Sex Differences in the Management and Outcomes of Heart Failure with Preserved Ejection Fraction in Patients Presenting to the Emergency Department with Acute Heart Failure

Abstract

Heart failure (HF) with preserved ejection fraction (HFpEF) represents 50% of the HF population. Although more common in women than men, there are limited data characterizing sex differences in the management and outcomes of HFpEF patients that present acutely to the emergency department (ED). Using data from the ADHERE-EM registry linked to Medicare claims, we conducted a retrospective analysis of patients presenting to the ED with acute HF. We identified patients with HFpEF (EF ≥40%) and stratified them by sex to compare baseline characteristics, ED therapies, hospital length of stay (LOS), in-hospital mortality, and postdischarge outcomes. We compared outcomes using Cox proportional hazards models and linear mixed models. Of 4161 patients with HFpEF, 2808 (67%) were women, and were typically older and more likely to have hypertension, but less likely to have diabetes or a smoking history (all p<0.01). Women were more likely than men to present to the ED with a systolic blood pressure >140mmHg (62.5% vs. 56.4%, p=0.0001), and also had a greater presenting EF. There were no sex differences in ED therapies, adjusted 30-and 180-day all-cause mortality, in-hospital mortality, or 30-and 180-day hospital readmissions. After adjusting for covariates, women had a longer hospital LOS (0.40 days; 95% CI 0.10, 0.70; p=0.008). Women with HFpEF presenting to the ED were more likely to have elevated systolic blood pressure, but overall ED management strategies were similar to men. We observed adjusted differences in hospital LOS, but no differences in 30-and 180-day outcomes.Key words: heart failure with preserved ejection fraction; sex differences in management; sex differences in outcomes 3 Heart failure (HF) is a major and increasing public health problem worldwide.HF affects more than 5 million Americans, leads to more than 1 million hospitalizations, and accounts for more than $30 billion in annual medical costs.1 HF with preserved ejection fraction (HFpEF) represents approximately 50% of the HF population, and has adverse event rates similar to HF with reduced ejection fraction. 2 The emergency department (ED) is the primary setting where initial acute HF management takes place; more than 80% of acute HF patients who present to the ED are admitted. 3 Recent studies highlight differences in baseline characteristics and initial management strategies for men versus women presenting to the ED with all types of HF, including HFpEF and HF with reduced ejection fraction, 4-6 but it is unknown whether these differences hold true in the HFpEF population, and whether there are sex differences in shortand long-term outcomes in HFpEF patients following acute HF ED presentation.To address these issues, we used data from the Acute Decompensated HF NationalRegistry Emergency Module (ADHERE-EM) database linked to Medicare claims to evaluate sex differences in patients with HFpEF that presented to the ED with acute HF, with regard to presentation, treatments, and outcomes. MethodsT h e ADHERE-EM registry enrolled patients that...

The prognostic impact of gender in patients with acute heart failure – An evaluation of the age of female patients with severely decompensated acute heart failure

“…Although the data detail was not shown in the present study, prognostic impact regarding LVEF and gender would be an important issue and should be discussed. Females accounted for a higher proportion of the study population in some previous studies of HF patients with preserved EF values [12,26]. The results of the present study were consistent with this finding.…”

“…Although some previous reports have focused on patients with acute or advanced decompensated HF [7,8,11,13,25,26], all of the subjects in those studies were non-Japanese. Earlier studies suggest that female HF patients showed better survival [25]; however, some recent analyses have suggested that male and female patients show similar outcomes [7,8,11,13,26]. It has been reported that gender differences of HF patients may be affected by race [8].…”

“…Previous studies have shown that male and female patients with reduced and preserved EF values have similar rates of inhospital mortality and long-term outcomes [10,12]. Furthermore, Zsilinszka et al examined sex differences in AHF patients with a preserved LVEF who were admitted to an emergency department and concluded that male and female patients showed similar 30day and 180-day mortalities [26]. In the present study, however, the prognosis of female patients was poorer among the group of patients with a reduced LVEF.…”

Sex differences in congestive markers in patients hospitalized for acute heart failure

“…Similar to prior studies in patients with AHF, 2,3,9–14 women were older and had higher systolic blood pressure in this cohort. The baseline LUS findings were similar in women and men and consistent with the baseline CXR findings, with respect to the presence of vascular congestion, interstitial oedema, or alveolar oedema, and, likewise, findings on lung auscultation.…”

“…Prior studies report differing congestive patterns in women and men with AHF with regard to physical examination findings and symptoms at baseline. 2,3,9,10,12,14 In ADHERE and PROTECT, women with AHF demonstrated more pronounced pulmonary congestion at baseline with a higher prevalence of dyspnoea, 2 orthopnoea, 3 and rales, 2,3 although these differences were subtle in the ADHERE registry. By contrast, in the ALARM-HF registry and the RELAX-AHF trial, there were no significant sex differences in measures of pulmonary congestion based on dyspnoea, orthopnoea, or rales at baseline between women and men.…”