|
10
|
Shiba N, Nochioka K, Kohno H, Matsuki M, Takahashi J, Tada T, Kagaya Y, Shimokawa H. Emerging problems of heart failure practice in Japanese women: lessons from the CHART study. Circ J 2008; 72:2009-14. [PMID: 18948671 DOI: 10.1253/circj.cj-07-1000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prognosis of patients with chronic heart failure (CHF) is poor in both men and women. However, the characteristics of, and effective treatment strategy for, female CHF patients still remain unclear. This study was designed to evaluate the prognosis and characteristics of female patients in a CHF cohort termed the Chronic Heart Failure Analysis and Registry in the Tohoku District. METHODS AND RESULTS Of 1,278 patients registered in the cohort, the study population comprised 1,166 symptomatic CHF patients with sufficient data. As compared with male patients, female patients were more likely to be older, have preserved systolic function and non-ischemic etiology of CHF, and underuse standard CHF medications. Although a previous study showed that sex-difference was not a significant prognostic factor in CHF patients, the unadjusted survival analysis revealed an increased event rate in female patients in the present study. Multivariate analysis revealed that older age, diabetes, ventricular tachycardia and anemia were significant prognostic risks in both men and women with CHF. CONCLUSIONS Female sex had a significant link with elderly CHF patients. Given the explosive increase in elderly patients in Westernized countries, further studies are needed to elucidate the evidence for treatment of female CHF patients.
Collapse
Affiliation(s)
- Nobuyuki Shiba
- Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
McAlister FA, Campbell NRC, Duong-Hua M, Chen Z, Tu K. Antihypertensive medication prescribing in 27,822 elderly Canadians with diabetes over the past decade. Diabetes Care 2006; 29:836-41. [PMID: 16567824 DOI: 10.2337/diacare.29.04.06.dc05-1875] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this study was to examine whether prescribing practices for elderly individuals with diabetes and hypertension changed over the past decade. RESEARCH DESIGN AND METHODS We linked the Ontario Diabetes Database and four administrative databases in Ontario, Canada, to identify 27,822 patients >65 years of age who had diabetes and were newly treated for hypertension between 1 January 1995 and 31 December 2001. All patients were followed for 2 years after their initial antihypertensive medication prescription. RESULTS The 27,822 patients in this study (mean age 72 years, 51% men) were treated with oral hypoglycemic agents alone (n = 17,128 patients, 62%), insulin alone (n = 2,346, 8%), both oral hypoglycemic agents and insulin (n = 2,205, 8%), or diet alone (n = 6,143, 22%). Management within the first 2 years of hypertension diagnosis consisted of antihypertensive monotherapy in 20,183 patients (73%), two antihypertensive drugs in 6,207 (22%), and three or more drugs in 1,432 (5%); the most frequently chosen antihypertensive drugs were ACE inhibitors (68%), thiazides (15%), and calcium channel blockers (9%). Between 1995 and 2001, physician prescribing practices changed: the population-adjusted rates of antihypertensive drug prescribing increased by 46% (95% CI 33-55%), the proportion of initial antihypertensive prescriptions for ACE inhibitors increased from 54 to 76% (P < 0.0001), and the use of multiple antihypertensive agents within the first 2 years of diagnosis increased from 21 to 32% (P < 0.0001). CONCLUSIONS Antihypertensive prescribing patterns in elderly individuals with diabetes changed over the past decade in Ontario in directions consistent with the evolving evidence base.
Collapse
Affiliation(s)
- Finlay A McAlister
- Department of Medicine, University of Alberta, Edmonton, Alberta T6G 2R7, Canada.
| | | | | | | | | |
Collapse
|
12
|
Kasje WN, Denig P, Stewart RE, de Graeff PA, Haaijer-Ruskamp FM. Physician, organisational and patient characteristics explaining the use of angiotensin converting enzyme inhibitors in heart failure treatment: a multilevel study. Eur J Clin Pharmacol 2005; 61:145-51. [PMID: 15761751 DOI: 10.1007/s00228-005-0897-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Accepted: 01/10/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Heart failure treatment in general practice is not concordant with guideline recommendations. Insight into the key determinants at different levels is needed in order to improve care. The aim was to assess the influence of physician, organisational and patient characteristics on the treatment of chronic heart failure with angiotensin converting enzyme (ACE) inhibitors in primary care. METHODS Physician and organisational data were collected by means of a questionnaire. Patient and treatment data were extracted from electronic medical records. Multilevel analysis was used to assess the effect of physician, organisational and patient factors on the treatment with ACE inhibitors in terms of prescription rate and dosage. RESULTS Data from 735 randomly selected heart failure patients were extracted from the medical records of 95 general practitioners (GPs). Patients who visited a cardiologist or an outpatient heart failure clinic were more likely to receive an ACE inhibitor. In addition, relatively young patients, male patients and patients already using a diuretic were more likely to receive an ACE inhibitor. Furthermore, male patients and patients with concomitant hypertension were more likely to receive a higher dose of ACE inhibitor. GP characteristics did not determine whether CHF patients received ACE inhibitor treatment. CONCLUSION The differences in ACE inhibitor prescribing seem to be linked more to patient than physician characteristics. Interventions to improve the quality of care should therefore focus on the treatment of specific patient groups. Specialised care, particularly through outpatient clinics, could lead to improvement in the use of ACE inhibitors.
Collapse
Affiliation(s)
- Willeke N Kasje
- Department of Clinical Pharmacology, University of Groningen, A. Deusinglaan 1, 9713AV, Groningen, The Netherlands
| | | | | | | | | |
Collapse
|
13
|
Opasich C, De Feo S, Ambrosio GA, Bellis P, Di Lenarda A, Di Tano G, Fico D, Gonzini L, Lavecchia R, Tomasi C, Maggioni AP. The 'real' woman with heart failure. Impact of sex on current in-hospital management of heart failure by cardiologists and internists. Eur J Heart Fail 2005; 6:769-79. [PMID: 15542415 DOI: 10.1016/j.ejheart.2003.11.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2002] [Revised: 06/23/2003] [Accepted: 11/13/2003] [Indexed: 11/29/2022] Open
Abstract
AIM To identify differences between sexes in the clinical profile, use of resources, management and outcome in a large population of 'real world' patients with heart failure (HF). METHODS A prospective cross-sectional survey was conducted on 2127 consecutive patients (47% women) admitted with HF to 167 cardiology and 250 internal medicine departments between February 14 and 25, 2000. RESULTS Women were older, had a higher prevalence of atrial fibrillation, and more frequently a hypertensive or valvular aetiology. Females were admitted more frequently in Medical than in Cardiology Departments. The rate of invasive and non-invasive procedures was lower in women than in men, slightly higher if managed by cardiologists. Women were less frequently prescribed ACE-inhibitors, amiodarone, and spironolactone, and more frequently prescribed digoxin. In-hospital mortality was similar, without difference between health-care providers. A 6-month follow-up was performed in 56.4% of the cases in both setting, but less frequently in women. Event rates were similar with nearly half of patients re-hospitalised at least once. CONCLUSION The 'real' HF woman has generally a more severe disease; she is an old lady who is more frequently hospitalised in a medical unit, receives few diagnostic, and cardiovascular procedures and pharmacological therapy, has a relatively low probability of dying in hospital, but a high likelihood of requiring readmission.
Collapse
Affiliation(s)
- C Opasich
- Department of Cardiology, Salvatore Maugeri Foundation, Pavia, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Muntwyler J, Cohen-Solal A, Freemantle N, Eastaugh J, Cleland JG, Follath F. Relation of sex, age and concomitant diseases to drug prescription for heart failure in primary care in Europe. Eur J Heart Fail 2005; 6:663-8. [PMID: 15302016 DOI: 10.1016/j.ejheart.2004.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2003] [Revised: 02/19/2004] [Accepted: 03/10/2004] [Indexed: 11/15/2022] Open
Abstract
AIM To study the role of sex, age and concomitant diseases for prescription of cardiovascular drugs among patients with heart failure cared for in the community. METHODS AND RESULTS In 15 European countries, a survey was conducted during 1999 and 2000 among 1363 primary care physicians who included 8256 patients with symptoms of heart failure. Predictors of drug prescription were assessed with multivariate logistic regression. Overall prescription rates for ACE-inhibitors/angiotensin receptor blockers (ACE-I/ARB), beta-blockers, digitalis, diuretics and oral anticoagulants were 69%, 30%, 41%, 75% and 18%. Women had no reduced likelihood to receive ACE-I/ARB and beta-blockers (odds ratio [OR]=0.96 [95% CI 0.87-1.06] and 1.02 [0.92-1.13], respectively), but prescription of oral anticoagulants was decreased (OR=0.74, 95% CI 0.65-0.84). Compared to patients <65 years of age, ACE-I/ARB prescription did not materially decline up to 75-85 years (R=0.91, 95% CI 0.81-1.04), whereas beta-blocker prescription was already significantly decreased in this age category (OR=0.49, 95% CI 0.43-0.56). There was no general under-prescription of evidence-based cardiovascular drugs in patients with concomitant diseases. CONCLUSIONS Among heart failure patients cared for in the community advanced age strongly predicts decreased prescription of beta-blockers. Female sex and comorbidity is not associated with a consistent underutilization of evidence-based cardiovascular drugs.
Collapse
Affiliation(s)
- Jorg Muntwyler
- Department of Internal Medicine, University Hospital, Zurich, Switzerland.
| | | | | | | | | | | |
Collapse
|
15
|
Rathore SS, Foody JM, Wang Y, Herrin J, Masoudi FA, Havranek EP, Ordin DL, Krumholz HM. Sex, quality of care, and outcomes of elderly patients hospitalized with heart failure: findings from the National Heart Failure Project. Am Heart J 2005; 149:121-8. [PMID: 15660043 PMCID: PMC2790278 DOI: 10.1016/j.ahj.2004.06.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Previous studies have demonstrated that women hospitalized for heart failure receive poorer quality of care and have worse outcomes than men. However, these studies were based upon selected patient populations and lacked quality of care measures. METHODS We used data from the National Heart Failure Project, a national sample of fee-for-service Medicare patients hospitalized with heart failure in the United States in 1998-1999, to evaluate differences in quality of care and patient outcomes between men and women. Multivariable hierarchical logistic regression models and chi2 analyses were used to examine sex differences in the documentation of left ventricular systolic function (LVSF), prescription of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for patients with left ventricular dysfunction, and mortality within 30 days and 1 year of admission in the study cohort (n = 30,996). RESULTS Women had lower overall rates of LVSF assessment than men (64.9% vs 69.5%, P < .001). Among patients classified as candidates for ACE inhibitor prescription, women had lower crude rates of ACE inhibitor prescription than men (70.1% vs 74.2%, P = .015), but treatment rates were similar when evaluating the prescription of ACE inhibitors or ARBs (78.9% women vs 81.3% men, P = .11). Despite lower rates of treatment, women had lower mortality rates than men at 30 days (9.2% vs 11.4%, P < .001) and 1 year (36.2% vs 43.0%, P < .001) after admission. Results were similar after multivariable adjustment. CONCLUSIONS There were small sex differences in the quality of care provided to fee-for-service Medicare patients hospitalized with heart failure, although women had higher rates of survival than men up to 1 year after hospitalization.
Collapse
Affiliation(s)
- Saif S Rathore
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn, USA
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Murphy NF, Simpson CR, McAlister FA, Stewart S, MacIntyre K, Kirkpatrick M, Chalmers J, Redpath A, Capewell S, McMurray JJV. National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland. Heart 2004; 90:1129-36. [PMID: 15367505 PMCID: PMC1768509 DOI: 10.1136/hrt.2003.029553] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK. DESIGN Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000. SETTING 53 primary care practices (307,741 patients). SUBJECTS 2186 adult patients with heart failure. RESULTS The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients > or = 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients > or = 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a beta blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p = 0.29 versus men), 7% (p = 0.02), and 34% (p < 0.001). Among patients < 75 years 26% were prescribed a beta blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients > or = 75 years were 19% (p = 0.04 versus patients < 75), 7% (p = 0.04), and 33% (p < 0.001). CONCLUSIONS Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women.
Collapse
Affiliation(s)
- N F Murphy
- Department of Cardiology, Western Infirmary, Glasgow, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Foody JM, Rathore SS, Wang Y, Herrin J, Masoudi FA, Havranek EP, Radford MJ, Krumholz HM. Predictors of cardiologist care for older patients hospitalized for heart failure. Am Heart J 2004; 147:66-73. [PMID: 14691421 DOI: 10.1016/j.ahj.2003.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies have suggested that cardiologists may provide higher quality heart failure care than generalists. However, national rates of specialty care during hospitalization for heart failure and factors associated with care by a cardiologist are unknown. METHODS We assessed specialty care in a sample of Medicare patients hospitalized nationwide with heart failure between 1998 and 1999 (n = 25,869). Multivariable hierarchical logistic regression models were used to identify factors independently associated with treatment by a cardiologist. RESULTS One-quarter (25.5%) of patients had a cardiologist as their attending physician, 31.3% of patients received a cardiology consult, and 43.2% of patients were not treated by a cardiologist during hospitalization. Older patients (age <75 years: referent; age 75-84 years: risk ratio [RR], 0.92; 95% CI, 0.86-0.98; age > or =85 years: RR, 0.81; 95% CI, 0.74-0.88) and women (RR, 0.87; 95% CI, 0.83-0.93) were less likely to have an attending cardiologist. Patients with a history of heart failure (RR, 1.13; 95% CI, 1.06-1.20), coronary disease (RR, 1.23; 95% CI, 1.14-1.32), coronary artery bypass grafting (RR, 1.42; 95% CI, 1.32-1.42), or percutaneous transluminal coronary angioplasty (RR, 1.30; 95% CI, 1.19-1.42) were more likely to be treated by a cardiologist, whereas patients with chronic obstructive pulmonary disease (RR, 0.74; 95% CI, 0.70-0.79) and dementia (RR, 0.61; 95% CI, 0.54-0.70) were less likely to be treated by a cardiologist. Patient race was not associated with treatment by a cardiologist. The strongest predictors of attending cardiology care were hospital factors, including large volume (>300 beds; RR, 1.45; 95% CI, 1.32-1.42) and geographic location (RR, 1.00 Northeast (referent) vs RR, 0.55; 95% CI 0.46-0.65 Midwest). CONCLUSIONS Slightly more than half of older patients with heart failure received care from a cardiologist. Several patient characteristics, including age and sex, were associated with the use of specialty care, suggesting that factors other than clinical presentation may independently influence the use of specialty care.
Collapse
Affiliation(s)
- JoAnne Micale Foody
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn 06520-8025, USA
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M, Fang J, Jarcho J, Mudge G, Stevenson LW. Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality. J Am Coll Cardiol 2003; 41:2029-35. [PMID: 12798577 DOI: 10.1016/s0735-1097(03)00417-0] [Citation(s) in RCA: 174] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study examined the hypothesis that patients who develop angiotensin-converting enzyme inhibitor intolerance attributable to circulatory-renal limitations (CRLimit) have more severe underlying disease and worse outcome. BACKGROUND Although the renin-angiotensin system contributes to the progression of heart failure (HF), it also supports the failing circulation. Patients with the most severe disease may not tolerate inhibition of this system. METHODS Consecutive inpatient admissions to the cardiomyopathy service of the Brigham and Women's Hospital between 2000 and 2002 were reviewed retrospectively for initial profiles, discharge medications, and documented reasons for discontinuation of angiotensin-converting enzyme inhibitors. Outcomes of death and transplantation were determined. RESULTS Of the 259 patients, 86 were not on an angiotensin-converting enzyme inhibitor at discharge. Circulatory-renal limitations of symptomatic hypotension, progressive renal dysfunction, or hyperkalemia were documented in 60 patients (23%); other adverse effects, including cough, in 24 patients; and absent reasons in 2 patients. Compared with patients on angiotensin-converting enzyme inhibitors, patients with CRLimit were older (60 vs. 55 years; p = 0.006), with longer history of HF (5 vs. 2 years; p = 0.009), lower systolic blood pressure (104 vs. 110 mm Hg; p = 0.05), lower sodium (135 vs. 138 mEql/l; p = 0.002), and higher initial creatinine (2.5 vs. 1.2 mg/dl; p = 0.0001). Mortality was 57% in patients with CRLimit and 22% in the patients on angiotensin-converting enzyme inhibitors during a median 8.5-month follow-up (p = 0.0001). CONCLUSIONS Development of CRLimit to angiotensin-converting enzyme inhibitor intolerance identifies patients with severe disease who are likely to die during the next year. New treatment strategies should be targeted to this population.
Collapse
Affiliation(s)
- Michelle Kittleson
- Departments of Medicine and Cardiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
McMurray J, Ostergren J, Pfeffer M, Swedberg K, Granger C, Yusuf S, Held P, Michelson E, Olofsson B. Clinical features and contemporary management of patients with low and preserved ejection fraction heart failure: baseline characteristics of patients in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme. Eur J Heart Fail 2003; 5:261-70. [PMID: 12798823 DOI: 10.1016/s1388-9842(03)00052-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
AIMS To describe the clinical characteristics and contemporary treatment of a broad spectrum of patients with chronic heart failure (CHF) randomised in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme, consisting of three component studies comparing placebo to candesartan. METHODS AND RESULTS CHARM Alternative, CHARM Added and CHARM Preserved enrolled 2028 low left ventricular ejection fraction (LVEF) ACE inhibitor intolerant patients, 2548 low LVEF ACE inhibitor treated patients and 3025 preserved LVEF patients, respectively. Patients in CHARM Preserved were more often female. The proportion of women in CHARM Preserved was 40% compared to 32% in CHARM Alternative and 21% in CHARM Added. Patients in CHARM Preserved were also more often hypertensive than in the other two trials (64% vs. 50% and 48%, respectively). Symptoms and signs (with the exception of a third heart sound) were similar in all three patient groups. Beta-blockers were used in over half of patients in all three groups. Digoxin and spironolactone were used less frequently and calcium antagonists more frequently in CHARM Preserved. Spironolactone was used most frequently in CHARM Alternative, i.e. in ACE inhibitor intolerant patients. CONCLUSIONS The CHARM Programme provides the largest and most detailed comparison to date of patients low- and preserved-LVEF CHF. It also describes the causes of ACE-inhibitor intolerance in a large cohort of patients and the other treatment which these patients receive.
Collapse
Affiliation(s)
- J McMurray
- Department of Cardiology, Western Infirmary, University of Glasgow, Glasgow G11 6NT, Scotland, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2001; 10:173-88. [PMID: 11499857 DOI: 10.1002/pds.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|