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	James L. Holly, M.D.

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Your Life Your Health - Women and Heart Disease: Congestive Heart Failure

James L. Holly,M.D.

March 01, 2005

Cardiology Review, Vol 22 No 3

Epidemiology

A striking difference between men and women with heart failure is the predominance of preserved left ventricular systolic function in women.
Mortality rates are lower for patients with preserved systolic function.
Heart failure patients with preserved systolic function have symptoms and rates of functional decline similar to those with LVSD.
Risk factors for the development of heart failure vary by gender.
1. Women with heart failure are more likely to have a history of hypertension
2. Hypertension imparts a higher risk of developing heart failure in women.
3. Even with LVSD, women are less likely to have underlying coronary artery disease.
4. Women with heart failure are significantly older. The average age of women admitted with CHF is 77 versus men 72.
5. Atrial Fibrillation is more common in women with heart failure.
Survival following onset of heart failure is better with women than men.
Prognosis for women with heart failure is poor - 20% one year morality and a median survival of four years.
Women often have more heart failure symptoms, lower exercise tolerance and more signs of heart failure on presentation than men.
Depression is independently associated with declines in heart failure health status.
Depression is more common and more severe in women

Medical Treatment

Women are under represented in clinical trials.
Women do not get the same benefit from ACE Inhibitors as women.
Women with symptomatic LVSD benefit from ACE but those with asymptomatic LVSD do not.
ARBS are beneficial in women with LVSD
Beta Blockers are beneficial in LVSD in men and women.
Inspra (eplerenone) is beneficial in women with heart failure following MI.
1. Requires careful monitoring for hyperkalemia particularly in patients with marginal renal function
2. Women have a lower glomerular filtration rate than men reliance on creatinine is insufficient to identify women at increased risk of hyperkalemia.
Digoxin
1. Some studies have shown an increased risk of death in women treated with lanoxin.
2. Guidelines recommend low-dose lanoxin for paints with symptomatic heart failure and LVSD.
Less data to guide therapy for heart failure with preserved systolic function
1. Current guidelines recommend treating underlying problem, i.e., hypertension, etc.
2. ARBs have shown a slight decrease in hospitalizations.
3. ACE Inhibitors have not been studied in randomized controlled studies.
4. ACEI may reduced the risk of death in women either systolic or diastolic dysfunction among those with renal insufficiency and heart failure.
Evidence supports that women do not received the quality of care for heart failure as men.
1. Less likely to undergo diagnostic testing.
2. Less likely to have left ventricular function assessment
3. Less often referred or coronary angiography.
4. Less likely to be evaluated by a cardiologist when admitted for heart failure.

Clinical Implications

Most important goal is to apply current heart failure guidelines equally to men and women.
Women presenting with heart failure deserve the same diagnostic evaluation as men.
Weight of evidence supports treatment of women with LVSD with ACE inhibitors or ARBs, as well as beta blocker, barring contraindications.
1. Higher rates of side effects - cough, renal insufficiency in women taking ACE inhibitors
2. Women should be followed closely after initiating treatment.
Aldosterone antagonists should be consider for women with:
1. LVSD and NYHA functional class III or IV
2. Women with acute MI complicated by heart failure
3. Estimated creatinine clearance should be calculated to assess the potential risk of hypekalemia
Digoxin should be prescribed to women with LVSD only with extreme caution.
1. Some one say it should be avoided in women
2. If used digoxin levels should be kept below 1.0 ng/mL
3. Particular caution in women with reduced creatinine clearance
4. No evidence to use lanoxin with preserved systolic function
For women with heart failure and preserved systolic function:
1. Aggressive treatment of hypertension
2. Strong consideration of using ARBs
Vigilance for atrial Fibrillation in women with heart failure is warranted.
Depression is common in women with heart failure and is associated with a broad range of adverse outcomes, strong consideration should be given to routine depression screening and treatment.

Other Articles in the Cardiovascular Disease in Women Series

	Women and Heart Disease: Primary Prevention Women and Heart Disease: Testing Guidelines Women and Heart Disease: Hormone Usage Women and Heart Disease: Hormone Replacement Therapy Women and Heart Disease: It can be prevented!

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