|Year : 2022 | Volume
| Issue : 1 | Page : 28-33
Gender differences among patients hospitalized with acute heart failure in a tertiary care teaching hospital: A cross-sectional study
Preema Dsa1, Soumya Umesh1, Deepak Kamath2
1 Department of General Medicine, St Johns Medical College Hospital, Bengaluru, Karnataka, India
2 Department of Pharmacology, St Johns Medical College Hospital, Bengaluru, Karnataka, India
|Date of Submission||29-Jan-2021|
|Date of Decision||03-May-2021|
|Date of Acceptance||08-May-2021|
|Date of Web Publication||06-Jan-2022|
Dr. Soumya Umesh
Department of General Medicine, St Johns Medical College Hospital, Sarjapur Road, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Heart failure (HF) prevalence in India is about 1% which is about 8–10 million, and significant gender differences exist. Aims: This study was done to investigate the differences in modes of presentation, cardiac etiology, comorbidities, and inhospital outcomes between both genders and to identify predictors of prolonged hospital stay. Settings and Design: We conducted a cross-sectional descriptive study from November 2016 in the coronary care unit. Materials and Methods: Consenting adult patients admitted with the primary diagnosis of acute HF were included. Patients with reversible noncardiac circulatory failure and malignancies were excluded. Their clinical details and inhospital outcomes were recorded. Results: Out of 150 patients, 86 (57.33%) were males and 64 (42.6%) females. More women were admitted with Stage 4 New York Heart Association (59 [92.2%], P = 0.002), cardiogenic shock (10 [15.6%], P = 0.04), or with hypertensive emergency (23 [35.9%], P = 0.027). The mean duration of stay in males was 6.17 ± 2.21 days and 7.23 ± 2.69 days in females (P = 0.009). Multivariate analysis showed that the adjusted risk of prolonged hospital stay (≥7 days) was 4.6 (95% confidence interval: 1.96, 10.82), with the risk being almost five times greater among patients with the presence of cardiorenal syndrome (CRS), compared to those who did not have it (P < 0.001). Statistical Analysis: Chi-square, Student's t-test, and logistic regression were used in the study. Conclusion: Our study highlighted that women were more vulnerable, and came in with advanced HF or hypertensive emergency and stayed in the hospital for a longer duration. CRS was the crucial predictor of prolonged hospital stay.
Keywords: Acute heart failure, cardiorenal syndrome, gender inequities
|How to cite this article:|
Dsa P, Umesh S, Kamath D. Gender differences among patients hospitalized with acute heart failure in a tertiary care teaching hospital: A cross-sectional study. APIK J Int Med 2022;10:28-33
|How to cite this URL:|
Dsa P, Umesh S, Kamath D. Gender differences among patients hospitalized with acute heart failure in a tertiary care teaching hospital: A cross-sectional study. APIK J Int Med [serial online] 2022 [cited 2022 Jun 29];10:28-33. Available from: https://www.ajim.in/text.asp?2022/10/1/28/335074
| Introduction|| |
Heart failure (HF) prevalence in Western countries is about 2% and in India is about 1% of the total population which is about 8–10 million individuals., The incidence in Western countries is about 0.2% per year. Indian HF studies, such as the INDUS study, the Trivandrum HF Registry, and the INTER-CHF study, have found that in our population, there is a higher prevalence of HF among males and mainly due to ischemic heart disease (IHD) and that patients present at least a decade earlier than in Western countries.,, The estimated mortality attributable to HF in India is about 0.1–0.16 million individuals per year and is higher than in other countries.,
There are several differences in HF between both genders. Male-to-female ratio is almost in equal proportions in the US and Africa, while in India, this ratio is 70:30 in hospitals., There is a growing interest in the life course and health perspective to explain gender differences. It considers chronic diseases in terms of the social and physical risks, and the related biological, behavioral, and psychosocial processes, that operate across all stages of the life span to cause or modify the risk of disease, especially in cardiovascular diseases. Similarly, gender differences in HF can be attributed to both biological and sociodemographic factors.
Biological factors such as estrogen levels, duration of estrogen exposure in females, and androgens in males affect myocardial signaling. The pathways of myocardial inflammation versus fibrosis are gene dependent, and therefore, in the presence of hemodynamic stress, female myocardial hypertrophy is concentric while the male is eccentric. Women are older and have a higher frequency of HF-preserved ejection fraction (HFpEF) and hypertension and valvular diseases as etiology. However, men have ischemia as the most common etiology and have a higher frequency of HF-reduced ejection fraction (HFrEF) or HF–mid-range ejection fraction. Anemia, iron deficiency, renal disease, depression, and (HFmEF) thyroid abnormalities that accompany HF are more common in women. Therefore, they have a higher symptom burden at any given EF resulting in a lower functional status.
Sociodemographic factors vary between genders in our country. Women are more vulnerable as they have a delayed detection of risk factors, inadequate control of risk factors, delayed identification, and inadequate treatment of HF and acute coronary syndromes. Only half the women access to the health-care system as compared to men in India., All these factors are responsible for women presenting in advanced HF and having worse outcomes in cardiovascular diseases.,
Despite significant gender differences, a majority of Western studies on HF, including the COPERNICUS, MERIT-HF, PARADIGM, and RALES, women were under represented and comprised only 11%–40% of the total patients enrolled. The CREATE registry of acute coronary syndromes in India has demonstrated gender disparity showing worse inhospital clinical outcomes in women with IHD. There is a lack of Indian data emphasizing the gender differences in patients hospitalized with HF comprehensively. Our objective was to investigate the differences in modes of presentation, underlying heart disease, comorbidities, and inhospital outcomes with a focus on gender differences. Furthermore, we aimed to identify the predictors for a prolonged hospital stay in our population.
| Materials and Methods|| |
We included patients admitted in the coronary care unit (CCU) of a tertiary care teaching hospital and conducted a cross-sectional descriptive study from November 2016 onward over 1 year. Institutional ethics committee approval was obtained for the protocol with the reference number – 376/2015, and consenting adult patients with a primary diagnosis of acute HF were included. The patients were then classified based on the ejection fraction (EF) on echocardiography. HFrEF was diagnosed when the EF <40%, HFmEF between 41% and 49%, and HFpEF >50%. Patients with reversible noncardiac circulatory failure caused by high output states such as anemia and thyrotoxicosis and those with HF secondary to comorbidities such as chronic obstructive pulmonary disease, chronic liver disease, chronic kidney disease, and malignancies were excluded.
We recruited consecutive patients admitted to the CCU. After patients were stabilized and shifted out, they consented. We captured the following data on a standardized data collection form. Demographic details including social status and residence, presenting HF symptoms including New York Heart Association (NYHA) class, clinical findings, underlying cardiac etiology, precipitating factors, comorbidities, complications such as cardiorenal syndrome (CRS), length of hospital stay, and status at discharge. A hospital stay of ≥7 days was considered to be a prolonged stay.
All the data were collected using a structured pro forma and then transcribed into an MS Excel worksheet.
Statistical analysis was done using a standard statistical package. Continuous data such as age, length of stay, and N-terminal pro–B-type natriuretic peptide levels were presented as mean ± standard deviation or median (interquartile range) for parametric and nonparametric data, respectively, after performing tests of normality (KS test). Categorical data such as symptoms, underlying heart disease, precipitating factors, and NYHA class were represented as a number (%). The data between males and females were compared using independent t-tests or Mann–Whitney U-tests as appropriate. Pearson Chi-square and Fisher's exact tests were used for comparing proportions between the two groups. Statistical significance assumed where P < 0.05. Multiple logistic regression was done to identify the predictors of prolonged hospital stay. Variables included in the univariate analysis were sociodemographic variables, gender, Ejection Fraction, comorbidities, NYHA status, cardiogenic shock, coronary interventions, and CRS. Covariates attaining a level of significance of P < 0.1 were chosen for multiple logistic regression, where simultaneous forced entry technique was used.
| Results|| |
We consented and recruited a total of 150 patients, of which 86 (57.33%) were males and 64 (42.6%) were females. The mean age in males (61.48 ± 13.45) and females (60.7 ± 13.5) was similar [Table 1]. Of the 64 females, 53 (82.8%) were postmenopausal. All the patients had exertional dyspnea, fatigue, elevated jugular venous pressure, pedal edema, and basal crackles. The most common cardiac etiology was IHD 79 (52.7%) followed by dilated cardiomyopathy (DCM) 48 (32%). The most common comorbidities were diabetes mellitus 94 (62.7%), hypertension, dyslipidemia, and hypothyroidism [Table 2]. The most common precipitating factor of HF was new-onset ischemic events (non-ST-elevation myocardial infarction [NSTEMI] 87 [58%] and ST-elevation myocardial infarction [STEMI] 20 [13.3%]). A hypertensive emergency was diagnosed in 40 (26.7%) patients. A hospital stay of ≥7 days was seen in 61 (40.7%) patients. History of hospitalization in the last 6 months was seen in 74% of the patients [Table 3]. There were no inhospital deaths.
|Table 1: Sociodemographic details compared between male and female heart failure patients|
Click here to view
|Table 2: Presenting features and comorbidities compared among male and female patients|
Click here to view
|Table 3: Underlying cardiac etiology, precipitating factors, and cardiac markers compared between male and female patients|
Click here to view
The frequency of symptoms was similar in both genders; however, the severity was more in females. This was evidenced by the higher proportion of females coming with Stage 4 NYHA 59 (92.2%) (P = 0.002), or in cardiogenic shock 10 (15.6%) (P = 0.04). More females 23 (35.9%) than males came in a hypertensive emergency (P = 0.027). Significantly more males had IHD (P = 0.011). HFpEF was significantly more common in females (P = 0.002) as also HFrEF was in males (P = 0.001). Hypertension was the most common comorbidity associated with HFpEF, and it was seen more commonly seen in older women. Of 35 females with HFpEF, 21 (60%) were above 60 years.
The mean duration of stay in males was 6.17 ± 2.21 and 7.23 ± 2.69 days in females (P = 0.009). Univariate analysis done to determine the predictors of prolonged hospital stay had a significance for older age, female sex, employment status, educational status, NYHA 4, and CRS as depicted in [Table 4]. Multivariate analysis showed that the adjusted risk of prolonged hospital stay (≥7 days) was 4.6 (95% confidence interval: 1.96, 10.82), with the risk being almost five times greater among patients with the presence of CRS, compared to those who did not have it (P < 0.001). 45.3% of the women had CRS as compared to 37.2% in males. However, it was not statistically significant (P = 0.318).
|Table 4: Comparison of demographic covariates, presenting features, comorbidities, and clinical characteristics between those with prolonged hospital stay and those with hospital stay<7 days|
Click here to view
| Discussion|| |
We found that most women were admitted with symptoms that were similar to men but of a greater severity and with life-threatening complications such as cardiogenic shock or hypertensive emergency and stayed in the hospital for a significantly longer duration than men. HFpEF and hypothyroidism were more common in women than in men. IHD and HFrEF were significantly more common in men, and they were more likely to be using substances such as alcohol and nicotine. CRS was the most crucial predictor of prolonged hospitalization and was more common in women. Our study has thus highlighted the gender differences in HF.
The proportion of hospitalized men was more than women, and this finding again reflects the higher prevalence of inhospital HF in males as seen in most other studies across the world and India., However, in the ADHERE registry from America, hospitalizations were similar in both genders. Higher prevalence of HF among men and inadequate access to health care by women both could explain the lower hospitalizations in our study.
We found a higher prevalence of HFrEF in men and HFpEF in women. Studies done by Kararigas et al. and Scantlebury and Borlaug to delineate the regulatory pathways for remodeling between both genders in patients with pressure overload states found that fibrosis-related pathways were induced in male ventricles while these were repressed in females. The most important determinant of HFpEF was female sex, and women were twice as likely as men to develop it, which is called a sex-specific maladaptation.,
IHD was the most common underlying heart disease and was significantly more common in males than in females. This is seen in most other studies. Apart from nicotine use which was seen mostly in men, all other risk factors for IHD were similar between both genders. Both STEMI and NSTEMI were important precipitating factors for HF, but the rates were not different between the two groups. It was also observed that coronary interventions were similar in both groups. In both the CREATE and ADHERE registries, it was observed that it was less likely for women to undergo coronary interventions., The difference in our study may indicate an increasing trend of interventions following ischemic events in women as compared to the findings of earlier trials.
Chronic disease epidemiology is now viewed with a life course approach. Chronic diseases develop due to specific biological processes. However, social and environmental determinants of health, experienced at different life course stages, over time during several stages of life have an impact on the occurrence and course of chronic diseases. Males and females are exposed to different biological, behavioral, social, and psychological states throughout their lives. These include pregnancies and menopause as well, and both conditions worsen HF.,
We have demonstrated that women came more often in advanced stages of HF such as NYHA Stage 4 or cardiogenic shock or hypertensive emergency, and they stayed in the hospital for a longer duration in hospital. All are potentially life-threatening conditions. These findings are similar even in other countries where women with HFpEF or DCM had worse NYHA stages., The CREATE registry too found that women with ischemic events were brought to the hospital much later than men.
Various reasons could explain the finding of women presenting later. First, we have demonstrated a significant gender disparity of worse educational and financial status of women. Second, studies have shown that many women have been found to suffer from greater physical and psychosocial comorbidities. They have higher rates of depression and report a poor quality of life., These are, in turn, likely to have an adverse impact on self-care practices and decision-making. Third, women have inadequate access to health-care facilities as compared to men. These factors may be contributing to the delay in seeking help despite the occurrence of life-threatening emergencies.
Each day in hospital contributes to the cost of care and the risk of hospital-associated infections and death. The women in our study stayed longer in hospital than men. This finding is similar to a study done by Zsilinszka et al. in HFpEF. However, in Puerto Rican and European studies, gender did not contribute to the length of stay., On regression, we found that the most critical predictor that prolonged the hospital stay was the presence of CRS. This is found in studies done by Wright et al., Alnajashi et al., and Bart et al. as well.,, With the acute worsening of renal function, the time for resolution of congestion increases. There is also associated dyselectrolytemia, resistance to diuretics, and a delay in the introduction of angiotensin-converting-enzyme/angiotensin-receptor blockers. The severity of HF is a predictor of CRS. Therefore, women are coming in worse HF stages and are at a higher risk of CRS and a more extended hospital stay. Therefore, there is a need for early hospitalization to prevent CRSs and to shorten the hospital stay.
The strength of our study is that ours is a tertiary care teaching hospital catering to patients from many neighboring states across all socioeconomic strata. Although it is a single-center experience, it is a reasonably representative population to study gender. The limitation of our study is that because of resource constraints, being an unfunded study, we have been unable to assess the difference in depression, quality of life, and self-care practices between both groups, which may also be mediators of poor outcomes.
| Conclusion|| |
Our study has highlighted that there are significant differences in genders in presentation and outcomes. The women are more vulnerable and came in with advanced HF, and stayed in the hospital for a longer duration. CRS prolonged the hospital stay in both genders.
There is a need for better support from governments, health-care professionals, and families of patients to rectify gender inequities. Moreover, there is a need for follow-up studies to look for long-term differences in adherence to guideline-based treatment and outcomes in both genders. We have reiterated an increasing need for gender-based data. It will then assist clinicians in tailoring optimum interventions for each gender, especially in cardiovascular diseases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Savarese G, D'Amario D. Sex Differences in Heart Failure. Adv Exp Med Biol. 2018;1065:529-544. doi: 10.1007/978-3-319-77932-4_32. PMID: 30051405.
Chaturvedi V, Parakh N, Seth S, Bhargava B, Ramakrishnan S, Roy A, et al
. Heart failure in India: The INDUS (India Ukieri Study) study. J Pract Cardiovasc Sci 2016;2:28-35. [Full text]
Harikrishnan S, Sanjay G, Anees T, Viswanathan S, Vijayaraghavan G, Bahuleyan CG, et al
. Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: The Trivandrum Heart Failure Registry. Eur J Heart Fail 2015;17:794-800.
Guha S, Harikrishnan S, Ray S, Sethi R, Ramakrishnan S, Banerjee S, et al
. CSI position statement on management of heart failure in India. Indian Heart J 2018;70:S1-72.
Gori M, Lam CS, Gupta DK, Santos AB, Cheng S, Shah AM, et al
. Sex-specific cardiovascular structure and function in heart failure with preserved ejection fraction. Eur J Heart Fail 2014;16:535-42.
Eisenberg E, Di Palo KE, Piña IL. Sex differences in heart failure. Clin Cardiol 2018;41:211-6.
Chow CK, Patel AA. Women's cardiovascular health in India. Heart 2012;98:456-9.
Sigamani A, Kamath D, Xavier D, Pais P. New evidence for gender disparities in cardiac interventions: 'CREATE'-ing some clarity. Int Cardiol (London) 2013;5:1-4.
Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S, et al
. Heart failure: Preventing disease and death worldwide. ESC Heart Fail 2014;1:4-25.
Galvao M, Kalman J, Demarco T, Fonarow GC, Galvin C, Ghali JK, et al
. Gender differences in in-hospital management and outcomes in patients with decompensated heart failure: Analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Card Fail 2006;12:100-7.
Kararigas G, Dworatzek E, Petrov G, Summer H, Schulze TM, Baczko I, et al
. Sex-dependent regulation of fibrosis and inflammation in human left ventricular remodelling under pressure overload. Eur J Heart Fail 2014;16:1160-7.
Scantlebury DC, Borlaug BA. Why are women more likely than men to develop heart failure with preserved ejection fraction? Curr Opin Cardiol 2011;26:562-8.
Lynch J, Smith GD. A life course approach to chronic disease epidemiology. Annu Rev Public Health 2005;26:1-35.
Ahmad WA, Khanom M, Yaakob ZH. Heart failure in pregnancy: An overview. Int J Clin Pract 2011;65:848-51.
Rahman I, Åkesson A, Wolk A. Relationship between age at natural menopause and risk of heart failure. Menopause 2015;22:12-6.
Halliday BP, Gulati A, Ali A, Newsome S, Lota A, Tayal U, et al
. sex- and age-based differences in the natural history and outcome of dilated cardiomyopathy. Eur J Heart Fail 2018;20:1392-400.
Thomas JR, Clark AM. Women with heart failure are at high psychosocial risk: a systematic review of how sex and gender influence heart failure self-care. Cardiol Res Pract. 2011 Mar 6;2011:918973. doi: 10.4061/2011/918973. PMID: 21403845; PMCID: PMC3051283.
Dewan P, Rørth R, Jhund PS, Shen L, Raparelli V, Petrie MC, et al
. Differential impact of heart failure with reduced ejection fraction on men and women. J Am Coll Cardiol 2019;73:29-40.
Alnajashi MA, Almasoud MA, Aldaham SA, Acuña JM, Zevallos JC. Association of gender and length of stay among Puerto Ricans hospitalized with decompensated heart failure. Medicine (Baltimore) 2016;95:e4255.
Zsilinszka R, Shrader P, DeVore AD, Hardy NC, Mentz RJ, Pang PS, et al
. Sex differences in the management and outcomes of heart failure with preserved ejection fraction in patients presenting to the emergency department with acute heart failure. J Card Fail 2016;22:781-8.
Wright SP, Verouhis D, Gamble G, Swedberg K, Sharpe N, Doughty RN. Factors influencing the length of hospital stay of patients with heart failure. Eur J Heart Fail 2003;5:201-9.
Bart BA, Goldsmith SR, Lee KL, Givertz MM, O'Connor CM, Bull DA, et al
. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med 2012;367:2296-304.
Metra M, Nodari S, Parrinello G, Bordonali T, Bugatti S, Danesi R, et al
. Worsening renal function in patients hospitalized for acute heart failure: Clinical implications and prognostic significance. Eur J Heart Fail 2008;10:188-95.
[Table 1], [Table 2], [Table 3], [Table 4]