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Tenth International Symposium
HEART FAILURE & Co.
CARDIOLOGY SCIENCE UPDATE
FEMALE DOCTORS SPEAKING
ON FEMALE DISEASES
Milano
9 - 10 aprile 2010
CRT: vi è un vantaggio maggiore nelle donne?
M.Cristina Porciani
FIRENZE
Heart Failure affects 5.3 millions Americans
Nearly 50% of these are women
Heart failure contributes 35% of the total female
cardiovascular disease mortality
Despite this fact, HF in women remains a poorly
recognized syndrome and has not received the same
public awareness as coronary artery disease
Where Are All the Women With Heart Failure?
Lindenfeld J JACC 1997
Prevalence rates of congestive heart failure (CHF) among Framingham
Heart Study subjects, by gender and age
Prevalence and Mortality from Congestive Herat Failure During years
2004 and 2005 based on Medicare Database
Alaeddini J PACE 2008
Patients who were admitted with diagnosis of congestive heart failure for the
years 2002 to 2004 based on Medicare Database
Alaeddini J PACE 2008
CRT
CRT has become a significant part of the management
of patients with HF
Several large-scale studies demonstrated significant
improvement in multiple endpoints, including quality of
life , hospitalization rate and survival in patients with
advanced HF
Gender Disparity in the Use of CRT in the United States
Females underwent CRT-PM or CRT-D implantation
2002
2003
2004
25%
26%
27%
Alaeddini J. PACE 2008
What is the response to CRT in women ?
► Analysis of previous large CRT Trials
► Few studies addressing this issue
MIRACLE study
The Multicenter InSync Randomized Clinical Evaluation (MIRACLE) was a
prospective, randomized, double-blinded study
A total of 453 pts ( 32%women) randomized to either CRT or a control
group.
MIRACLE study
EFFECT OF CRT ON EFFICACY END POINTS
Abraham WT NEJM 2002
CRT reverses LV remodeling
tSutton MG Circulation 2003
Woo G W et al Journal Int Card Electroph 2005
Analysis of the MIRACLE Study
Women
Men
Time to first HF hospitalization
Woo G W et al J Int Card Electroph 2005
Analysis of the MIRACLE Study
Women
Men
Time to first HF hospitalization or death
Woo G W et al Journal Int Card Electroph 2005
CARE-HF Study
813 pts (26%women)
CARE-HF Study
Cleland JGF NEJM 2005
MADIT CRT
1820 pts 24% women
NYHA class I or II
MADIT CRT
Risk of Death or Heart Failure, According to Selected Clinical Characteristics
Moss AJ NEJM 2009
610 pts
NYHA class I or II
Linde C JACC 2008
REVERSE Study
Effect of CRT on LVESVI
610 pts
NYHA class I or II
Linde C JACC 2008
141 pts
Yu CM Circulation 2005
Few observational studies have shown
that ………….
Does a Gender Difference in Response to C RT Exist?
Bleeker GB PACE 2005
Does a Gender Difference in Response to C RT Exist?
Bleeker GB PACE 2005
Does a Gender Difference in Response to C RT Exist?
Response based on improvement in NYHA class
Bleeker GB PACE 2005
The Impact of Age and Gender on Cardiac Resynchronization
Therapy Outcome
Baseline Characteristics of Patients Stratified by Gender
Zardkoohi O et al PACE 2007
The Impact of Age and Gender on Cardiac Resynchronization
Therapy Outcome
Hospitalization for heart failure and/or death free survival
curve
Zardkoohi O et al PACE 2007
The Impact of Age and Gender on Cardiac Resynchronization
Therapy Outcome
When stratified by the etiology of the underlying cardiomyopathy, ischemic women
appear to have a worse long-term outcome than all other groups
Zardkoohi O et al PACE 2007
CRT: Gender Related Differences in Left Ventricular Reverse Remodeling
195pts (23%women)
Lilli A PACE 2007
CRT: Gender Related Differences in Left Ventricular Reverse Remodeling
◄
◄
Lilli A PACE 2007
CRT: Gender Related Differences in Left Ventricular Reverse Remodeling
Lilli A PACE 2007
CRT: Gender Related Differences in Left Ventricular Reverse Remodeling
Lilli A PACE 2007
CRT Trials and observational studies show discordant results
However a gender related difference in response to CRT
seems to occur
It is not surprising since there are many reasons why male
and female hearts are not the same
Gender Differences in Advanced HF: Insights From the BEST Study
Baseline Clinical Characteristics by Gender
2708 pts(28%omen
Randomized to
Bucindolo or Placebo
Ghali JK JACC 2003
Heart Failure in Women :A Need for Prospective Data
Left ventricular Ejection Fractionin Women and Men with Congestive
Heart Failure
Hsich EM JACC 2009
Sex-Related Differences in Myocardial Remodeling
Myocardial Response to Pressure Overload
Women
Men
Piro M et al JACC 2010
Left ventricular geometry and function in patients with aortic stenosis:
gender differences
Echocardiographic characteristics of patients with aortic stenosis
Kostkiewicz M Int J Cardiol 1999
Placebo
TAC Transverse Aortic Constriction
E2
van Eickels M Circulation 2001
Myocyte Death in the Failing Human Heart Is Gender Dependent
Guerra S Circulation Research 1999
Gender-related survival rates and how they might be influenced by different
pathophysiologic mechanisms in men and women.
LVH, left ventricular hypertrophy; RAS, renin-angiotensin system; SNS,
sympathetic nervous system.
Jessup, M. J Thorac Cardiovasc Surg 2004
Conclusioni
CRT: vi è un vantaggio maggiore nelle donne?
Al momento attuale la scarsa rappresentazione delle donne negli studi
sulla terapia cardiaca resincronizzante fa si che ancora non vi siano
chiare evidenze su un loro maggior beneficio
tuttavia
Le particolari caratteristiche dello scompenso cardiaco ed in
particolare i diversi meccanismi che modulano il rimodellamento
ventricolare nelle done rappresentano importanti presupposti per una
loro migliore risposta