Across the Globe, Some Sex Gaps Still Seen in Congestive Heart Failure

Men and women with congestive heart failure (HF) diverge in many ways—in terms of not only the disease itself but also its impact on all-cause mortality. But the sex-related patterns are consistent across countries regardless of economic status, international data from the Global Congestive Heart Failure (G-CHF) registry suggest.

As in prior studies, male patients were more likely than female to get an implantable cardioverter-defibrillator (ICD), report Marjan Walli-Attaei, PhD (Population Health Research Institute and Hamilton Health Sciences, Hamilton, Canada; University of Oxford, England), and colleagues in the Lancet Global Health. But, unlike in earlier data showing acute HF care for women falls short, here management was largely similar irrespective of sex, with no differences in chronic medication use or hospitalization for HF.

Co-author Philip Joseph, MD (Population Health Research Institute and Hamilton Health Sciences), said the G-CHF registry data capture a broad swath of information. “The study is pretty unique because we were able to look at characteristics, management, and outcomes in women compared to men on a more global [scale],” he told TCTMD, noting that there has been some controversy in the literature about the extent of sex-related differences in heart failure.

What the results also highlight, said Joseph, is that any disparities between male and female patients are smaller than those between lower- and higher-income countries. “The biggest gaps that we see from a global heart failure management standpoint . . . are between countries of different income levels,” he noted.

Walli-Attaei et al analyzed data for 23,341 people (60.1% male) enrolled in the G-CHF study across 257 centers in 40 countries over a 4-year period ending in September 2020. Follow-up lasted a mean of 2.6 years.

The mean age was 64 for men and 62 for women. Hypertensive HF was the most common etiology for women, at 25.5%, whereas the most common etiology in men was ischemic HF (45.6%). Women in general had a higher LVEF, with fewer female than male patients having an LVEF of 40% or lower (51.7% vs 66.2%). A third of women had an LVEF of 50% or higher, as compared with 18.6% of men.

Female patients were more likely to have signs and symptoms of congestion (NYHA functional class III or IV: 42.6% vs 37.9%). They also reported lower health-related quality of life.

For the most part, treatments were similar by sex. There were no significant differences in the use of heart failure drugs or cardiac tests. Importantly, though, women were less likely to receive an ICD (8.7% vs 17.2%).

Women and men, after adjusting for potential confounders, were also equally likely to be hospitalized for HF, with 10 admissions per 100 person-years in each group. Across the world, the largest difference was seen in Europe, where 9.4 women and 11.5 men per 100 person-years were hospitalized for heart failure. Hospitalization rates were consistent among countries categorized by economic status and within geographical regions.

There was, however, a gap in all-cause mortality: the incidence of death was 10.8 per 100 person-years in women and 13.5 per 100 person-years in men (adjusted HR 0.79; 95% CI 0.75-0.84). Again, the largest disparity was seen in Europe, where the per 100 person-year incidence was 7.8 in women and 11.8 in men, and results were similar within geographical regions and within countries of the same income level. Female patients, compared with male, had lower mortality in both high-/upper-middle-income countries (HR 0.81; 95% CI 0.71-0.93) and low-/lower-middle-income countries (HR 0.80; 95% CI 0.69-0.93).

“The paradox of why men have a higher mortality than women despite having less severe symptoms of heart failure, similar or lower age, after adjustment for ejection fraction levels, mostly similar levels of medications, and similar rates of heart failure hospitalization is not clear,” the authors note, urging that there need to be vigorous efforts to both investigate and mitigate whatever is driving the worse survival.

Additionally, Joseph said that the difference in ICD use merits a closer look, given how consistently it’s being seen. A possible explanation is concerns about the possibility of higher complication rates among women versus men receiving ICDs.

The paradox of women having more symptomatic heart failure and men having higher mortality “really needs to be understood, because from a patient perspective both of these are quite important,” Joseph added.