Special Considerations in the Care of Women With Advanced Heart Failure

Abstract

Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.

Cardiomyopathies in Women

“…80 A 2022 manuscript by Ebong et al highlighted several barriers to therapies for women, one of which was the higher prevalence of poor social determinants of health in women that was felt to contribute to physician bias and delayed referral. 81 Increased personal caregiving responsibilities, actual or perceived inadequacy in social support, and mental health issues were recognized as other factors negatively impacting referral bias towards women. 81 If a woman is referred and deemed an acceptable candidate for heart transplantation, she has a higher risk of dying on the wait-list or being removed from the wait-list due to clinical deterioration.…”

“…81 Increased personal caregiving responsibilities, actual or perceived inadequacy in social support, and mental health issues were recognized as other factors negatively impacting referral bias towards women. 81 If a woman is referred and deemed an acceptable candidate for heart transplantation, she has a higher risk of dying on the wait-list or being removed from the wait-list due to clinical deterioration. 82,83 Women are less likely to be bridged with an LVAD while awaiting transplant and also are less likely to receive temporary mechanical support devices (such as intra-aortic balloon pump, microaxial LVADs, or extracorporeal membrane oxygenation) in the setting of cardiogenic shock, despite having a higher mortality rate in cardiogenic shock from HF compared to men.…”

“…79 Although evidence is mixed, overall post-LVAD outcomes appear to be similar between the two genders. 81,86 This again was supported by the sexspecific analysis of the MOMENTUM 3 study, of which 20.4% of participants were female with average age of 57.3 +/-12.4 years, 44.2% Black race, and 23.9% ischemic etiology compared to 79.6% of participants who were male with an average age of 60.4 +/-12.1 years, 23.6% Black race, and 49.6% ischemic in etiology. 87 The analysis confirmed no difference between men and women in survival or the composite end point of survival free from disabling stroke or reoperation to replace or remove a malfunctioning pump at 2 years.…”

Pumping for Two: Pregnancy in Patients Supported With a Left Ventricular Assist Device

“…5,24 According to the Interagency Registry for Mechanical Circulatory Support, 5,766 females (21.6%) had an LVAD implanted between 2011 and 2020, 6 and 1,288 women of age 49 years or younger had an LVAD implanted between 2008 and 2017. 3,[7][8][9] Notably, women on LVAD support are not included in current cardio-obstetric risk assessment scores. The modified World Health Organization (WHO) classification of maternal risk in patients with cardiovascular disease considering pregnancy uses a scoring system to evaluate the maternal mortality risk but is lacking information about women on LVAD support.…”

“…Patient-related factors include the hemodynamic stress induced by pregnancy, most importantly increased circulating volume, and an increased risk of right ventricular (RV) failure during delivery. 3,5,7 Other patient-related considerations include the hypercoagulable state of pregnancy, which may precipitate thrombotic events within the LVAD, and potential teratogenicity through exposure of the fetus to medications used to treat LVAD patients. 3,5,8,12,13 Left ventricular assist device-related factors include disruption of normal coagulation and angiogenesis pathways, leading to an increase in both bleeding and thromboembolic events, and the risk of uterine impingement on intra-abdominal LVAD components.…”