Heart Failure Treatment Gaps: Q&A With Advisory Board Member Ileana Piña, MD

Researchers remarked that the “decrease in IHD [ischemic heart disease] hospitalization rates could have been even greater, had it not been for the frequency of excessive weight, which not only failed to decline but actually rose.”⁹

However, the study also demonstrated the success of the smoking control strategies instituted in the 1990s. Sale restrictions, price increases, and advertising limitations were all passed via legislative measures. Information on smoking-related risks and antismoking campaigns also became more prominent.⁹

Other countries, including the United States, have also seen changes in heart disease mortality and morbidity after the legal ban on workplace smoking. In 2012, a meta-analysis evaluated 45 studies of 33 smoke-free laws.¹⁰ Comprehensive smoke-free legislation (covering workplaces, restaurants, and bars) was associated with significantly lower rates of hospital admissions or deaths for coronary events, other heart disease (including angina, coronary heart disease, and out-of-hospital sudden cardiac death), cerebrovascular accidents, and respiratory disease.^10,11

Q: What are some highlights of sex-specific differences in heart failure and other cardiovascular diseases?

A: Recently, the genVAD Working Group was formed to understand specific sex differences in advanced heart failure therapy. In a perspective paper, they highlighted the fact that while ventricular assistance devices (VAD) are now available in smaller sizes, fewer women receive VADs compared to men. Women also continue to be underrepresented in clinical trials. For example, in the Heartmate II BTT trial, women made up only 22% of the patients and only 28% in the HeartWare Ventricular Assist Device ADVANCE BTT trial. In the latter trial, women had longer hospital stays and spent more days in intensive care units. Overall, women are less likely to be referred to a cardiologist and are instead managed by their primary care physician, despite their symptom severity.¹²

In a study of 2088 patients with chronic heart failure (50.7% women),¹³ researchers found that statins were prescribed more frequently to men than women (38.4% vs 23.4%), and this was observed across all age groups. Unsurprisingly, after the 1-year follow-up, cardiovascular death accounted for deaths in 61.5% of women vs 53.4% of men. Female gender was independently associated with a reduced probability of statin prescription, in addition to inadequate dosing. And ultimately, both therapy and appropriate dosing were associated with improved 1-year survival rates that were independent of gender.¹³

We as cardiac researchers need to do more to investigate various differences between women and men—symptoms, for example, especially the bleeding aspects.  More work focused on women’s issues is definitely needed.^12-16

References

1. Pereira-Barretto AC. Cardiac and hemodynamic benefits: mode of action of ivabradine in heart failure. Adv Ther. 2015;32(10):906-919. doi: 10.1007/s12325-015-0527-6.
2. Franke J, Wolter JS, Meme L, et al. Optimization of pharmacotherapy in chronic heart failure: is heart rate adequately addressed? Clin Res Cardiol. 2013;102(1):23-31. doi: 10.1007/s00392-012-0489-2.
3. Pereira-Barretto AC. Addressing major unmet needs in patients with systolic heart failure: the role of ivabradine. Am J Cardiovasc Drugs. 2016. Jan 27 [Epub ahead of print].
4. O’Connor CM, Whellan DJ, Lee KL, et al; for the HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure. HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439-1450.
5. Study suggests starting exercise later in life reduces heart failure risk. Johns Hopkins News Tips from the American Heart Association Scientific Sessions [news release]. Baltimore, MD: Johns Hopkins Medicine News and Publications; November 11, 2015. Accessed February 1, 2016.
6. Shah RV, Murthy VL, Colangelo LA, et al. Association of fitness in young adulthood with survival and cardiovascular risk: the Coronary Artery Risk Development in Young Adults (CARDIA) study. JAMA Intern Med. 2016;176(1):87-95. doi: 10.1001/jamainternmed.2015.6309.
7. Mohee K, Wheatcroft SB. Optimal medical therapy and percutaneous coronary intervention for stable angina: why patients should ‘be taking’ and ‘keep taking’ the tablets. J Clin Pharm Ther. 2014;39:331-333.
8. Ardati AK, Pitt B, Smith DE, et al. Current medical management of stable coronary artery disease before and after elective percutaneous coronary intervention. Am Heart J. 2013;165:778-784.
9. Medrano MJ, Alcalde-Cabero E, Ortiz C, Galan I. Effect of cardiovascular prevention strategies on incident coronary disease hospitalization rates in Spain; an ecological time series analysis. BMJ. 2014. doi: 10.1136.bmjopen-2013-04257.
10. Tan CE, Glantz SA. Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory disease. A meta-analysis. Circulation. 2012;126:2177-2183. doi: 10.1161/CIRCULATIONAHA.112.121301/-/DC1.
11. Dove MS, Dockery DW, Mittleman MA, et al. The impact of Massachusetts’ smoke-free workplace laws on acute myocardial infarction deaths. Am J Public Health. 2010;100:2206-2212. doi: 10.2105/AJPH.2009.189662.
12. Cook JL, Grady KL, Colvin M, et al; for the genVAD Working Group. Sex differences in the care of patients with advanced heart failure. Circ Cardiovasc Qual Outcomes. 2015;8:S56-S59. doi: 10.1161/CIRCOUTCOMES.115.001730.
13. Ballo P, Balzi D, Barchielli A, Turco L, Franconi F, Zuppiroli A. Gender differences in statin prescription rates, adequacy of dosing, and association of statin therapy with outcome after heart failure hospitalization: a retrospective analysis in a community setting. Eur J Clin Pharmacol. 2015. doi: 10.1007/s00228-015-1980-2.
14. Freudenberger RS, Cheng B, Mann DL, et al; for the WARCEF Investigators. The first prognostic model stroke and death in patients with systolic heart failure. J Cardiol. 2015. doi: 10.1016/j.jjcc.2015.09.014.
15. Herz ND, Engeda J, Zusterzeel R, et al. Sex differences in device therapy for heart failure: utilization, outcomes, and adverse events. J Womens Health (Larchmt). 2015;24(4):261-271. doi: 10.1089/jwh.2014.4980.
16. Meyer S, Brouwers FP, Voors AA, et al. Sex differences in new-onset heart failure. Clin Res Cardiol. 2015;104:342-350. doi: 10.1007/s00392-014-0788-x.