Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
ESC Heart Fail. 2024 Oct;11(5):3095-3104. doi: 10.1002/ehf2.14888. Epub 2024 Jun 11.
Sex differences in long-term post-discharge clinical outcomes in Asian patients hospitalized for acute decompensated heart failure (HF) persist despite the world-wide implementation of guideline-directed medical therapy for decades. The present study aims to elucidate the puzzling dilemma and to depict the directions of solution.
Between 2011 and 2020, a total of 12 428 patients (6518 men and 5910 women, mean age 73.50 ± 14.85) hospitalized for acute decompensated HF were retrospectively enrolled from a university HF cohort. Compared with men, women hospitalized for acute decompensated HF were older in age (76.40 ± 13.43 vs. 71.20 ± 15.67 years old, P < 0.0001) with more coexisting hypertension, diabetes, hyperlipidaemia and moderate to severe chronic kidney disease, but less with ischaemic heart disease, cerebrovascular disease and chronic obstructive pulmonary disease (P < 0.0001). In echocardiography measurement parameters, women had smaller left ventricular and left atrial dimensions, higher left ventricular mass index, higher left ventricular ejection fraction (LVEF) and more in HF with preserved ejection fraction (EF) category (LVEF > 50%) than men (P < 0.0001). In HF therapy, women compared with men received more guideline-directed medical HF therapies including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors, but similar beta-blockers and mineralocorticoid receptor antagonists (P < 0.0001). Post-discharge long-term clinical outcomes after multivariate-adjusted analysis revealed that women compared with men had lower all-cause mortality [adjusted hazard ratio (aHR): 0.89, 95% confidence interval (CI): 0.84-0.93], lower cardiovascular mortality (aHR: 0.89, 95% CI: 0.80-0.99) and lower 1 year mortality (aHR: 0.91, 95% CI: 0.84-0.99) but similar HF rehospitalization rate (aHR: 1.02, 95% CI: 0.95-1.09) over 8 years of follow-up. The superiority of women over men in all-cause mortality was shown in HF with preserved EF (>50%) and HF with mildly reduced EF (40%-50%), but not in HF with reduced EF (<40%) category. Subgroup forest plot analysis showed body mass index, coexisting hypertension and chronic obstructive pulmonary disease as significant interacting factors.
With more coronary risk factors and medical comorbidities, less cardiac remodelling and better adherence to guideline-directed HF therapy, women hospitalized for acute decompensated HF demonstrated superiority over men in long-term post-discharge clinical outcomes, including all-cause mortality, cardiovascular mortality and 1 year mortality, and mainly in HF with preserved and mid-range EF categories, in the Asian HF cohort.
尽管几十年来全球范围内都在实施指南指导的医学治疗，但亚洲因急性失代偿性心力衰竭（HF）住院的患者在出院后的长期临床结局方面仍存在性别差异。本研究旨在阐明这一令人费解的困境，并描绘解决问题的方向。
在 2011 年至 2020 年期间，从一所大学 HF 队列中回顾性纳入了 12428 名因急性失代偿性 HF 住院的患者（6518 名男性和 5910 名女性，平均年龄 73.50±14.85 岁）。与男性相比，因急性失代偿性 HF 住院的女性年龄更大（76.40±13.43 岁比 71.20±15.67 岁，P<0.0001），且合并高血压、糖尿病、高脂血症和中重度慢性肾脏病的患者更多，但合并缺血性心脏病、脑血管病和慢性阻塞性肺疾病的患者更少（P<0.0001）。在超声心动图测量参数中，女性的左心室和左心房尺寸更小，左心室质量指数更高，左心室射血分数（LVEF）更高，射血分数保留的心力衰竭（HFpEF）（LVEF>50%）患者更多（P<0.0001）。HF 治疗方面，与男性相比，女性接受了更多指南指导的 HF 治疗，包括血管紧张素转换酶抑制剂、血管紧张素受体阻滞剂、血管紧张素受体-脑啡肽酶抑制剂和钠-葡萄糖共转运蛋白 2 抑制剂，但β受体阻滞剂和盐皮质激素受体拮抗剂的使用相似（P<0.0001）。多变量校正后的出院后长期临床结局分析显示，与男性相比，女性的全因死亡率更低[校正后的危险比（aHR）：0.89，95%置信区间（CI）：0.84-0.93]、心血管死亡率更低（aHR：0.89，95%CI：0.80-0.99）和 1 年死亡率更低（aHR：0.91，95%CI：0.84-0.99），但心力衰竭再住院率相似（aHR：1.02，95%CI：0.95-1.09），随访 8 年。在射血分数保留（>50%）和射血分数中度降低（40%-50%）的心力衰竭患者中，女性的全因死亡率优于男性，但在射血分数降低（<40%）的心力衰竭患者中则不然。亚组森林图分析显示，体重指数、合并高血压和慢性阻塞性肺疾病是显著的交互因素。
在亚洲 HF 队列中，与急性失代偿性 HF 住院的男性相比，因急性失代偿性 HF 住院的女性具有更多的冠状动脉危险因素和合并症、更少的心脏重构以及更好地遵循指南指导的 HF 治疗，因此在出院后的长期临床结局方面表现出优势，包括全因死亡率、心血管死亡率和 1 年死亡率，并且主要在射血分数保留和中等范围 EF 类别中。
