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López Ferreruela I, Obón Azuara B, Malo Fumanal S, Rabanaque Hernández MJ, Aguilar-Palacio I. Gender inequalities in secondary prevention of cardiovascular disease: a scoping review. Int J Equity Health 2024; 23:146. [PMID: 39044250 PMCID: PMC11264402 DOI: 10.1186/s12939-024-02230-3] [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: 02/03/2024] [Accepted: 07/09/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Despite significant progress in cardiovascular disease (CVD) management, it remains a public health priority and a global challenge. Within the disease process, health care after a cardiovascular event (secondary prevention) is essential to prevent recurrences. Nonetheless, evidence has suggested the existence of gender disparities in CVD management, leaving women in a vulnerable situation. The objective of this study is to identify all available evidence on the existence of gender differences in health care attention after a major adverse cardiovascular event. METHODS A scoping review following the structure of PRISMA-ScR was conducted. To define the inclusion criteria, we used Joanna Briggs Institute (JBI) population, concept, context framework for scoping reviews. A systematic search was performed in MEDLINE (PubMed), EMBASE and Cochrane. The methods of this review are registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) (INPLASY202350084). RESULTS The initial search retrieved 3,322 studies. 26 articles were identified manually. After the reviewing process, 93 articles were finally included. The main intervention studied was the pharmacological treatment received (n = 61, 66%), distantly followed by guideline-recommended care (n = 26, 28%) and cardiac rehabilitation (CR) referral (n = 16)". Literature described gender differences in care and management of secondary prevention of CVD. Women were less frequently treated with guideline-recommended medications and seem more likely to be non-adherent. When analysing guideline recommendations, women were more likely to make dietary changes, however, men were more likely to increase physical activity. Studies also showed that women had lower rates of risk factor testing and cholesterol goals attainment. Female sex was associated with lower rates of cardiac rehabilitation referral and participation. CONCLUSIONS This review allowed us to compile knowledge on the existence of gender inequalities on the secondary prevention of CVD. Additional research is required to delve into various factors influencing therapeutic disparities, referral and non-participation in CR programs, among other aspects, in order to improve existing knowledge about the management and treatment of CVD in men and women. This approach is crucial to ensure the most equitable and effective attention to this issue.
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Affiliation(s)
- Irene López Ferreruela
- Internal Medicine Service, Miguel Servet University Hospital, Saragossa, Spain.
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain.
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain.
| | - Blanca Obón Azuara
- Intensive Medicine Service, Lozano Blesa University Hospital, Saragossa, Spain
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
| | - Sara Malo Fumanal
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain
| | - María José Rabanaque Hernández
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain
| | - Isabel Aguilar-Palacio
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain
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Mamataz T, Lee DS, Turk-Adawi K, Hajaj A, Code J, Grace SL. Factors Affecting Healthcare Provider Referral to Heart Function Clinics: A Mixed-Methods Study. J Cardiovasc Nurs 2024; 39:18-30. [PMID: 37669639 DOI: 10.1097/jcn.0000000000001029] [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: 09/07/2023]
Abstract
BACKGROUND Heart failure (HF) care providers are gatekeepers for patients to appropriately access lifesaving HF clinics. OBJECTIVE The aim of this study was to investigate referring providers' perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic. METHODS An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semistructured interviews were performed with a purposive sample of HF providers eligible to refer (ie, nurse practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Microsoft Teams. Transcripts were analyzed concurrently by 2 researchers independently using NVivo, using a deductive-thematic approach. Then, a cross-sectional survey of similar providers across Canada was undertaken via REDCap (Research Electronic Data Capture), using an adapted version of the Provider Attitudes toward Cardiac Rehabilitation and Referral scale. RESULTS Saturation was achieved upon interviewing 7 providers. Four themes arose: knowledge about clinics and their characteristics, providers' clinical expertise, communication and relationship with their patients, and clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were skepticism regarding clinic benefit (4.1 ± 0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral versus other professionals ( P s < .02), among other differences. One-third (n = 13) reported the pandemic impacted their referral practices (eg, limits to in-person care, patient concerns). CONCLUSION Although there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.
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Radhoe SP, Jakus N, Veenis JF, Timmermans P, Pouleur A, Rubís P, Van Craenenbroeck EM, Gaizauskas E, Barge‐Caballero E, Paolillo S, Grundmann S, D'Amario D, Braun OÖ, Gkouziouta A, Planinc I, Macek JL, Meyns B, Droogne W, Wierzbicki K, Holcman K, Flammer AJ, Gasparovic H, Biocina B, Milicic D, Lund LH, Ruschitzka F, Brugts JJ, Cikes M. Sex‐related differences in left ventricular assist device utilization and outcomes: results from the PCHF‐VAD registry. ESC Heart Fail 2022; 10:1054-1065. [PMID: 36547014 PMCID: PMC10053365 DOI: 10.1002/ehf2.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/05/2022] [Accepted: 11/27/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Data on sex and left ventricular assist device (LVAD) utilization and outcomes have been conflicting and mostly confined to US studies incorporating older devices. This study aimed to investigate sex-related differences in LVAD utilization and outcomes in a contemporary European LVAD cohort. METHODS AND RESULTS This analysis is part of the multicentre PCHF-VAD registry studying continuous-flow LVAD patients. The primary outcome was all-cause mortality. Secondary outcomes included ventricular arrhythmias, right ventricular failure, bleeding, thromboembolism, and the haemocompatibility score. Multivariable Cox regression models were used to assess associations between sex and outcomes. Overall, 457 men (81%) and 105 women (19%) were analysed. At LVAD implant, women were more often in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 or 2 (55% vs. 41%, P = 0.009) and more often required temporary mechanical circulatory support (39% vs. 23%, P = 0.001). Mean age was comparable (52.1 vs. 53.4 years, P = 0.33), and median follow-up duration was 344 [range 147-823] days for women and 435 [range 190-816] days for men (P = 0.40). No significant sex-related differences were found in all-cause mortality (hazard ratio [HR] 0.79 for female vs. male sex, 95% confidence interval [CI] [0.50-1.27]). Female LVAD patients had a lower risk of ventricular arrhythmias (HR 0.56, 95% CI [0.33-0.95]) but more often experienced right ventricular failure. No significant sex-related differences were found in other outcomes. CONCLUSIONS In this contemporary European cohort of LVAD patients, far fewer women than men underwent LVAD implantation despite similar clinical outcomes. This is important as the proportion of female LVAD patients (19%) was lower than the proportion of females with advanced HF as reported in previous studies, suggesting underutilization. Also, female patients were remarkably more often in INTERMACS profile 1 or 2, suggesting later referral for LVAD therapy. Additional research in female patients is warranted.
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Affiliation(s)
- Sumant P. Radhoe
- Department of Cardiology, Thorax Center Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Nina Jakus
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Jesse F. Veenis
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | | | - Anne‐Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases Cliniques Universitaires St. Luc Brussels Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain Louvain Belgium
| | - Pawel Rubís
- Department of Cardiac and Vascular Diseases Krakow Jagiellonian University Medical College, John Paul II Hospital Krakow Poland
| | | | - Edvinas Gaizauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine Vilnius University Vilnius Lithuania
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences Federico II University of Naples Naples Italy
| | - Sebastian Grundmann
- Faculty of Medicine Heart Center Freiburg University, University of Freiburg Freiburg Germany
| | - Domenico D'Amario
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Oscar Ö. Braun
- Department of Cardiology, Clinical Sciences Lund University and Skåne University Hospital Lund Sweden
| | | | - Ivo Planinc
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Jana Ljubas Macek
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Bart Meyns
- Department of Cardiac Surgery University Hospital Leuven Leuven Belgium
| | - Walter Droogne
- Department of Cardiology University Hospital Leuven Leuven Belgium
| | - Karol Wierzbicki
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology Jagiellonian University Medical College, John Paul II Hospital Krakow Poland
| | - Katarzyna Holcman
- Department of Cardiac and Vascular Diseases Krakow Jagiellonian University Medical College, John Paul II Hospital Krakow Poland
| | | | - Hrvoje Gasparovic
- Department of Cardiac Surgery University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Davor Milicic
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
| | - Lars H. Lund
- Department of Medicine Karolinska Institute Stockholm Sweden
| | - Frank Ruschitzka
- Clinic for Cardiology University Hospital Zurich Zurich Switzerland
| | - Jasper J. Brugts
- Department of Cardiology, Thorax Center Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Maja Cikes
- Department of Cardiovascular Diseases University of Zagreb School of Medicine and University Hospital Center Zagreb Zagreb Croatia
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Abstract
PURPOSE OF REVIEW Heart transplantation remains the gold standard therapy for end stage heart failure, but barriers remain, preventing equitable access to and affecting outcomes following transplantation. The objective of this review is to summarize current and historical literature on the disparities that persist, and to highlight the gaps in evidence for further investigation. RECENT FINDINGS Although progress has been made to increase the rates of advanced heart failure therapies to racial/ethnic minority populations and those with lower socioeconomic status, differential access and outcomes remain. The disparities that persist are categorized by patient demographics, social influences, geopolitical factors, and provider bias. SUMMARY Disparities in heart transplantation exist, which span a wide spectrum. Healthcare professionals need to be cognizant of these disparities that patients face in terms of access to and outcomes for heart transplantation. Further research and system changes are needed to make heart transplantation a fairer option for patients of varying backgrounds with end stage heart failure.
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5
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de Boer AR, Vaartjes I, Gohar A, Valk MJM, Brugts JJ, Boonman-de Winter LJM, van Riet EE, van Mourik Y, Brunner-La Rocca HP, Linssen GCM, Hoes AW, Bots ML, den Ruijter HM, Rutten FH. Heart failure with preserved, mid-range, and reduced ejection fraction across health care settings: an observational study. ESC Heart Fail 2021; 9:363-372. [PMID: 34889076 PMCID: PMC8787985 DOI: 10.1002/ehf2.13742] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/12/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS This study aimed to assess the sex-specific distribution of heart failure (HF) with preserved, mid-range, and reduced ejection fraction across three health care settings. METHODS AND RESULTS In this descriptive observational study, we retrieved the distribution of HF types [with reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF)] for men and women between 65 and 79 years of age in three health care settings from a single country: (i) patients with screening-detected HF in the high-risk community (i.e. those with shortness of breath, frailty, diabetes mellitus, and chronic obstructive pulmonary disease) from four screening studies, (ii) patients with confirmed HF from primary care derived from a single observational study, and (iii) patients with confirmed HF from outpatient cardiology clinics participating in a registry. Among 1407 patients from the high-risk community, 288 had screen-detected HF (15% HFrEF, 12% HFmrEF, 74% HFpEF), and 51% of the screen-detected HF patients were women. In both women (82%) and men (65%), HFpEF was the most prevalent HF type. In the routine general practice population (30 practices, 70 000 individuals), among the 160 confirmed HF cases, 35% had HFrEF, 23% HFmrEF, and 43% HFpEF, and in total, 43% were women. In women, HFpEF was the most prevalent HF type (52%), while in men, this was HFrEF (41%). In outpatient cardiology clinics (n = 34), of the 4742 HF patients (66% HFrEF, 15% HFmrEF, 20% HFpEF), 36% were women. In both women (56%) and men (71%), HFrEF was the most prevalent HF type. CONCLUSIONS Both HF types and sex distribution vary considerably in HF patients of 65-79 years of age among health care settings. From the high-risk community through to general practice to the cardiology outpatient setting, there is a shift in HF type from HFpEF to HFrEF and a decrease in the proportion of HF patients that are women.
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Affiliation(s)
- Annemarijn R de Boer
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands.,Dutch Heart Foundation, The Hague, The Netherlands
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands.,Dutch Heart Foundation, The Hague, The Netherlands
| | - Aisha Gohar
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Mark J M Valk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Evelien E van Riet
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Yvonne van Mourik
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | | | - Gerard C M Linssen
- Department of Cardiology, Hospital Group Twente, Almelo and Hengelo, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Hester M den Ruijter
- Experimental Cardiology, Division Heart & Lung Disease, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
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6
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Van Spall HGC, DeFilippis EM, Lee SF, Oz UE, Perez R, Healey JS, Allen LA, Voors AA, Ko DT, Thabane L, Connolly SJ. Sex-Specific Clinical Outcomes of the PACT-HF Randomized Trial. Circ Heart Fail 2021; 14:e008548. [PMID: 34711072 DOI: 10.1161/circheartfailure.121.008548] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Transitional care may have different effects in males and females hospitalized for heart failure. We assessed the sex-specific effects of a transitional care model on clinical outcomes following hospitalization for heart failure. METHODS In this stepped-wedge cluster randomized trial of adults hospitalized for heart failure in Ontario, Canada, 10 hospitals were randomized to a group of transitional care services or usual care. Outcomes in this exploratory analysis were composite all-cause readmission, emergency department visit, or death at 6 months; and composite all-cause readmission or emergency department visit at 6 months. Models were adjusted for stepped-wedge design and patient age. RESULTS Among 2494 adults, mean (SD) age was 77.7 (12.1) years, and 1258 (50.4%) were female. The first composite outcome occurred in 371 (66.3%) versus 433 (64.1%) males (hazard ratio [HR], 1.04 [95% CI, 0.86-1.26]; P=0.67) and in 326 (59.9%) versus 463 (64.8%) females (HR, 0.83 [95% CI, 0.69-1.01]; P=0.06) in the intervention and usual care groups, respectively (P=0.012 for sex interaction). The second composite outcome occurred in 357 (63.8%) versus 417 (61.7%) males (HR, 1.03 [95% CI, 0.85-1.24]; P=0.76) and 314 (57.7%) versus 450 (63.0%) females (HR, 0.81 [95% CI, 0.67-0.99]; P=0.037) in the intervention and usual care groups, respectively (P=0.024 for sex interaction). The sex differences were driven by a reduction in all-cause emergency department visits among females (HR, 0.66 [95% CI, 0.51-0.87]; P=0.003), but not males (HR, 1.10 [95% CI, 0.85-1.43]; P=0.46), receiving the intervention (P<0.001 for sex interaction). CONCLUSIONS A transitional care model offered a reduction in all-cause emergency department visits among females but not males following hospitalization for heart failure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02112227.
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Affiliation(s)
- Harriette G C Van Spall
- Department of Medicine (H.G.C.V., J.S.H.), McMasterUniversity, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact (H.G.C.V., S.F.L., J.S.H., L.T., S.J.C.), McMasterUniversity, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada (H.G.C.V., S.F.L., J.S.H., S.J.C.)
| | | | - Shun Fu Lee
- Department of Health Research Methods, Evidence, and Impact (H.G.C.V., S.F.L., J.S.H., L.T., S.J.C.), McMasterUniversity, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada (H.G.C.V., S.F.L., J.S.H., S.J.C.)
| | - Urun Erbas Oz
- Institute for Clinical Evaluative Sciences, Ontario, Canada (U.E.O., R.P., D.T.K.)
| | - Richard Perez
- Institute for Clinical Evaluative Sciences, Ontario, Canada (U.E.O., R.P., D.T.K.)
| | - Jeff S Healey
- Department of Medicine (H.G.C.V., J.S.H.), McMasterUniversity, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact (H.G.C.V., S.F.L., J.S.H., L.T., S.J.C.), McMasterUniversity, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada (H.G.C.V., S.F.L., J.S.H., S.J.C.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A.)
| | - Adriaan A Voors
- University Medical Center Groningen, the Netherlands (A.A.V.)
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences, Ontario, Canada (U.E.O., R.P., D.T.K.).,Department of Medicine, University of Toronto, Ontario, Canada (D.T.K.)
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (H.G.C.V., S.F.L., J.S.H., L.T., S.J.C.), McMasterUniversity, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Department of Health Research Methods, Evidence, and Impact (H.G.C.V., S.F.L., J.S.H., L.T., S.J.C.), McMasterUniversity, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada (H.G.C.V., S.F.L., J.S.H., S.J.C.)
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7
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Fluschnik N, Strangl F, Kondziella C, Goßling A, Becher PM, Schrage B, Schnabel RB, Bernadyn J, Bremer W, Grahn H, Bernhardt AM, Reichenspurner H, Rybczynski M, Blankenberg S, Kirchhof P, Magnussen C, Knappe D. Gender differences in characteristics and outcomes in heart failure patients referred for end-stage treatment. ESC Heart Fail 2021; 8:5031-5039. [PMID: 34486813 PMCID: PMC8712844 DOI: 10.1002/ehf2.13567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/04/2021] [Accepted: 08/04/2021] [Indexed: 11/20/2022] Open
Abstract
Aims Despite signals from clinical trials and mechanistic studies implying different resilience to heart failure (HF) depending on gender, the impact of gender on presentation and outcomes in patients with HF remains unclear. This study assessed the impact of gender on clinical presentation and outcomes in patients with HF referred to a specialised tertiary HF service. Methods and results Consecutive patients with HF referred to a specialised tertiary HF service offering advanced therapy options including left ventricular assist devices (LVAD) and heart transplantation were prospectively enrolled from August 2015 until March 2018. We assessed clinical characteristics at baseline and performed survival analyses and age‐adjusted Cox regression analyses in men vs. women for all‐cause death and a combined disease‐related endpoint comprising death, heart transplantation, and LVAD implantation. Analyses were performed for the overall study population and for patients with HF with reduced ejection fraction (HFrEF). Of 356 patients included, 283 (79.5%) were male. The median age was 58 years (interquartile range 50–67). Two hundred and fifty‐one (74.5%) patients had HFrEF. HF aetiology, ejection fraction, functional status measures, and most of the cardiac and non‐cardiac comorbidities did not differ between men and women. In a median follow‐up of 3.2 years, 50 patients died (45 men, 5 women), 15 patients underwent LVAD implantation, and 8 patients heart transplantation. While all‐cause death was not significantly different between both genders in the overall population [16.9 vs. 6.0%, P = 0.065, hazard ratio (HR) 2.29 (95% confidence interval 0.91–5.78), P = 0.078], in the HFrEF subgroup, a significant difference between men and women was observed [20.7% vs. 3.9%, P = 0.017, HR 3.67 (95% confidence interval 1.13–11.91), P = 0.031]. The combined endpoint was more often reached in men than in women in both the overall population [21.6% vs. 9.0%, P = 0.053, HR 2.51 (1.08–5.82), P = 0.032] and the HFrEF subgroup [27.1% vs. 7.7%, P = 0.015, HR 3.58 (1.29–9.94), P = 0.014]. Conclusions Patients referred to a specialised tertiary HF service showed a similar clinical profile without relevant gender differences. In the mid‐term follow‐up, more male than female patients died or underwent heart transplantation and LVAD implantation. These findings call for independent validation and for further research into gender‐specific drivers of HF progression.
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Affiliation(s)
- Nina Fluschnik
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Felix Strangl
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Christoph Kondziella
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Peter Moritz Becher
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Julia Bernadyn
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Wiebke Bremer
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Hanno Grahn
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Centre Hamburg, Hamburg, Germany
| | - Meike Rybczynski
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Christina Magnussen
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Dorit Knappe
- Department of Cardiology, University Heart & Vascular Centre Hamburg, Martinistrasse 52, Hamburg, 20246, Germany
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8
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Veenis JF, Rocca HPBL, Linssen GCM, Erol-Yilmaz A, Pronk ACB, Engelen DJM, van Tooren RM, Koornstra-Wortel HJJ, de Boer RA, van der Meer P, Hoes AW, Brugts JJ. Impact of sex-specific target dose in chronic heart failure patients with reduced ejection fraction. Eur J Prev Cardiol 2021; 28:957-965. [DOI: 10.1177/2047487320923185] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Abstract
Aims
A recent study suggested that women with heart failure and heart failure reduced ejection fraction might hypothetically need lower doses of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers ( = renin-angiotensin-system inhibitors) and β-blockers than men to achieve the best outcome. We assessed the current medical treatment of heart failure reduced ejection fraction in men and women in a large contemporary cohort and address the hypothetical impact of changing treatment levels in women.
Methods
This analysis is part of a large contemporary quality of heart failure care project which includes 5320 (64%) men and 3003 (36%) women with heart failure reduced ejection fraction. Detailed information on heart failure therapy prescription and dosage were collected.
Results
Women less often received renin-angiotensin-system inhibitors (79% vs 83%, p < 0.01), but more often β-blockers (82% vs 79%, p < 0.01) than men. Differences in guideline-recommended target doses between sexes were relatively small. Implementing a hypothetical sex-specific dosing schedule (at 50% of the current recommended dose in the European Society of Cardiology guidelines in women only) would lead to significantly higher levels of women receiving appropriate dosing (β-blocker 87% vs 54%, p < 0.01; renin-angiotensin-system inhibitor 96% vs 75%, p < 0.01). Most interestingly, the total number of women with >100% of the new hypothetical target dose would be 24% for β-blockers and 52% for renin-angiotensin-system inhibitors, which can be considered as relatively overdosed.
Conclusion
In this large contemporary heart failure registry, there were significant but relatively small differences in drug dose between men and women with heart failure reduced ejection fraction. Implementation of the hypothetical sex-specific target dosing schedule would lead to considerably more women adequately treated. In contrast, we identified a group of women who might have been relatively overdosed with increased risk of side-effects and intolerance.
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Affiliation(s)
- Jesse F Veenis
- Department of Cardiology, University Medical Center Rotterdam, the Netherlands
| | | | | | | | - Arjen C B Pronk
- Department of Cardiology, Elisabeth-TweeSteden Ziekenhuis, the Netherlands
| | | | - Rob M van Tooren
- Department of Cardiology, St Antonuis Ziekenhuis, the Netherlands
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, the Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, the Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, University Medical Center Rotterdam, the Netherlands
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9
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Fowokan A, Frankfurter C, Dobrow MJ, Abrahamyan L, Mcdonald M, Virani S, Harkness K, Lee DS, Pakosh M, Ross H, Grace SL. Referral and access to heart function clinics: A realist review. J Eval Clin Pract 2021; 27:949-964. [PMID: 33020996 DOI: 10.1111/jep.13489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIM, AND OBJECTIVES Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics. METHODS Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory. RESULTS A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome). CONCLUSION Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.
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Affiliation(s)
| | | | - Mark J Dobrow
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- St. Paul's Hospital, University of British Columbia, and Cardiac Services BC, Vancouver, British Columbia, Canada
| | - Karen Harkness
- CorHealth Ontario, Toronto, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Douglas S Lee
- University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Heather Ross
- University Health Network, Toronto, Ontario, Canada
| | - Sherry L Grace
- University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Faculty of Health, York University, Toronto, Ontario, Canada
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10
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Sullivan K, Doumouras BS, Santema BT, Walsh MN, Douglas PS, Voors AA, Van Spall HG. Sex-Specific Differences in Heart Failure: Pathophysiology, Risk Factors, Management, and Outcomes. Can J Cardiol 2021; 37:560-571. [DOI: 10.1016/j.cjca.2020.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
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11
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Jerónimo A, Ferrández-Escarabajal M, Ferrera C, Noriega FJ, Diz-Díaz J, Fernández-Jiménez R, McInerney A, Fernández-Ortiz A, Viana-Tejedor A. Cardiogenic Shock Clinical Presentation, Management, and In-Hospital Outcomes in Patients Admitted to the Acute Cardiac Care Unit of a Tertiary Hospital: Does Gender Play a Role? J Clin Med 2020; 9:jcm9103117. [PMID: 32992550 PMCID: PMC7601399 DOI: 10.3390/jcm9103117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 12/22/2022] Open
Abstract
Cardiogenic shock (CS), as the most severe form of heart failure, is associated with very high mortality rates despite therapeutic advances in the last decades. Gender differences in outcomes have been widely reported regarding several cardiovascular diseases. The aim of our study was to evaluate potential gender disparities in clinical presentation, management, and in-hospital outcomes of all (n = 138) patients admitted to the Acute Cardiac Care Unit of a tertiary hospital from 2013 to 2019. Information on demographic characteristics, past medical history, haemodynamic and clinical status at admission, therapeutic management, and in-hospital outcomes was retrospectively collected. Women represented 31.88% of the cohort, were significantly older than the men and had a lower proportion of smokers, chronic obstructive pulmonary disease, and previous acute myocardial infarction (AMI). Most CSs in both groups were AMI-related. Left ventricular ejection fraction at admission was higher in women, who were less likely to receive vasopressors. No differences were observed regarding mechanical circulatory support use and in-patient outcomes, with age being the only factor associated with in-hospital mortality on multivariate analysis.
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Affiliation(s)
- Adrian Jerónimo
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Marcos Ferrández-Escarabajal
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Carlos Ferrera
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Francisco J. Noriega
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Jesús Diz-Díaz
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Rodrigo Fernández-Jiménez
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
- Centro Nacional de Investigación Cardiovascular (CNIC), 28029 Madrid, Spain
| | - Angela McInerney
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Antonio Fernández-Ortiz
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Ana Viana-Tejedor
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
- Correspondence: ; Tel.: +34-91-330-33-000 (ext. 20655)
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12
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Collado-Lledó E, Llaó I, Rivas-Lasarte M, González-Fernández V, Noriega FJ, Hernández-Perez FJ, Alegre O, Sionis A, Lidón RM, Viana-Tejedor A, Segovia-Cubero J, Ariza-Solé A. Clinical picture, management and risk stratification in patients with cardiogenic shock: does gender matter? BMC Cardiovasc Disord 2020; 20:189. [PMID: 32664921 PMCID: PMC7362401 DOI: 10.1186/s12872-020-01467-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/05/2020] [Indexed: 01/04/2023] Open
Abstract
Background Early recognition and risk stratification are crucial in cardiogenic shock (CS). A lower adherence to recommendations has been described in women with cardiovascular diseases. Little information exists about disparities in clinical picture, management and performance of risk stratification tools according to gender in patients with CS. Methods Data from the multicenter Red-Shock registry were used. All consecutive patients with CS were included. Both CardShock and IABP-SHOCK II risk scores were calculated. The primary end-point was in-hospital mortality. The discriminative ability of both scores according to gender was assessed by binary logistic regression, calculating Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC). Results A total of 793 patients were included, of whom 222 (28%) were female. Women were significantly older and had a lower proportion of chronic obstructive pulmonary disease and prior myocardial infarction. CS was less often related to acute coronary syndromes (ACS) in women. The use of vasoactive drugs, renal replacement therapy, invasive ventilation, therapeutic hypothermia and mechanical circulatory support was similar between both groups. In-hospital mortality was 346/793 (43.6%). Mortality was not significantly different according to gender (p = 0.194). Cardshock risk score showed a good ability for predicting in-hospital mortality both in man (AUC 0.69) and women (AUC 0.735). Likewise, the IABP-II successfully predicted in-hospital mortality in both groups (man: AUC 0.693; women: AUC 0.722). Conclusions No significant differences were observed regarding management and in-hospital mortality according to gender. Both the CardShock and IABP-II risk scores depicted a good ability for predicting mortality also in women with CS.
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Affiliation(s)
- Elena Collado-Lledó
- Intensive Cardiac Care Unit. Cardiology Department, Hospital Universitari de Bellvitge -IDIBELL, Feixa Llarga s/n. 08907. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Isaac Llaó
- Intensive Cardiac Care Unit. Cardiology Department, Hospital Universitari de Bellvitge -IDIBELL, Feixa Llarga s/n. 08907. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mercedes Rivas-Lasarte
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBER-CV, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Victor González-Fernández
- Cardiovascular Critical Care Unit, Cardiology Department, Vall d'Hebron Hospital, CIBER-CV Vall d'Hebron Hospital, Barcelona, Spain
| | - Francisco J Noriega
- Acute Cardiac Care Unit, Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Francisco José Hernández-Perez
- Advanced Heart Failure and Transplant Unit, Cardiology Department, Hospital Universitario Puerta de Hierro, CIBER-CV, Universidad Autónoma de Madrid, Madrid, Spain
| | - Oriol Alegre
- Intensive Cardiac Care Unit. Cardiology Department, Hospital Universitari de Bellvitge -IDIBELL, Feixa Llarga s/n. 08907. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBER-CV, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Rosa M Lidón
- Cardiovascular Critical Care Unit, Cardiology Department, Vall d'Hebron Hospital, CIBER-CV Vall d'Hebron Hospital, Barcelona, Spain
| | - Ana Viana-Tejedor
- Acute Cardiac Care Unit, Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Javier Segovia-Cubero
- Advanced Heart Failure and Transplant Unit, Cardiology Department, Hospital Universitario Puerta de Hierro, CIBER-CV, Universidad Autónoma de Madrid, Madrid, Spain
| | - Albert Ariza-Solé
- Intensive Cardiac Care Unit. Cardiology Department, Hospital Universitari de Bellvitge -IDIBELL, Feixa Llarga s/n. 08907. L'Hospitalet de Llobregat, Barcelona, Spain.
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