Management options for heart failure may include a combination of lifestyle changes, medications, implantable devices such as a pacemaker, PA pressure monitor or a defibrillator providing cardiac resynchronization therapy (CRT). Later stage advanced treatment options include a left ventricular assist device (LVAD) or transplant.
Women also experience differences in the epidemiology and pathophysiology that impact treatment of HFrEF and HFpEF.1 Factors such as lower body weight and plasma volume can contribute to a longer duration of action of lipophilic drugs and higher peak plasma concentrations of hydrophilic drugs. Similarly, lower cardiac output in women contributes to higher plasma levels of both hydrophilic and lipophilic drugs in women.2
Treatment of HFrEF in Women & Men1
Neurohormonal Blockade
Women
May need lower doses of ACE inhibitors or ARBs than men, but insufficient representation in clinical trials makes this benefit unclear.
Men
Sufficient representation of men in clinical trials shows clearer evidence base for improved outcomes and mortality.
Device Therapy
Women
Eligible women are less likely to have an ICD inserted making survival benefit data unclear. Women experience greater quality of life outcomes from CRT and improved hospitalization and mortality.
Men
More likely to have an ICD inserted. Percutaneous mitral valve intervention is shown to have a greater impact on HF hospitalization.
Advanced HF Management
Women
Women are both less likely to receive MCS for a cardiogenic shock and more likely to experience complications on durable MCS support.
Men
Men are more likely to receive both a durable LVAD or heart transplantation and experience lower mortality and better outcomes on LVAD support.
Underlying Mechanisms of HFpEF1
Cardiac Aging
Women
Experience greater concentric remodeling, load-induced diastolic dysfunction, arterial elastance and earlier wave reflection.
Men
Experience greater injury response myocardial necrosis and adverse remodeling with aging.
Exercise Hemodynamics
Women
Reduced cardiac output reserve with exercise can contribute to a greater rise in PCWP and poorer systemic and pulmonary artery compliance.
Men
Experience adverse RV-PA coupling with reduced RV contractile reserve.
Therapeutic Response
Women
Benefit from ARNI due to relative natriuretic peptide deficit. Experience significant sex treatment with mineralocorticoid receptor antagonists.
Men
Underlying ATTR pathology may limit neurohormonal blockage response.
What’s Next: Outcomes for Female Patients with Advanced Heart Failure
References:
- Ersilia M. DeFilippis , Anna Beale, Trejeeve Martyn, Anubha Agarwal , Uri Elkayam , Carolyn S.P. Lam , Eileen Hsich (2022) Heart Failure Subtypes and Cardiomyopathies in Women Circulation Research. 2022;130:436-454. DOI: 10.1161/CIRCRESAHA.121.319900
- Santema et al.; Identifying optimal doses of heart failure medications in men compared with women: a prospective, observational, cohort study. Lancet 2019; 394: 1254-63.
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