Diapositiva 1

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HEART FAILURE PREVENTION AND MANAGEMENT FROM
DRUGS TO DEVICES
Genova, 1-2 aprile 2005
Linsufficienza cardiaca diastolica e sesso
femminile il diavolo è nella donna?
Cristina Opasich Fondazione S. Maugeri- IRCCS-
Pavia
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(No Transcript)
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Scompenso con funzione sistolica preservata
Predittori di scompenso
Ospedalizzazioni per scompenso
Prognosi
Terapia
Soggettività
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EuroHeart Failure survey

Women (n 2048)
Men (n 3249)
lt10
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-80
Left Ventricular Ejection Fraction ()
Eur H J 2003
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EuroHeart Failure survey
Severity of LV systolic dysfunction
?
?
None
Mild
Moderate
Severe
Eur H J 2003
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EuroHeart Failure survey
Demography
yrs
All plt0.001

women gt70 years
Preserved LVEF
LV systolic dysfunction
Eur H J 2004
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EuroHeart Failure survey
Comorbidity
plt0.001

plt0.001
n.s.
Preserved LVEF
LV systolic dysfunction
Eur H J 2004
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National Heart Failure Project
N 19710 older patients with known LVSF
66
34
71
Women (n 4795)
Men (n 1959)
Preserved LVEF
LV systolic dysfunction
Masoudi F,JACC 2003
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National Heart Failure Project

All plt0.001
diabetes
CAD
Preserved LVEF
LV systolic dysfunction
Masoudi F,JACC 2003
10
National Heart Failure Project
Risk ratio for the association between
female gender and preserved LVSF
Masoudi F,JACC 2003
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Responsible mechanisms for the high prevalence
of diastolic dysfunction in women
Unclear
Biological factors Different cardiac
remodeling Reduced rate of myocyte loss Different
transcriptional regulation by estrogens of genes
implicated in cardiac hypertrophy
Different impact of co-morbid conditions
Different response to prevention therapy
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Predittori di scompenso
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PREDICTORS of Heart Failure among postmenopausal
women with coronary disease
2391 women followed for 6.3 ? 1.4 years 237 women
were hospitalized or died of heart failure
HR 3.1 (2.3-4.2)
Diabetes
HR 2.9 (1.4-6.2)
Atrial fibrillation
HR 2.5 (1.7-3.7)
Recurrent MI
HR 2.3 (1.4-3.6)
Renal failure
Heart and Estrogen/Progestin Replacement
Study Bibbins-Domingo K, Circulation 2004
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PREDICTORS of Heart Failure among postmenopausal
women with coronary disease
2391 women followed for 6.3 ? 1.4 years 237 women
were hospitalized or died of heart failure
Hypertension (BP gt140 mmHg)
HR 2.1 (1.3-3.3)
HR 1.9 (1.2-2.8)
Current smoking
Obesity (BMI gt 35 Kg/m2)
HR 1.9 (1.1-3.0)
HR 1.6 (1.0-2.4)
LBBB
HR 1.5 (1.0-1.7)
LV hypertrophy
Heart and Estrogen/Progestin Replacement
Study Bibbins-Domingo K, Circulation 2004
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PREDICTORS of Heart Failure
Postmenopausal women with CAD, no-HF (n 2391)
Diabetes
Yes (n 380)
No (n 2001)
Cr Cl lt42.8 ml/min
No (n 343)
Yes (n 47)
BMIgt36 Kg/m2
Yes (n 75)
No (n 268)
Annual HF incidence
1.2
2.8
7.0
12.8
HERS, Bibbins-Domingo K, Circulation 2004
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PREVENTION of Heart Failure in Women
Treatment of long-standing hyperglycemia (?)
(CHARMP, HOPE)
Hypertension therapy (!) (7th Report of JNC)
Halting the development / progression for renal
disease (?) (UKPDS,MICRO-HOPE,IDNT)
Obesity treatment (?)
Stop smoking (?)
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Ospedalizzazioni per scompenso
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Annual Hospitalization for Heart Failure
1990
2000
year
National Hospital Discharge Survey-USA Koelling
T, Am Heart J 2004
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Annual Hospitalization for Heart Failure as a
primary diagnosis adjusted for age
Per 1000 persons
1990
2000
year
National Hospital Discharge Survey-USA Koelling
T, Am Heart J 2004
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New York Heart Failure Consortium
N 619 pts admitted for HF with a preserved LVEF
age
yrs

plt0.001
72.5
comorbidity

All n.s.
Women (n 449)
Men (n 170)
Hyp
Diab
COPD
CAD
Klapholz,JACC 2004
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New York Heart Failure Consortium
N 619 pts admitted for HF with a preserved LVEF
Increased LV mass
LVSD
LVDD
n.s.

mm
LV mass index
g/m2
p0.005
n.s.
Women (n 449)
Men (n 170)
Klapholz,JACC 2004
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TEMISTOCLE Italian data
Consecutive admissions for AHF


47

Women (n 1000)
Men (n 1127)
Opasich C, Eur J Heart Fail. 2004
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TEMISTOCLE Italian data
Clinical characteristics
All plt0.05

HBP
diabetes
age
?75
AF
FEgt40
valvular
anemia
Women (n 1000)
Men (n 1127)
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Clinical characteristics
Women (n 1000)

plt0.01
n.s.
plt0.01
plt0.01
age
?75
comorbidity
NYHA IV
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Precipitating factors
All plt0.05
ischemia
HBP
anemia
endocrine
iatrogenic
Women (n 1000)
Men (n 1127)
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Diagnostic procedures

All plt0.001
n.s.
LOS
ECHO
HOLTER
ExT
Women (n 1000)
Men (n 1127)
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Diagnostic procedures
Women (n 1000)

All plt0.001
plt0.001
LOS
ECHO
HOLTER
ExT
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Drug therapy at discharge
plt0.05
plt0.01
n.s.
ACE-i/ARBs
ß-B
spironolactone
Women (n 1000)
Men (n 1127)
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Drug therapy at discharge
Women (n 935)
All plt0.05
ACE-i/ARBs
ß-B
spironolactone
Opasich C, Eur J Heart Fail 2004
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Prognosi
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TEMISTOCLE Italian data
In hospital mortality
Women (n 1000)

n.s.
n.s.

Women (n 1000)
Men (n 1127)
Opasich C, Eur J Heart Fail 2004
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TEMISTOCLE Italian data
Predictors of in-hospital mortality in women
Opasich C, Eur J Heart Fail 2004
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Predictors of mortality
Postmenopausal CAD and HF women (n 702,FU 5.8
years)
Cr Cl lt60 ml/min
Diabetes
Agegt70 yrs
Limited exercise
Current smoking
gt1 MI
NYHA III/IV
Atrial fibrillation
HERS, Bibbins-Domingo K, JACC 2004
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GENDER

• Framingham cohort
• women had a better prognosis than men
• SOLVD trials
• women had a poorer prognosis than men
• FIRST study
• only women with a non-ischemic etiology
• had a better prognosis than men

Ho, JACC 1993 Bourassa, JACC 1993 Adams,
Circulation 1999
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GENDER
IN-CHF (ANMCO)
1-year all-cause mortality
All n.s.
Total
Ischemic
Valvular
DCM
? BP
Others
women
men
IN-CHF, Opasich, Am J Cardiol 2000
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GENDER
CIBIS II
?
?
?
?
Simon, Circulation 2001
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GENDER
MERIT-HF
Ghali, Circulation 2002
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GENDER
DIAMOND
N 5491 pts admitted with HF (40 women) But,
when the age difference between men and women
was adjusted for, male gender was associated
with an increased risk of death RR 1.25
(1.171.34), p0.001
p0.23
Gustafsson, Eur Heart J 2004
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Terapia
40
CHARM-Preserved Primary outcome CV death or CHF
hospitalisation

30
366(24)
25
333(22)
Placebo
20
Candesartan
15
10
HR 0.89 (95 CI 0.77-1.03) p 0.118Adjusted
HR 0.86, p 0.051
5
0
0
1
2
3
3.5
2.5
1.5
0.5
(3025 pts women40)
Years
Yusuf S,The Lancet 2003
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CHARM-Overalldeath /first HF admission
AGE
lt65
p0.26
?65lt75
? 75
SEX
Male
p0.87
Female (gt30)
1
Candesartan better
Pfeffer,The Lancet 2003
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I-PRESERVED trial CV event
Elderly (gt 60 years) HF symptomatic patients with
LVEF gt 45
Irbesartan up to 300 mg vs placebo
Sanofi-Synthelabo/Bristol-Myers Squibb
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DIG trial death


Interaction Sex/digoxin abs diff 5.8 p0.03
Placebo
Digoxin
Women (n 755 on digoxin, 764 on placebo)
Men (n 2642 on digoxin, 2639 on placebo)
Rathore, N Engl J Med 2002
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Soggettività
45
more accepting HF less
likely experience social isolation and loss
more fear
Costello, Can J Cardiovsc Nurs 2004
more feeling insecure about
themselves and in relation to their
surroundings .more feeling of worthlessness
Martensson, J of Adv Nurs 1998
...less improvement in physical
health status and lower perceived quality of
life and care
SOLVD, Chin, Med Cre 1998
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ANXIETY
n.s
NEUROTICISM
plt0.05
DEPRESSION
plt0.05
Women (n 44)
Men (n 40)
Majani, Montescano
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Donne
48
Diabete mellito e scompenso cardiaco
Kaiser Permanente Medical Care Program Northern
California-Diabetes Registry n. 48.858 pz.
diabetici, ? 49, distribuzione tipo e
trattamento diabete simile ai maschi. Follow up
2.2 anni 516 HF eventi negli ? e 419 nelle ?
Hb AIc ? 10 vs lt7
1 ? Hb AIc
1.3-fold
Women
1.04 (0.98-1.09)
1.8-fold
Men
1.12 (1.07-1.18)
Iribarren C, Circulation 2001