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

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 resultsConsecutive 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.

Sex differences in clinical characteristics and outcomes in patients undergoing heart transplantation

“…This sex distribution has also been documented in previous UNOS‐ and non‐UNOS based studies 12,25 and did not change over the last years 26 . This sex disparity might be partly explained by differences in disease course, symptom patterns, delayed clinical presentation, and selection and/or referral bias of patients with advanced HF 27,28 . Sex differences for patients listed for HTx have been previously reported 3,28 .…”

“…26 This sex disparity might be partly explained by differences in disease course, symptom patterns, delayed clinical presentation, and selection and/or referral bias of patients with advanced HF. 27,28 Sex differences for patients listed for HTx have been previously reported. 3,28 In line with prior studies, men were older, showed a worse CV risk profile and had, consecutively, a higher prevalence of ischaemic cardiomyopathy in our analysis.…”

Gender differences in the assessment, decision‐making and outcomes for ventricular assist devices and heart transplantation: An analysis from a UK transplant center

“…We, and others, have demonstrated marked differences at all stages of the heart transplant assessment pathway 13–17 . Two of our findings suggest that there is not a systematic bias against female referrals or transplantation: [1] the percentage of females assessed (32%) is very similar to the ratio reported in the UK National Heart Failure audit of hospitalised patients with heart failure (2019/2020 data: 32% 55–64 years; 30% 45–54 years) 1 .…”

“…We, and others, have demonstrated marked differences at all stages of the heart transplant assessment pathway. [13][14][15][16][17] Two of our findings suggest that there is not a systematic bias against female referrals or transplantation: [1] the percentage of females assessed (32%) is very similar to the ratio reported in the UK National Heart Failure audit of hospitalised patients with heart failure (2019/2020 data: 32% 55-64 years; 30% 45-54 years). 1 The UK National Heart Failure Audit is a comprehensive audit of all patients in the United Kingdom admitted with heart failure to hospital and so is a comprehensive database, and our best way to look at the issue of community prevalence of heart failure and gender (at least in those that are admitted to hospital); [2] females are more likely to be too well for transplant rather than unsuitable for transplant, suggesting that we are not seeing females too late.…”

Sex differences in patients with heart failure and mildly reduced left ventricular ejection fraction

“…Although the treatment of HF varies in some regions between men and women 8 , 29 , many disadvantageous factors still exist for women with HF. For instance, women with HF have a poorer quality of life and continue to receive suboptimal treatment 19 , even less access to a cardiologist 30 , 31 , and lower use of left ventricular assist devices 32 , 33 . Male heart failure patients were independently associated with cardiac death but not with a composite endpoint or all-cause mortality 34 .…”