Author + information
- Khadijah Breathett, MD, MS∗ ()
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, ArizonaDivision of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
- ↵∗Address for correspondence:
Dr. Khadijah Breathett, Division of Cardiology, University of Arizona, 1501 North Campbell Avenue, Tucson, Arizona 85724.
“I believe that the most important single thing, beyond discipline and creativity is daring to dare.”
—Maya Angelou (1)
Heart failure is a global disease that affects both women and men (2). Internationally, women have a higher prevalence of heart failure than men but lower mortality rate (2). Sex differences vary further across ethnic groups, particularly in the United States (2). However, sex-related differences in heart failure remain understudied in many other countries.
In this issue of JACC: Heart Failure, Stolfo et al. address sex differences along the heart failure continuum using the Swedish Heart Failure Registry (3). The Swedish Heart Failure Registry is a national population study which captures more than one-half of prevalent heart failure admissions for Sweden. In this study, patients were grouped by sex and followed for approximately 2 years to understand sex-related differences in heart failure phenotype, treatment, and prognosis.
More than one-third of the 42,987 patients studied were women (3). Compared to men, Stolfo et al. found that Swedish women with heart failure were older, less educated, had less income, and received less follow-up care with cardiology specialists. Women had a higher prevalence of heart failure with preserved ejection fraction and lower prevalence of heart failure with midrange and reduced ejection fraction.
Heart failure treatments and outcomes varied by sex (3). In models fully adjusted for demographics, comorbidities, and socioeconomic factors, women were >30% more likely to receive beta-blockers and >10% more likely to receive digoxin when compared to men irrespective of heart failure phenotype. However, women were 26% less likely to receive defibrillator or cardiac resynchronization therapy compared to men with heart failure with reduced ejection fraction. There were no sex-related differences for treatment with other heart failure medications. Adjusted risks for combined mortality and heart failure hospitalizations were lower for women than men, particularly in heart failure with reduced ejection fraction.
Unequal Treatment is a Global Issue for Women With Heart Failure
Across the world, women and men receive unequal treatment for heart failure (4,5). In Sweden, the sex gaps in evidence-based medications appear to be narrowing but persist in device therapies (3). In the United States, women are less likely to receive defibrillators and cardiac resynchronization therapy despite appropriate indications, and women receive less than one-quarter of advanced heart failure therapies, including heart transplantation and mechanical circulatory support (4). Sex disparities of advanced heart failure therapies increase further when examining ethnic minority groups (6), but this was not addressed in the study by Stolfo et al. (3). Internationally, women receive <10% of heart transplants despite having a higher prevalence of heart failure than men (7).
Several reasons may contribute to sex-related differences in heart failure therapies. First, multiple countries have observed that women with heart failure have lower referral rates to cardiologists than men (3,8), which may impact receipt of therapies. Second, the lower global socioeconomic position of women (9) may limit access to specialists and appropriate therapy. Third, women develop heart failure at older ages than men (2) and may have more comorbidities that limit access to heart failure therapies. Fourth, women may lack desire for heart failure therapies more so than men. Last, gender bias has been identified as an etiology of variability in medical treatment (10).
Dare to Change the Narrative
Health equity will entail a concerted effort. Since multiple studies have shown that women have better survival than men with heart failure (2,3), there is a risk for clinical inertia. However, 5-year mortality rates with heart failure remain unacceptably high for both sexes (2). Every woman and man with heart failure deserves access to evidence-based treatments that improve survival and quality of life. In an era of precision medicine, there may be an opportunity to develop individualized care that benefits women. International implementation of patient-centered approaches will be necessary for providing evidence-based care, including appropriate referrals to specialists. Multidisciplinary care may help manage social determinants of health and provide patient counseling to prevent heart failure and the associated comorbidities. Education in shared decision making and health care professional bias training will support equitable access to care. Success will require equal representation of women in clinical trials as patients, investigators, and sponsors. Patients, health care professionals, and stakeholders must unite and dare to achieve health equity in heart failure.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Breathett has received support from the National Heart, Lung, and Blood Institute K01HL142848, University of Arizona Health Sciences, Strategic Priorities Faculty Initiative Grant, and the University of Arizona, Sarver Heart Center, Women of Color Heart Health Education Committee.
- 2019 American College of Cardiology Foundation
- ↵Anon. Maya Angelou Quotes (Author of I Know Why the Caged Bird Sings) (page 3 of 33). Available at: https://www.goodreads.com/author/quotes/3503.Maya_Angelou?page=3. Accessed May 3, 2019.
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