Tenth International Symposium

HEART FAILURE & Co.CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING

ON FEMALE DISEASES

Milano9 - 10 aprile 2010

CRT: vi è un vantaggio maggiore nelle donne?

M.Cristina Porciani

FIRENZE

Heart Failure affects 5.3 millions Americans

Nearly 50% of these are women

Heart failure contributes 35% of the total female cardiovascular disease mortality

Despite this fact, HF in women remains a poorly recognized syndrome and has not received the samepublic awareness as coronary artery disease

Where Are All the Women With Heart Failure?

Lindenfeld J JACC 1997

Prevalence rates of congestive heart failure (CHF) among Framingham Heart Study subjects, by gender and age

Alaeddini J PACE 2008

Prevalence and Mortality from Congestive Herat Failure During years 2004 and 2005 based on Medicare Database

Alaeddini J PACE 2008

Patients who were admitted with diagnosis of congestive heart failure for theyears 2002 to 2004 based on Medicare Database

CRT has become a significant part of the managementof patients with HFSeveral large-scale studies demonstrated significant improvement in multiple endpoints, including quality of life , hospitalization rate and survival in patients with advanced HF

CRT

Alaeddini J. PACE 2008

Gender Disparity in the Use of CRT in the United States

Females underwent CRT-PM or CRT-D implantation 2002 2003 2004 25% 26% 27%

What is the response to CRT in women ?

► Analysis of previous large CRT Trials

► Few studies addressing this issue

The Multicenter InSync Randomized Clinical Evaluation (MIRACLE) was a prospective, randomized, double-blinded study

A total of 453 pts ( 32%women) randomized to either CRT or a control group.

MIRACLE study

EFFECT OF CRT ON EFFICACY END POINTS

MIRACLE study

Abraham WT NEJM 2002

CRT reverses LV remodeling

tSutton MG Circulation 2003

Woo G W et al Journal Int Card Electroph 2005

Analysis of the MIRACLE Study

Woo G W et al J Int Card Electroph 2005

Time to first HF hospitalization

Women Men

Analysis of the MIRACLE Study

Woo G W et al Journal Int Card Electroph 2005

Time to first HF hospitalization or death

Women Men

813 pts (26%women)

CARE-HF Study

CARE-HF Study

Cleland JGF NEJM 2005

1820 pts 24% womenNYHA class I or II

MADIT CRT

MADIT CRT

Risk of Death or Heart Failure, According to Selected Clinical Characteristics

Moss AJ NEJM 2009

Linde C JACC 2008

610 pts NYHA class I or II

REVERSE Study

Linde C JACC 2008

610 pts NYHA class I or II

Effect of CRT on LVESVI

141 pts

Yu CM Circulation 2005

Few observational studies have shown that ………….

Does a Gender Difference in Response to C RT Exist?

Bleeker GB PACE 2005

Does a Gender Difference in Response to C RT Exist?

Bleeker GB PACE 2005

Does a Gender Difference in Response to C RT Exist?

Bleeker GB PACE 2005

Response based on improvement in NYHA class

The Impact of Age and Gender on Cardiac Resynchronization Therapy Outcome

Baseline Characteristics of Patients Stratified by Gender

Zardkoohi O et al PACE 2007

The Impact of Age and Gender on Cardiac Resynchronization Therapy Outcome

Hospitalization for heart failure and/or death free survival curve

Zardkoohi O et al PACE 2007

The Impact of Age and Gender on Cardiac Resynchronization Therapy Outcome

When stratified by the etiology of the underlying cardiomyopathy, ischemic women appear to have a worse long-term outcome than all other groups

Zardkoohi O et al PACE 2007

Lilli A PACE 2007

CRT: Gender Related Differences in Left Ventricular Reverse Remodeling

195pts (23%women)

Lilli A PACE 2007

CRT: Gender Related Differences in Left Ventricular Reverse Remodeling

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Lilli A PACE 2007

CRT: Gender Related Differences in Left Ventricular Reverse Remodeling

Lilli A PACE 2007

CRT: Gender Related Differences in Left Ventricular Reverse Remodeling

CRT Trials and observational studies show discordant results

However a gender related difference in response to CRT seems to occur

It is not surprising since there are many reasons why male and female hearts are not the same

Gender Differences in Advanced HF: Insights From the BEST Study

Baseline Clinical Characteristics by Gender

Ghali JK JACC 2003

2708 pts(28%omenRandomized to Bucindolo or Placebo

Left ventricular Ejection Fractionin Women and Men with Congestive Heart Failure

Hsich EM JACC 2009

Heart Failure in Women :A Need for Prospective Data

Myocardial Response to Pressure Overload

Women Men

Sex-Related Differences in Myocardial Remodeling

Piro M et al JACC 2010

Echocardiographic characteristics of patients with aortic stenosis

Left ventricular geometry and function in patients with aortic stenosis: gender differences

Kostkiewicz M Int J Cardiol 1999

Placebo E2

van Eickels M Circulation 2001TAC Transverse Aortic Constriction

Myocyte Death in the Failing Human Heart Is Gender Dependent

Guerra S Circulation Research 1999

Jessup, M. J Thorac Cardiovasc Surg 2004

Gender-related survival rates and how they might be influenced by different pathophysiologic mechanisms in men and women.

LVH, left ventricular hypertrophy; RAS, renin-angiotensin system; SNS,

sympathetic nervous system.

CRT: vi è un vantaggio maggiore nelle donne?

Al momento attuale la scarsa rappresentazione delle donne negli studi sulla terapia cardiaca resincronizzante fa si che ancora non vi siano chiare evidenze su un loro maggior beneficio

tuttavia

Le particolari caratteristiche dello scompenso cardiaco ed in particolare i diversi meccanismi che modulano il rimodellamento ventricolare nelle done rappresentano importanti presupposti per una loro migliore risposta

Conclusioni