Sex-Related Differences in Catheter Ablation for Patients With Atrial Fibrillation and Heart Failure

Gender and Age Differences in the Evaluation and Clinical Outcomes of Patients with Palpitations

BACKGROUND

Palpitations represent a common clinic complaint.

OBJECTIVE

To explore gender and age differences in the evaluation and outcomes of patients with palpitations in outpatient settings.

DESIGN/PARTICIPANTS

This is a retrospective observational study of 58,543 patients with no known structural cardiac disease or arrythmias presenting to primary care and cardiology clinics in an integrated health system in California with palpitations between January 2017 and December 2021. The primary and secondary endpoints were hospitalization for arrhythmia and all-cause mortality at 1 year. Multivariable logistic regression models evaluated the association between gender, age, and outcomes.

RESULTS

Men and women were equally as likely to be started on beta-blockers (adjusted OR 0.96, 95% CI 0.90-1.02) and evaluated with electrocardiograms (adjusted OR 0.95, 95% CI 0.90-1.01) and cardiac monitors (adjusted OR 1.04, 95% CI 0.99-1.08). Patients who completed Holter or event monitors had a lower rate of hospitalization for cardiovascular disease at 1 year than those without (2.3% vs. 2.7%, p = 0.001). At 1 year, women had a lower risk of all-cause mortality (adjusted OR 0.47, 95% CI 0.35-0.64) and hospitalization for atrial fibrillation (adjusted OR 0.47, 95% CI 0.30-0.72) and arrhythmias (adjusted OR 0.73, 95% CI 0.58-0.91) compared to men. Among older women and men (≥ 80 years), there was no significant difference in 1-year all-cause mortality (adjusted OR 0.57, 95% CI 0.29-1.12), hospitalization for atrial fibrillation (adjusted OR 0.58, 95% CI 0.17-1.97), or arrhythmias (adjusted OR 1.15, 95% CI 0.12-11.07).

CONCLUSIONS

There were no gender differences in referrals for cardiac monitoring or prescriptions for beta-blockers. Women had a better prognosis with a lower risk of hospitalization for arrhythmias and death at 1 year compared to men. However, 1-year risks for mortality and hospitalization for arrythmias among older women were comparable to those of older men, underscoring the importance of considering age and gender in managing patients with palpitations.

Sex differences in atrial fibrillation ablation outcomes in patients with heart failure

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.

HFpEF and sex: understanding the role of sex differences

Heart failure is a complex clinical syndrome with many etiological factors and complex pathophysiology affecting millions worldwide. Males and females can have distinct clinical presentation and prognosis, and there is an emerging understanding of the factors that highlight the similarities and differences to synthesize and present available data for sex-specific differences in heart failure with preserved ejection fraction (HFpEF). While the majority of data demonstrate more similarities than differences between females and males in terms of heart failure, there are key differences. Data showed that females have a higher risk of developing HFpEF, but a lower risk of mortality and hospitalization. This can be conditioned by different profiles of comorbidities, postmenopausal changes in sex hormone levels, higher levels of inflammation and chronic microvascular dysfunction in females. These factors, combined with different left ventricular dimensions and function, which are more pronounced with age, lead to a higher prevalence of LV diastolic dysfunction at rest and exercise. As a result, females have lower exercise capacity and quality of life when compared to males. Females also have different activities of systems responsible for drug transformation, leading to different efficacy of drugs as well as higher risk of adverse drug reactions. These data prove the necessity for creating sex-specific risk stratification scales and treatment plans.

A systematic review of health disparities research in deep brain stimulation surgery for Parkinson's disease

Background

Deep brain stimulation (DBS) is the primary surgical intervention for Parkinson's disease (PD) patients with insufficient response to medication, significantly improving motor symptoms and quality of life. Despite FDA approval for over two decades, access to this therapy remains limited. This systematic review aims to evaluate the influence of gender, race/ethnicity, socioeconomic status, and age on health disparities associated with DBS for PD, providing an overview of current research in this field.

Methods

A systematic literature search was conducted in PubMed/MEDLINE, Embase, Web of Science and Cochrane databases from 1960 to September 12th, 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies that examine the disparities in accessing DBS among patients with PD were included, comparing different demographic factors. Findings were synthesized and presented narratively to identify and understand DBS disparities.

Results

After screening for relevance, 25 studies published between 1960 and 2023 were included, with 16 studies meeting full-text review criteria. While reviewing the references of the 16 articles, two additional studies were included, bringing the total number of included studies to 18. Most studies originated from the United States (44%). The identified studies were categorized as identifying disparities, understanding disparities, or reducing disparities. The majority focused on identifying disparities (72%), while fewer studies delved into understanding the underlying factors (28%). No studies evaluated strategies for reducing disparities. The findings indicate that elderly, female, and Black people, as well as those from low socioeconomic backgrounds and developing countries face greater obstacles in accessing DBS for PD.

Conclusion

This study highlights factors contributing to disparities in DBS utilization for PD, including race, gender, and socioeconomic status. Public health policymakers, practitioners, and clinicians should recognize these inequalities and work toward reducing disparities, particularly among vulnerable populations.

Do Elderly Patients with Atrial Fibrillation Have Comparable Ablation Outcomes Compared to Younger Ones? Evidence from Pooled Clinical Studies

Background: Age is an independent risk factor of the progress and prognosis of atrial fibrillation (AF). However, ablation outcomes between elderly and younger patients with AF remain elusive. Methods: Cochrane Library, Embase, PubMed, and Web of Science were systematically searched up to 1 April 2022. Studies comparing AF ablation outcomes between elderly and younger patients and comprising outcomes of AF ablation for elderly patients were included. Trial sequential analysis (TSA) was performed to adjust for random error and lower statistical power in our meta-analysis. Subgroup analysis identified possible determinants of outcome impact for elderly patients after ablation. Moreover, linear and quadratic prediction fit plots with confidence intervals were performed, as appropriate. Results: A total of 27 studies with 113,106 AF patients were eligible. Compared with the younger group, the elderly group was significantly associated with a lower rate of freedom from AF (risk ratio [RR], 0.95; p = 0.008), as well as a higher incidence of safety outcomes (cerebrovascular events: RR, 1.64; p = 0.000; serious hemorrhage complications: RR, 1.50; p = 0.035; all-cause death: RR, 2.61; p = 0.003). Subgroup analysis and quadratic prediction fit analysis revealed the follow-up time was the potential determinant of freedom from AF for elderly patients after AF ablation. Conclusions: Our meta-analysis suggests that elderly patients may have inferior efficacy and safety outcomes to younger patients with AF ablation. Moreover, the follow-up time may be a potential determinant of outcome impact on freedom from AF for elderly patients after AF ablation.

Gender gap in deep brain stimulation for Parkinson's disease

Previous studies have shown less access to deep brain stimulation (DBS) for Parkinson’s disease (PD) in women compared to men raising concerns about a potential gender gap resulting from nonclinical factors or gender differences in clinical efficacy for postoperative quality of life (QoL), motor, and nonmotor symptoms (NMS) outcomes. This was a cross-sectional and a longitudinal, prospective, observational, controlled, quasi-experimental, international multicenter study. A total sample size of 505 consisted of 316 consecutively referred patients for DBS indication evaluation at the University Hospital Cologne (01/2015–09/2020) and 189 consecutively treated patients at DBS centers in the University Hospitals Cologne and Marburg, Salford’s Royal Hospital Manchester, and King’s College Hospital London. In the cross-sectional cohort, we examined gender proportions at referral, indication evaluations, and DBS surgery. In the longitudinal cohort, clinical assessments at preoperative baseline and 6-month follow-up after surgery included the PD Questionnaire-8, NMSScale, Scales for Outcomes in PD-motor scale, and levodopa-equivalent daily dose. Propensity score matching resulted in a pseudo-randomized sub-cohort balancing baseline demographic and clinical characteristics between women with PD and male controls. 316 patients were referred for DBS. 219 indication evaluations were positive (women n = 102, respectively n = 82). Women with PD were disproportionally underrepresented in referrals compared to the general PD population (relative risk [RR], 0.72; 95%CI, 0.56–0.91; P = 0.002), but more likely to be approved for DBS than men (RR, 1.17; 95%CI, 1.03–1.34; P = 0.029). Nonetheless, their total relative risk of undergoing DBS treatment was 0.74 (95%CI, 0.48–1.12) compared to men with PD. At baseline, women had longer disease duration and worse dyskinesia. Exploring QoL domains, women reported worse mobility and bodily discomfort. At follow-up, all main outcomes improved equally in both genders. Our study provides evidence of a gender gap in DBS for PD. Women and men with PD have distinct preoperative nonmotor and motor profiles. We advocate that more focus should be directed toward the implementation of gender equity as both genders benefit from DBS with equal clinical efficacy. This study provides Class II evidence of beneficial effects of DBS in women with PD compared to male controls.