QOL With Ambulatory Advanced Heart Failure Worse for Women Than Men

By Will Boggs MD

June 18, 2019

NEW YORK (Reuters Health) - Quality of life in patients with ambulatory advanced heart failure is worse among women than among men, according to findings.

"Despite physicians assigning similar overall levels of illness to men and women (by INTERMACS profile or NYHA class), patients themselves reported different burdens of heart failure (HF) according to sex," Dr. Garrick C. Stewart from Brigham and Women's Hospital, in Boston, told Reuters Health by email.

Both women and men face a growing burden of morbidity and mortality from HF, and previous studies have shown that women are less likely than men to be listed for heart transplant or to receive left ventricular assist devices (LVADs).

Dr. Stewart and colleagues used data from the Registry Evaluation for Vital Information on Ventricular Assist Devices in Ambulatory Life (REVIVAL) study to compare clinical characteristics, quality of life and functional impairments in 99 women and 301 men with ambulatory advanced systolic HF.

All patients were NYHA functional class II-IV, had left ventricular ejection fraction (LVEF) of 35% or less and a HF diagnosis more than 12 months before registration. Moreover, all patients were on maximum-tolerated doses of evidence-based HF medical and electrical therapies or had a documented contraindication or intolerance to medication use. A high-risk feature for mortality in HF was also present.

Health-related and HF-specific quality-of-life scores were similar overall for women and men, but women were significantly more likely than men to report problems with usual activities, physical limitations and depression. Six-minute walk distance was also significantly lower in women than in men (309 vs. 347 m), the researchers report in JACC Heart Failure, online May 8.

Similar proportions of women (30%) and men (26%) expressed definite or probable willingness to consider an LVAD to treat their current level of HF, and most men and women reported that they wanted to have life-sustaining therapies.

Women and men did not differ significantly in the primary one-year combined outcome of freedom from death, durable mechanical circulatory support (MCS), or urgent transplant or in the freedom from the primary combined outcome events or first unplanned HF hospitalization.

Women with chronic systolic HF who had not experienced a primary outcome event at one-year follow-up continued to have worse depression scores, shorter six-minute walk distances and worse physical limitation scores, compared with men.

"These results suggest an opportunity to further optimize treatments to reduce these observed disparities," the researchers conclude. "Iterative assessment of HF prognosis, quality of life, functional capacity, and elicitation of care preferences and values will inform shared decision making in women with advanced ambulatory HF."

"Ambulatory patients with advanced heart failure are at high risk for death, transplant, or VAD despite being outpatients on guideline-directed medical therapy," Dr. Stewart said. "Patient-reported measures of functioning and quality of life should be integrated into routine clinical care and targeted for future studies of HF therapies."

"Multiple additional analyses from REVIVAL are underway to explore the burden of ambulatory advanced HF, describe the prognosis of these patients, and identify target populations for next-generation clinical trials for drugs and devices (LVADs) in so-called 'less sick' advanced-HF patients," he said.

"Only 25%-35% of patients who are referred to advanced HF centers are women," writes Dr. Prateeti Khazanie of the University of Colorado School of Medicine, in Aurora, writes in a related editorial. "Once women get to an advanced HF center, data from REVIVAL demonstrate that they are just as willing and just as likely as men to receive heart replacement therapies. Taken together, these data suggest a problem with women getting excluded in the community rather than once they are at an advanced HF center."

"Disparities are debatable, but sex differences in advanced HF care are undeniable," she adds. "The next challenge is to move upstream in the patient pathway and characterize walking wounded women and men living with advanced HF in the community."

Dr. Susan E. Howlett from Dalhousie University, in Halifax, Canada, who recently reviewed differences in cardiovascular aging in men and women, told Reuters Health by email, "It is critically important to investigate both men and women in clinical studies, as one cannot assume results will be the same in both groups. It is also clear, as highlighted by the authors, that patient-centered outcome measures are helpful to detect such differences and these should be used more widely."

"Women are more likely to get HF with preserved ejection fraction (HFpEF) than men," explained Dr. Howlett, who was not involved in the study. "Frail individuals (those with accelerated aging) of both sexes are also more likely to get HFpEF than non-frail individuals. This is important because evidence-based therapies are much more helpful to treat HF with reduced ejection fraction (HFrEF) - the form of HF seen in younger, less frail men."

"We need more studies on mechanisms involved in HFpEF and frailty in both sexes, and my lab is working on that," she said. "On the other hand, this study just looked at men and women with reduced ejection fraction - so a similar study on HFpEF would be very interesting."

SOURCE: https://bit.ly/2wlJEs8 and https://bit.ly/2QtoBwY

JACC Heart Fail 2019.