Ambulatory Advanced Heart Failure in Women
Study Questions:
What are the clinical characteristics and outcomes of women with ambulatory advanced heart failure (HF) compared with men?
Methods:
Patients included were enrolled in the REVIVAL registry, which is a prospective, observational, multicenter cohort of ambulatory patients with advanced HF. Eligible patients were between 18 and 80 years old with New York Heart Association (NYHA) class II-IV symptoms, LVEF ≤35%, diagnosis of HF for >12 months, and two HF hospitalizations in 1 year or one hospitalization with elevated outpatient B-type natriuretic peptide levels. Extensive data were collected including patient characteristics, health status measures, and their opinion on receiving left ventricular assist device (LVAD) therapy. The primary endpoint was a composite of death, receipt of advanced HF therapy including LVAD, or heart transplant.
Results:
A total of 400 patients were enrolled between July 2015 and June 2016, including 99 women. There were no differences in age, LVEF, and HF severity, as assessed by NYHA class and INTERMACS patient profiles between men and women. Women were more likely to be African American, nonsmokers, and have nonischemic cardiomyopathy. Rates of guideline-directed optimal medical and electrical therapy were comparable between men and women, with the exception of greater use of angiotensin antagonists in women (91% vs. 82%; p = 0.039), but lesser use of cardiac resynchronization therapy in women (40% vs. 52%; p = 0.05). Compared with men, women were more likely to report limitations with usual activities, with higher rates of depression. Baseline 6-minute walk distance was lower in women despite adjustment for height (309 m vs. 347 m; p < 0.01). Women were as likely to express definite or probable willingness in considering LVAD therapy.
A similar proportion of women and men received LVAD by 1 year (10% vs. 12%; p = 0.72). However, median time to receipt of LVAD was longer in women than men, but not statistically significant (209 days vs. 114 days; p = 0.13). Rates of death, durable mechanical circulatory support, and urgent heart transplantation were similar between men and women at 1 year. Women alive at 1 year who did not receive advanced HF therapies were assigned INTERMACS profile 3-7 and had worse scores for depression and shorter 6-minute walk distances.
Conclusions:
In this analysis of a prospective cohort of advanced HF patients, women had similar clinical profiles as compared with men and received similar rates of appropriate HF therapy. Despite this, women had shorter 6-minute walk distances, worse quality-of-life measures, and higher rates of depression compared with men. Nonetheless, rates of death and receipt of advanced HF therapies were similar at 1 year between men and women.
Perspective:
This study describes contemporary trends in the largest prospective cohort of ambulatory women with advanced HF. Notably, not only were there similar rates of use of guideline-directed HF therapy, clinical profiles of women were similar to men. Interestingly, despite these clinical similarities, women had more depression, worse quality-of-life scores, and shorter 6-minute walk distances compared with men. This suggests that conventional measures of HF severity markers such as NYHA class and INTERMACS profile may not reliably detect severity of illness in women. Other notable findings include longer median time to LVAD therapy in women compared with men (which likely did not reach statistical significance due to the small sample size), despite similar willingness to receive LVAD therapy in both the genders. Departing from other retrospective reports, this study showed similar rates of 1-year outcomes in women with advanced ambulatory HF compared with men, which is encouraging.
Limitations of this study include enrollment of patients from referral centers providing LVAD therapy and small number of participants. Notable strengths include its prospective design and collection of extensive data on HF severity including functional measures such as 6-minute walk distance and other quality-of-life measures that are not available in retrospective registries. These results highlight opportunities to reduce disparities noted in treatment of women with advanced HF.
Keywords: Angiotensins, Cardiac Resynchronization Therapy, Cardiomyopathies, Depression, Heart Failure, Heart Transplantation, Heart-Assist Devices, Natriuretic Peptide, Brain, Outpatients, Quality of Life, Women
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