Transcript Tenth International Symposium HEART FAILURE & Co. Milano …

Tenth International Symposium
HEART FAILURE & Co.
CARDIOLOGY SCIENCE UPDATE
FEMALE DOCTORS SPEAKING
ON FEMALE DISEASES
S. HUNT
Milano
9 - 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, MD
Stanford 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
Rosamond, W. et al. Circulation 2008;117:e25-e146
Prevalence of HF by sex and age
1999-2004
Copyright ©2008 American Heart Association
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
Framingham Database – People with HF
Hsich, E. M. et al. J Am Coll Cardiol 2009;54:491-498
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
CHF
60
16
59
Men
58
Women
Men
14
Women
12
57
10
%
%
56
8
55
6
54
53
4
52
2
51
0
BARI 1989-91
CAVEAT 1991-92
NHLBI 1997-98
BARI 1989-91
CAVEAT 1991-92
NHLBI 1997-98
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:
MALE
FEMALE
ISCHEMIC
57%
40%
NON-ISCHEMIC
43%
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
Kaplan-Meier Curves for All-Cause Mortality in the CHARM Study
Hsich, E. M. et al. J Am Coll Cardiol 2009;54:491-498
Kaplan-Meier Probabilities of Survival by Etiology of Heart Failure and Gender
POOLED DATA FROM 5 LARGE HF TRIALS
Frazier, C. G. et al. J Am Coll Cardiol 2007;49:1450-1458
Overall, however, HF is getting more
prevalent and costing more
REASONS INCLUDE
Increasing survival post-MI
Better therapy prolonging lives
“Ageing” of the population
Rosamond, W. et al. Circulation 2008;117:e25-e146
Incidence of heart failue
1980-2003
Copyright ©2008 American Heart Association
Hospital discharges for HF by sex
1979-2005
Rosamond, W. et al. Circulation 2008;117:e25-e146
Copyright ©2008 American Heart Association
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

Effect of angiotensin-converting enzyme inhibitors on mortality in male and
female patients with heart failure (random effects pooled estimate)
MALE
FEMALE
Shekelle, P. G. et al. J Am Coll Cardiol 2003;41:1529-1538
Copyright ©2003 American College of Cardiology Foundation. Restrictions may apply.
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
blockers
There 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