Ottawa, Canadá (special for SIIC)

Heart failure is a leading cause of death in women and men around the world. Despite recent advances in the management of heart failure, we still have a long way to go in our understanding of how healthcare delivery, response to treatment and patient outcomes differ by biological sex. Indeed, women and men suffer from different types of heart failure and they present with different symptoms. Research suggests that women are less likely to receive invasive testing when they present with coronary artery disease, and they may be referred later than men for coronary artery bypass surgery especially after an episode of hospitalization for heart failure. Evidence also suggests that women may be less likely than men to receive guideline-directed heart failure therapy, and the doses of their medications are titrated less optimally than in their male counterparts. This knowledge prompts further research to provide more sex-specific information that will inform policy decisions at a population level. We studied 90,707 patients with new diagnoses of heart failure among ambulatory Ontario residents from 2009 to 2013. We found that in recent years, the incidence of heart failure has declined overall in both sexes and remains higher in men. But women are more likely to die from the disease. Almost 17 percent of women died within a year of follow-up, compared with just under 15 percent of men. We also found that rates of hospitalization decreased over this time period in men but increased in women. Our research suggests that women and men had different clinical characteristics at the time of their heart failure diagnosis. Women were more likely to be older, more frail, from a lower income bracket, and have chronic lung disease, dementia, depression, high blood pressure, hypothyroidism, and advanced cancer. On the other hand, men presenting with heart failure were more likely to have had heart attacks, heart valve disease, atrial fibrillation, peripheral arterial disease, diabetes, liver and kidney disease, and to abuse alcohol. But even after accounting for these differences in risk factors, death rates were still higher in women. These differences in risk factors elude to the fact that women and men are actually prone to different types of heart failure. Men are more likely to develop a form of heart failure where the pumping function of the heart is reduced. This form of heart failure often results from heart attacks, and it is therefore not surprising that men with heart failure often also have multiple risk factors for coronary artery disease. This type of heart failure has been studied extensively, and there are a number of medications that have been proven to be efficacious in reducing mortality and the need for hospitalization in this context. Women, on the other hand, more often suffer from a type of heart failure with preserved pump function, which has few effective therapies. The prevalence of hypertension in older women make them more prone to developing this type of heart failure. Women also tend to present with symptoms that are different or “atypical” as compared to men, which potentially lead to missed or delayed diagnosis. For instance, shortness of breath in an obese woman may more likely be attributed to obesity or lung disease rather than heart failure itself. Aside from physiologic differences, sociodemographic differences may also come into play. For instance, women and men may exhibit different health-seeking behavior, attention to self care and compliance to therapy. Research has also shown that physicians may recognize, investigate and treat heart diseases and stroke differently in male and female patients. Our paper serves to highlight the disparity in outcomes between women and men in the modern era, within the context of a state-of-the-art healthcare system with universal coverage for all medically necessary services and procedures. This observed disparity is in part due to a lack of education and awareness on behalf of patients, healthcare providers, and the community as a whole. Much of the evidence that drives modern management and decision-making in heart patients is based on clinical trials that enrolled predominately men. The findings from these trials were often extrapolated to women without consideration that medical and surgical therapy may affect women and men differently. Better outcomes also come with better primary and secondary prevention, and this poses another important area of investigation, to determine whether sex-specific lifestyle and medical interventions could improve the health of populations around the world. In closing, public and professional awareness are extremely important in bridging the gap in clinical care and research that aim to elevate the quality of care we provide to women and men alike.