A new study suggests that women with heart failure (HF) are less likely to be on life-saving treatments for HF and ischemic heart disease than men and even more likely to receive medications exacerbating HF.

The study, which appears in the September issue of JACC: Heart Failure, says that women were less likely to be on renin-angiotensin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.

Women were also less likely to receive cardiac implantable electronic devices and undergo appropriate non-invasive and invasive diagnostics and therapeutics for acute coronary syndromes regardless of ischemic history or precipitant.

“The present results extend previous findings and emphasize an ongoing unmet need to address sex differences in HF management,” said the paper’s authors, adding that these differences are observed in all geographic regions, regardless of country income level. “Sex-neutral interventions, such as electronic decision support tools to optimize care or polypill delivery for heart failure with reduced ejection fraction (HFrEF) treatment, might reduce sex differences in HF management. Furthermore, it is important to investigate further specific underlying country-specific structural barriers to HF management, such as care costs or sociocultural norms, which might affect men and women differently.”

Analysis of REPORT-HF registry

The analysis of the Registry to Assess Medical Practice With Longitudinal Observation for the Treatment of Heart Failure (REPORT-HF) found that women (n=7,181), were older than men (n=11,372), and were more likely to have HF with preserved left ventricular ejection fraction (LVEF).

These women were also found to have more comorbid conditions (except for coronary artery disease) and have more severe signs and symptoms at admission.

Further findings revealed that coronary angiography, cardiac stress tests, and coronary revascularization were less frequently performed in women than in men.

Led by Jasper Tromp, MD, PhD, from the National University of Singapore and National University Health System, the research team also found that women with acute heart failure (AHF) and reduced LVEF were less likely to receive an implanted device, regardless of region or country income level.

Women were more likely to receive treatments that could worsen HF than men (18% vs 13%; P<0.0001).

In countries with low-income disparity, women had better 1-year survival than men. This advantage was lost in countries with greater income disparity (P<0.001).

“More countries in REPORT-HF had higher income disparity than in previous registries,” said the paper’s authors. “Country income inequality tracks well with a country-level gender pay gap, leading to a more significant impact on women’s financial means to access high-quality treatment, which might explain this finding. This suggests that in countries with more significant differences between richer and poorer households, women in poorer households might be more deprived of access to care than men.“

Socioeconomic factor consideration

Authoring an accompanying editorial comment, Nosheen Reza, MD, from the University of Pennsylvania, pointed out that REPORT-HF did not capture socioeconomic factors in detail.

“… We can hypothesize that in countries with low-income inequality, women may have greater access to longitudinal and preventive health care …,” she said. “Similarly, in these countries, women with HF may be cared for in systems with wider availability of life-sustaining and life-prolonging HF therapies. The opposite may be true in countries with high-income inequality where gender inequality is known to be highly prevalent, especially with regard to access to health services, education, and economic opportunities. Women in these countries may encounter more active obstacles to seeking care, therefore presenting to the hospital with a greater severity of HF—as was seen in the current analysis—and remaining at elevated mortality risk post discharge.”

Reza put forward a potential way forward that could involve constructing standardized care paradigms, agnostic to patient sex, which are scalable across a diversity of care settings and cultures.

She added that, fortunately, interest within the HF community in rigorously evaluating the implementation of HF therapies is rapidly growing.

Study methodology

The globally representative analysis of REPORT-HF, which was funded by Novartis Pharma, involved the authors investigating differences between men and women in treatment and outcomes in 18,553 patients hospitalized for AHF in 44 countries.

REPORT-HF enrolled participants during hospitalization with a primary diagnosis of AHF.

Of the patients enrolled, 7,181 (39%) were women, who were older than men, more often had heart failure with preserved ejection fraction (HFpEF) and had more severe symptoms and signs of HF at admission.

Investigators were encouraged to adhere to local standards and recommendations for diagnosing and treating AHF.

HFrEF was defined with a left ventricular ejection fraction (LVEF) of <40%, while HF with midrange ejection fraction was defined with an LVEF of 40% to 49%. HFpEF was defined as an LVEF of ≥50%.

The researcher team calculated the maximum daily doses attained at discharge and at 6 months for patients prescribed beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists.

Data on medication that might cause or exacerbate HF were captured as well and classified according to the level of evidence (A, B, or C) based on an American Heart Association scientific statement.

Participants’ follow-up information was collected via telephone interview at 6 and 12 months after discharge unless a regular follow-up visit was planned for routine care at the investigator’s site.

Sources:

Tromp J, Ezekowitz JA, Ouwerkerk W, et al. Global Variations According to Sex in Patients Hospitalized for Heart Failure in the REPORT-HF Registry. JACC Heart Fail. 2023;11:1262–1271.

Reza N. A Woman’s Work Is Never Done: Overcoming Sex and Income Inequalities in Heart Failure Care. JACC Heart Fail. 2023;11:1272–1274.

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