Effect of gender difference in management of heart failure patients in aseer, saudi arabia.

BACKGROUND: Heart failure (HF) is a common medical problem with a high impact on public health. Evidence of gender difference in management of HF is scarce. We conducted a retrospective study to evaluate the presence of gender difference in management of HF patients admitted to the tertiary care hospital in the Aseer region/Saudi Arabia. PATIENTS AND METHODS: A chart review was conducted at Aseer Central Hospital (ACH) on consecutive patients admitted with the primary diagnosis of HF between Jun 2007 and May 2009. Data were collected on clinical and management profiles and analyzed for the presence of gender difference in HF management.
RESULTS: A total of 206 male patients and 94 female patients with HF were reviewed. Ischemic and dilated cardiomyopathy etiologies were significantly higher in male patients (42.7 vs. 28.7%, P < 0.021) and (13.1% vs. 3.2%, P < 0.008), respectively. Renal failure and atrial fibrillation were significantly higher in female patients with HF (20.2 vs., 5.3% P < 0.001) and (20.2 vs. 10.2%, P < 0.018), respectively. Smoking was significantly higher in male patients (11.7 vs. 0%, P < 0.001). Echocardiography was performed equally for both genders and ejection fraction was significantly higher in female patients (38.2 ± 16.9% vs. 30.4 ± 16.6%, P < 0.001). Beta-blockers were prescribed significantly less to female patients (36.2 vs. 57.8%, P < 0.001), while ACE inhibitors and digoxin were prescribed significantly less to male patients (64.1 vs.75.5%, P < 0.049) and (24.8 vs. 36.2%, P < 0.042), respectively.
CONCLUSION: Gender differences were detected in clinical presentation and management of HF. Female patients with HF had less ischemic etiology and smoking, but more atrial fibrillation and renal dysfunction. Female patients were under-treated by Beta-blockers while male patients were under-treated by ACE inhibitors and digoxin. Both genders were investigated equally, and female patients had a better ejection fraction.

INTRODUCTION

Heart failure (HF) is a common medical problem, in which the heart fails to meet the peripheral tissue demands at a normal filling pressure.[1] The global prevalence of HF is estimated to be 2.3–3.9% per annum.[2-4] Around 25 million people around the world are suffering from HF, and each year 2 million new cases of HF are diagnosed. It has a high mortality and morbidity rates and an enormous impact on health care system and public health.[5-10] The incidence and prevalence of HF continue to increase likely due to therapeutic improvement in the treatment of acute myocardial infarction and hypertension and also due to increase in the aging population.

Evidence from the literature showed that gender discrepancies in HF management may exist.[11-16] Elderly women make up a greater proportion of HF patients in those over 75 years of age.[78] Earlier studies such as Framingham reported better survival among female patients with HF compared to males.[69] Other recent trials with accurate assessment of left ventricular function showed contradicting results where female patients with HF had a higher mortality rate.[17] Although gender bias in ischemic heart disease (IHD) management is well studied,[18-29] the evidence of gender bias in HF management is scarce.

The Aseer region (population of 1,200,000) is located in the southwest of Saudi Arabia covering an area of more than 80,000 km2. The region extends from the high mountains of Sarawat (with an altitude of 3200 m above sea level) to the Red Sea. Health service delivery in the Aseer region is provided by a network of 244 primary health care centers, 16 referral hospitals and one tertiary hospital, Aseer Central Hospital (ACH). ACH, with 500 beds, is run by the Ministry of Health and the College of Medicine of King Khalid University (KKU), Abha.

This study was designed to investigate whether gender difference exists in the management of HF patients admitted to ACH, Aseer region/Saudi Arabia.

PATIENTS AND METHODS

A retrospective cohort of all consecutive patients admitted to ACH with the diagnosis of HF during the period from June 2007 to May 2009 were studied. Patients′ data were reviewed and tabulated for both genders. These data including the clinical profile of HF (demographic data, etiologic factors for HF, associated risk factors for HF such as: diabetes, hypertension, atrial fibrillation, and renal failure), and echocardiographic features. Data on the management profile of HF using different therapeutic agents were obtained. Data on both genders were collected and compared. Approval of the local medical ethical committee was obtained. Data were analyzed using SPSS software package. Frequency, percentage, mean, standard deviation, and median were used to present the data. Chi square and the Student “t” were used as tests of significance at the 5% level.

RESULTS

A total of 206 male patients (68.7%) and 94 female patients (31.3%) with the diagnosis of HF were included.

Clinical profile of HF patients

Table 1 showed gender differences in the clinical profile of HF patients. Male patients were significantly older than female patients (68.83 ± 13.5 vs. 64.33 ± 13.5, respectively, P < 0.008).

Table 1

Gender differences in clinical profile of heart failure patients

As an etiology for heart failure ischemic heart disease and dilated cardiomyopathy were significantly higher in male patients than female patients (42.7 vs. 28.7%, P < 0.021) and (13.1 vs. 3.2%, P < 0.008), respectively, the prevalence of other etiologies were the same in both genders.

Regarding the associated risk factors for HF, smoking was significantly higher in male patients (11.7 vs. 0%, respectively, P < 0.001), whereas atrial fibrillation and renal dysfunction were significantly higher in female patients (20.2 vs. 10.2%, P < 0.018) and (20.2 vs. 5.3%, P < 0.001), respectively. The prevalence of other associated risk factors was the same in both genders.

Echocardiography was performed for the vast majority of male and female patients equally (99% and 97.9%, respectively, P =0.42). However, ejection fraction was significantly higher in female patients compared to male patients (38.2% ± 16.9 vs. 30.4% ± 16.6, respectively, P < 0.001).

Drug treatment for HF patients

Table 2 shows gender differences in drug treatment of HF. Male patients with HF were prescribed ACE inhibitors and digoxin less significantly than female patients (64.1 vs. 75.5%. P < 0.049) and (24.8 vs. 36.2%, P < 0.042), respectively. Whereas female patients with HF were prescribed beta-blockers and nitrate therapies less significantly than male patients (36.2 vs. 57.8%, P < 0.001) and (13.8 vs. 35.4%, P < 0.001) respectively. In addition, aspirin and lipid lowering therapies were prescribed significantly less for female patients with HF compared to male patients (64.9 vs. 84.5%, P < 0.001) and (22.3 vs. 48.5%, P < 0.001), respectively. The rest of therapeutic agents used in treatment of HF were prescribed for both sexes without a significant difference.

Table 2

Gender differences in drug treatment of heart failure

DISCUSSION AND CONCLUSION

The primary finding of this study relates to the presence of sex differences in both clinical presentation as well as management of HF patients admitted to ACH. Some of these differences are related to biologic differences between both genders, but others could be due to true gender bias in management of HF patients.

In our series ischemic etiology of HF was found more significantly in male patients compared to female patients. This sex difference was reported in other studies.[1130-32] It is a well known fact that the male gender is a risk factor for IHD. HF due to IHD carries a worse prognosis than HF due to nonischemic causes, thus this finding of less prevalence of IHD in female patients with HF may reflect on better outcomes compared to male patients.

Smoking was significantly less in female patients compared to male patients, which was likely due to the local Saudi conservative sociocultural environment. Renal failure and atrial fibrillation are known risk factors for HF which make prognosis worse when they are associate with HF.[3334] In our study, both risk factors were significantly more in female patients with HF compared to male patients. These findings make female patients in our series at greater risk regarding worse prognosis. Echocardiography is the mainstay investigational tool for the assessment of left ventricular function in HF patients, our series showed that echocardiography was performed on the vast majority of patients with HF, and there was no evidence of gender difference in utilizing this important investigation. Other reports showed evidence of sex-linked differences in investigating HF patients with less utilization of echocardiography in female patients with HF.[35] Ejection fraction is a practical and useful tool for assessing left ventricular function in HF patients and implicates a prognostication value. Female patients in our series had a better ejection fraction values compared to male patients, a similar finding detected in other studies.[1132] This might reflect on a better survival in female patients with HF compared to male patients.

Certain therapeutic agents have shown survival benefit and improve morbidity when prescribed to HF patients (beta-blockers, ACE inhibitors, K-sparing diuretics, and digoxin).[36-46] . In our series female patients with HF were significantly prescribed less beta-blockers than male patients with HF. Male patients with HF were prescribed significantly less ACE inhibitors and digoxin compared to female patients with HF.

The underutilization of beta-blockers in female patients with HF could be due to true gender bias or to lower incidence of ischemic etiology for HF in female patients, in which beta-blockers are indicated for ischemic indication.

While underutilization of ACE inhibitors and digoxin in male patients with HF compared to female patients with HF was an unexpected finding, this could be a true paradoxical gender bias (i.e. this time against male patients). There is no logical explanation for under-prescribing both therapies to male patients with HF. Interestingly a similar earlier finding was reported regarding under-prescription of digoxin to male compared to female patients.[47]

In conclusion, several baseline clinical and echocardiographic features were found in our series to differ significantly between women and men. Some characteristics are expected to confer a better prognosis, namely having a higher prevalence of nonischemic etiology, higher left ventricular ejection fraction. Some other features, however, have been related to worse outcome including higher prevalence of atrial fibrillation and renal dysfunction.

Gender differences in therapeutic management of HF were detected in both genders. Female patients were prescribed less beta-blockers while male patients were prescribed less ACE inhibitors and digoxin. The presence of this gender difference in the management of HF should be avoided by better adherence to evidence-based medicine regardless of a patient's gender.