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0,533 Terre
0,949 Terre
Cardiologie au
féminin
Mars ou Venus
Mars est désarmé par Venus et les grâces
Jacques Louis David
L’insuffisance cardiaque
Epidemiologie
11327 sur 6
semaines et plus
de 150 centres
FEVG <40%: Hommes: 51 % vs Femmes: 28 %
Cleland European Heart Journal (2003) 24, 442–463
11,327 patients.
47% de femmes.
51 % de femmes et 30% d’hommes ont plus de 75 ans.
53 % des patients ont un diagnostic d’IC avant l’hospitalisation (index).
>90% vont bénéficier de: ECG, X-ray, HB, Iono (cf reco de l’ESC)
FEVG échocardiographique dans 84% des cas
FEVG mesurée seulement chez
57% des hommes
41% des femmes
FEVG normale:
45% des femmes
22% des hommes
Après 12 semaines
24% vont être réadmis pour IC
13.5% vont décéder.
Cleland European Heart Journal (2003) 24, 442–463
Les traitements de l’insuffisance
cardiaque
Cas des IEC, Beta -
IEC/bthe CONSENSUS-1 study showed a statistically
significant reduction in mortality with enalapril
in men but not in women. Whereas men
achieved a 51% reduction in 6-month mortality
(P,0.001), women achieved only a 6% reduction
(P=NS).
The SOLVD investigators found that men
and women treated with enalapril experienced
a reduction in mortality and hospitalizations,
although this effect was less for women.
Sous représentation des femmes+ Design des études..,
Pas prévues pour démontrer un bénéfice en terme de mortalité , dans le sous
groupe feminin
Overview of randomized trials of angiotensin-converting
enzyme inhibitors on mortality and morbidity in
patients with heart failure.
.
Faible nombre d’événements
OR et 95% CI
Garg R, Yusuf S : JAMA. 1995;273:1450–145
Overview of randomized trials of angiotensin-converting
enzyme inhibitors on mortality and morbidity in
patients with heart failure.
Mortalité totale
Sous représentatio dans les études?
Bénéfice inférieur des IEC?
Effet propre, différence de structure , de fonction
Overview of randomized trials of angiotensin-converting
enzyme inhibitors on mortality and morbidity in
patients with heart failure.
Mortalité totale
et hospitalisation
bMerit HF, CIBIS, Copernicus
COPERNICUS
% hommes, % de CMI,et FEVG !!!!
COPERNICUS
COPERNICUS
DEATH
DEATH and HOSPIT
MERIT-HF - Entry Characteristics
Meto CR/XL
Mean age(years)
Male sex(%)
NYHA class
II(%)
III(%)
IV(%)
Ejection fraction
Placebo
64
77
64
78
41
56
3.5
41
55
3.8
0.28
0.28
The MERIT-HF Study Group, Lancet 1999;353:2001-07
Total Mortality
Per cent
2
0
Placebo
15
p = 0.0062 (adjusted)
p = 0.00009 (nominal)
Metoprolol CR/XL
10
Risk reduction = 34%
5
RR for female gender: NS
0
0
3
6 9 12 15 18 21
Months of follow-up
The MERIT-HF Study Group, Lancet 1999;353:2001-07
Groupe placebo de Merit HF: après ajustement le meilleur pronostic
des femmes persiste
Plus faible proportion de CMI, plus de CMD primitive
CIBIS 2
The estimated annual mortality rate was 8·8% in the bisoprolol
group and 13·2% in the placebo group (hazard ratio 0·66 [95% CI
0·54–0·81
Sex differences in the prognosis of congestive heart failure: results from the
Cardiac Insufficiency Bisoprolol Study (CIBIS II).
Simon T, Mary-Krause M, Funck-Brentano C et al
Age, Pas, BBG,CMI-, tabac
Circulation. 2001;103:375–380.
Sex differences in the prognosis of congestive heart failure: results from the
Cardiac Insufficiency Bisoprolol Study (CIBIS II).
Simon T, Mary-Krause M, Funck-Brentano C et al
FU: 1,3y
CMD/CMI
Female sex in CIBIS-II also significantly and independently predicted improved survival in
patients with heart failure, independent both of -blocker treatment and of baseline
clinical profile.
Circulation. 2001;103:375–380.
Sex differences in the prognosis of congestive heart failure: results from the
Cardiac Insufficiency Bisoprolol Study (CIBIS II).
Simon T, Mary-Krause M, Funck-Brentano C et al
Sex et traitement
sont des
prédicteurs
indpendants
Circulation. 2001;103:375–380.
Gender Differences in Survival in Advanced
Heart Failure Insights From the FIRST Study
Kirkwood F. Adams, C
Metoprolol CR/XL in female patients with heart failure: analysis of the
experience in MERIT-HF.
The 23% of women enrolled in MERIT-HF was the only subgroup for whom mortality
benefit was not demonstrated.
Circulation. 2002;105;1585–1591.
Gender Differences in Survival in Advanced
Heart Failure Insights From the FIRST Study
Background—Previous natural history studies in broad populations of heart failure patients have
associated female gender with improved survival, particularly in patients with a non ischemic etiology
of ventricular dysfunction. This study investigates whether a similar survival advantage for women
would be evident among patients with advanced
heart failure.
Kirkwood F. Adams, C
Circulation. 1999;99:1816-1821.
Predictors of Sudden Cardiac Death and Appropriate Shock
in the Comparison of Medical Therapy, Pacing, and
Defibrillation in Heart Failure (COMPANION) Trial
+ higher benefit of CRT
Circulation. 2006;114:2766-27
MERIT-HF, PRAISE, PRAISE-2, PROMISE, and VEST
EF Male: 23.6% Female: 23.2% , AGE 60.2 ans
Frazier. J Am Coll Cardiol 2007;49:1450–8
La prise en charge
The EuroHeart Failure Survey
European Heart Journal (2003) 24, 464-474
The EuroHeart Failure Survey
Being male:
More Beta –
More anti thrombotic
agents
More spironolactone
More aspirin
More ACE
Less Ca -
European Heart Journal (2003) 24, 464-474
Influence of gender of physicians and patients on
guideline-recommended treatment of chronic
heart failure in a cross-sectional study
Magnus Baumhackel
Influence of gender of physicians and patients on
guideline-recommended treatment of chronic
heart failure in a cross-sectional study
Magnus Baumhackel
Patient
femme
traité
par un
homme
Patient
homme
traité
par une
femme
Elements fondamentaux de la
différence
Adaptation to pressure overload different (case of AS)
More efficient myocardial fn in HF, HFPEF
Gender difference in activation of SRAA
Gender and fibroses related to hypertrphy
Estrogens and vasodilatation
Apoptosis
Plasma Brain Natriuretic Peptide
Concentration: Impact of Age and Gender
Margaret M. Redfield
J Am Coll Cardiol 2002;40:976–82
Plasma Brain Natriuretic Peptide
Concentration: Impact of Age and Gender
Margaret M. Redfield
HRT= hormonothérapie substitutive
J Am Coll Cardiol 2002;40:976–82
Gender Differences and Normal Left Ventricular
Anatomy in an Adult Population Free of Hypertension
A Cardiovascular Magnetic Resonance Study
of the Framingham Heart Study Offspring Cohort
Autres facteurs?
Salton. J Am Coll Cardiol 2002;39:1055–60
Role of Gender in Heart Failure with Normal Left Ventricular Ejection Fraction
Vera Regitz-Zagrosek, Progress in Cardiovascular Diseases, Vol. 49, No. 4, 2007: pp 241-251
Effects of Age, Gender, and Left Ventricular Mass on
Septal Mitral Annulus Velocity (E=) and the Ratio of
Transmitral Early Peak Velocity to E= (E/E=)
Am J Cardiol 2005;95:1020–1023
Hypertrophic Remodeling: Gender Differences in the Early Response
to Left Ventricular Pressure Overload
female
male
female
male
Bonne adaptation au stress barométrique
Douglas J Am Coll Cardiol 1998;32:1118–25
Peptides 30 (2009) 2309–2315
Vera Regitz-Zagrosek, Progress in Cardiovascular Diseases, Vol. 49, No. 4, 2007: pp 241-251
Kirkwood F. Adams, C
Estrogen signaling in the cardiovascular system. Estrogen (E2) can activate a cytosolic protein-bound ER that then shuttles
into the nucleus and activates gene transcription at an estrogen responsive element (ERE) at AP1or SP1 elements. Caveolaeassociated ER may stimulate Src, PI3kinase, AKT, and GSK3b b b leading to NOS activation and NO production. Estrogen
receptor a a a can also interact with the MAPkinase pathway, can modulate
calcium influx at the L-type calcium channel, or calcium handling at the sarcoplasmatic reticulum. Growth factors (GFs) can
activate ERs in a ligand-independent manner.
Pour résumer
• Le pronostic de l’IC à FEVG basse est meilleur chez la
femme (non ischémique).
• La représentation féminine dans l’ins cardiaque à FEVG
préservée est plus importante … mais multifactoriel.
• Chez la femme, en cas de surcharge barométrique, nette
HVG, réduction de la taille de la cavité, importante
réduction du stress pariétal et efficience myocardique
accrue.
• Chez l’homme évolution fibrosante plus importante. La
composition de l’ »hypertrophie » est différente.
• La réduction de l’HVG s’associe à une composition
myocardique également différente.
• Les récepteurs estrogéniques jouent un rôle prépondérant
des cette adaptation