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S. HUNTS. HUNT
Tenth International Symposium
HEART FAILURE & Co.CARDIOLOGY SCIENCE UPDATE
FEMALE DOCTORS SPEAKING ON FEMALE DISEASES
Milano9 - 10 aprile 2010
Tenth International Symposium
HEART FAILURE & Co.Milano 9-10 Abrille 2010
Epidemiology of Heart Failure: The Need for Sex Specific Data
Sharon A. Hunt, MDStanford University, California
INTRODUCTION
There is actually some good data on gender specific epidemiology in
heart failure*
*See (among others): Rosamond et al Heart disease and stroke statistics—2008 update: a report from the AHA statistics committee and
stroke statistics subcommittee. Circ 2008;117:e25-146.
HEART FAILURE ITSELF APPEARS TO HAVE DIFFERENT EPIDEMIOLOGIC CHARACTERISTICS
IN MEN AND WOMEN, ATTRIBUTABLE TO…
Age. Women older at onset
Ventricular function. Systolic more often preserved in women
Cause of HF. Less often ischemic in women.
Survival Overall better for women
Copyright ©2008 American Heart Association
Rosamond, W. et al. Circulation 2008;117:e25-e146
Prevalence of HF by sex and age1999-2004
HEART FAILURE ITSELF APPEARS TO HAVE DIFFERENT EPIDEMIOLOGIC CHARACTERISTICS
IN MEN AND WOMEN, ATTRIBUTABLE TO…
Age. Women older at onset
Ventricular function. Systolic more often preserved in women
Cause of HF. Less often ischemic in women.
Survival Overall better for women
Hsich, E. M. et al. J Am Coll Cardiol 2009;54:491-498
Framingham Database – People with HF
Better LVEF, more CHF
Despite having a more preserved LV ejection fraction than men, women have higher rates of heart failure, likely reflecting differences in LV modeling and incidence of diastolic heart failure in women
Ejection Fraction
51
52
53
54
55
56
57
58
59
60
BARI 1989-91 CAVEAT 1991-92 NHLBI 1997-98
%
Men
Women
CHF
0
2
4
6
8
10
12
14
16
BARI 1989-91 CAVEAT 1991-92 NHLBI 1997-98
%
Men
Women
HEART FAILURE ITSELF APPEARS TO HAVE DIFFERENT EPIDEMIOLOGIC CHARACTERISTICS
IN MEN AND WOMEN, ATTRIBUTABLE TO…
Age. Women older at onset
Ventricular function. Systolic more often preserved in women
Cause of HF. Less often ischemic in women.
Survival Overall better for women
Women less often have ischemic etiology of HF
Pooled populations of 5 large clinical HF trials which included 8,791 men and 2,851 women showed:
ISCHEMIC NON-ISCHEMIC
MALE 57% 43%
FEMALE 40% 60%
HEART FAILURE ITSELF APPEARS TO HAVE DIFFERENT EPIDEMIOLOGIC CHARACTERISTICS
IN MEN AND WOMEN, ATTRIBUTABLE TO…
Age. Women older at onset
Ventricular function. Systolic more often preserved in women
Cause of HF. Less often ischemic in women.
Survival Overall better for women
Hsich, E. M. et al. J Am Coll Cardiol 2009;54:491-498
Kaplan-Meier Curves for All-Cause Mortality in the CHARM Study
Frazier, C. G. et al. J Am Coll Cardiol 2007;49:1450-1458
Kaplan-Meier Probabilities of Survival by Etiology of Heart Failure and GenderPOOLED DATA FROM 5 LARGE HF TRIALS
Overall, however, HF is getting more prevalent and costing more
REASONS INCLUDE
Increasing survival post-MIBetter therapy prolonging lives“Ageing” of the population
Copyright ©2008 American Heart Association
Rosamond, W. et al. Circulation 2008;117:e25-e146
Incidence of heart failue1980-2003
Copyright ©2008 American Heart Association
Rosamond, W. et al. Circulation 2008;117:e25-e146
Hospital discharges for HF by sex1979-2005
Cost is Astronomical
Estimated direct and indirect cost of HF in the US alone for the year 2008
$34.8 BILLION
Despite these striking epidemiological differences in HF between the sexes…
Most clinical trials have not planned to prospectively analyze the female
cohort or enroll any certain percentage of women.
Enrollment of Women in NHLBI RCTs
Kim et al. J Am Coll Cardiol 2008;52:672-675
Mean percent of women enrolled in all trials (27%) vs. mean percent of all patients with CVD who were women (53%)
Some data have been teased out with meta-analyses:
ACE INHIBITORS
Probably work as well in women as in men, at least for treatment
Possibly not for prevention of HF
Copyright ©2003 American College of Cardiology Foundation. Restrictions may apply.
Shekelle, P. G. et al. J Am Coll Cardiol 2003;41:1529-1538
Effect of angiotensin-converting enzyme inhibitors on mortality in male and female patients with heart failure (random effects pooled estimate)
MALE
FEMALE
Some data have been teased out with meta-analyses:
BETA BLOCKERS
Similar meta-analysis strongly suggests similar reduced mortality
when men and women with symptomatic HF treated with beta
blockersThere are, of course, no prevention
Trials with beta blockers
Some data have been teased out with post-hoc analyses:
ALDOSTERONE ANTAGONISTS
Both RALES and EPHESUS show a total mortality
benefit for women with systolic HF
HYDRALAZINE/NITRATES
A-HeFT was stopped prematurely for
benefit in both men and women
Some data have been teased out with post-hoc analyses:
DEVICE THERAPY
CRT and ICD’S
Few of the large multicenter trials
have reported sex-specific data
Post-hoc analyses of the few women
enrolled suggest that they do benefit
