Heart Failure in Women

Abstract

Heart failure (HF) has steadily increased in prevalence and affects both males and females equally. Despite this, there has been a significant underrepresentation of women in large scale HF trials. This disparity has lead to a deficit in understanding important gender-based differences in pathophysiology, diagnosis and treatment strategies. We review these gaps and explore a biological basis for varying outcomes. Endogenous estrogen plays an important role in epidemiology and outcome. The administration of exogenous estrogen has had varied success in treatment and is outlined extensively below. Additionally, we highlight unique HF syndromes through pregnancy and important sex-specific issues concerning transplant and mechanical circulatory support. A central theme remains: there is a clear need for increased female recruitment in clinical trials, and more studies exploring the role of gender-based biology in HF treatment. IntroductionThe prevalence of heart failure (HF) has steadily increased and is now the leading cause of hospital admissions in the adult population in the United States. 1 Women constitute approximately one half of the patients hospitalized for HF, and deaths from HF contribute 35% of the total cardiovascular disease (CVD) mortality in women. 1 -3 Despite this, women have been historically under-represented in clinical HF trials. Although the population estimate of women among patients with HF in the Unites States is about 50%, only 17% to 23% of HF randomized controlled trials enrolled women. 4 This disparity has limited our understanding of gender-related differences in HF. The objective of this article is to review the relationships between sex and the epidemiology, etiology, clinical characteristics, therapeutic management, and outcomes in patients with HF.

Gender-related differences in clinical profile and outcome of patients with heart failure. Results of the RICA Registry

“…In fact, women represent approximately half of all patients hospitalized for HF, 2--- 6 and an even higher percentage if we only consider the departments of internal medicine. 7 However, women have been scarcely represented in most clinical trials on HF, 8 constituting less than 25% 5 of the population in most of these studies. HF in women has demonstrated a series of differences in terms of its epidemiology, etiology, pathophysiology and symptoms.…”

Early menopause and subsequent cardiovascular disease

“…Women with early menopause consequently have a shorter total duration of premenopausal estrogen exposure than women with later menopause and are hypothesized to have an elevated risk of CVD. 9 The present study, conducted by Rahman et al, 10 addressed the relationship of early onset of menopause with incidence of HF, with special consideration of the impact of smoking history. 8 To date, few previous analyses have addressed whether early menopause also predicts heart failure (HF).…”

Most Important Outcomes Research Papers on Cardiovascular Disease in Women

“…Disease presentation may likewise vary among men versus women, as may patterns of therapy and quality of care . 39,40 Women have been under-represented in many major HF trials . As a result, significant uncertainty exists about the effectiveness of HF therapies in this population .…”

“…As a result, significant uncertainty exists about the effectiveness of HF therapies in this population . 39,41 The summaries included in this section describe gender-specific findings related to the medical management of HF with preserved ejection fraction, use of mechanical circulatory support in advanced HF, and use of primary prevention therapies including implantable cardioverter defibrillators .…”