HF in women: Undertreated and understudied?
Women with heart failure with reduced ejection fraction (HFrEF) continue to receive suboptimal care and treatment for their condition compared with their male counterparts, a recent study finds, highlighting the persisting gaps in management of cardiovascular (CV) conditions, in particular HF, between men and women.
“[T]he continued demonstration of undertreatment of women with other pharmacological, device, and exercise therapies even in the setting of randomized trials is appalling … If patients in the care of experienced investigators remain undertreated and inadequately referred, the average patient faces impossible odds,” wrote the editorialists led by Dr Mary Norine Walsh from St. Vincent Heart Center in Indianapolis, Indiana, US in an accompanying commentary. [J Am Coll Cardiol 2019;73:40-43]
The plight of women
“Women with HF are more symptomatic, have more evidence of volume overload, have lower health-related quality of life, and have greater impairment in activities of daily living than men do,” summarized Walsh and co-authors.
Using participants data from two large trials on HFrEF — PARADIGM and ATMOSPHERE — the current study compared characteristics and outcomes of 12,058 men vs 3,357 women. [J Am Coll Cardiol 2019;73:29-40]
In terms of baseline HF characteristics, the investigators found that women reported more symptoms than men, including pedal oedema (23.4 percent vs 19.9 percent; p<0.0001), dyspnoea on effort (88.7 percent vs 84.7 percent) and at rest (6.1 percent vs 3.4 percent; p<0.0001), had higher LVEF (29.6 percent vs 28.8 percent; p<0.0001), and showed more evidence of congestion such as rales (p<0.001) and jugular venous distension (p=0.004).
“It seems quite possible that the excess social stressors for women may lead to the symptom differences discussed,” suggested Walsh and co-authors.
Given the greater evidence of congestion among women, they were relatively undertreated with diuretics, in particular thiazides (p=0.0061). They were also less likely to be treated with ACE inhibitors (p<0.0001). In contrast, ARBs (p<0.0001) and calcium channel blockers (p=0.0245) were more often received by women than men, whereas the use of beta blockers were similar between both sexes.
Anticoagulants were similarly given less often to women than men overall (p<0.0001), even in patients with atrial fibrillation previously (p<0.001) or at baseline (p=0.029), which according to the researchers, reflects “registry and ‘real-world’ data."
In addition, fewer women than men received a device such as pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy (p<0.0001 for all). Women were also less likely to be prescribed an exercise regimen (p=0.002) or referred to disease-management programmes (p=0.008).
“The lower use of cardiac resynchronization therapy in women is especially notable, as that this intervention may be even more effective in women than men and given that left bundle branch block is more common in women,” the researchers pointed out.
Despite having better outcomes than men in terms of the primary composite outcome*** (adjusted hazard ratio [HR], 0.75, 95 percent CI, 0.72–0.89) as well as all-cause mortality (HR, 0.68, 95 percent CI, 0.62–0.74), women reported a worse quality of life (median KCCQ# score, 71.3 vs 81.3; p<0.0001).
“Although women with HFrEF live longer than men, their additional years of life are of poorer quality, with greater self-reported psychological and physical disability,” the researchers noted.
Filling the gap
“Women continue to receive suboptimal treatment, compared with men, with no obvious explanation for this shortfall,” said the researchers.
They suggested that therapeutic strategies be tailored for women with HF, and there should be more referrals to cardiac rehabilitation programmes and psychosocial support for these women.
“All future funded research will need to account for sex as a biological variable in the development of research questions and study designs … Women must be enrolled in research trials in adequate numbers [and] subgroup endpoints [be prespecified and analysed],” urged Walsh and co-authors.
“Only with these measures will we be able to offer all our patients, both women and men, diagnostic and therapeutic strategies that are patient-centric and optimally beneficial.”