S. HUNT Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010.

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