Post on 16-Dec-2015
Tenth International Symposium
HEART FAILURE & Co.CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING
ON FEMALE DISEASES
Milano9 - 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 samepublic 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
Alaeddini J PACE 2008
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 theyears 2002 to 2004 based on Medicare Database
CRT has become a significant part of the managementof patients with HFSeveral large-scale studies demonstrated significant improvement in multiple endpoints, including quality of life , hospitalization rate and survival in patients with advanced HF
CRT
Alaeddini J. PACE 2008
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%
What is the response to CRT in women ?
► Analysis of previous large CRT Trials
► Few studies addressing this issue
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
MIRACLE study
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
Woo G W et al J Int Card Electroph 2005
Time to first HF hospitalization
Women Men
Analysis of the MIRACLE Study
Woo G W et al Journal Int Card Electroph 2005
Time to first HF hospitalization or death
Women Men
813 pts (26%women)
CARE-HF Study
CARE-HF Study
Cleland JGF NEJM 2005
1820 pts 24% womenNYHA class I or II
MADIT CRT
MADIT CRT
Risk of Death or Heart Failure, According to Selected Clinical Characteristics
Moss AJ NEJM 2009
Linde C JACC 2008
610 pts NYHA class I or II
REVERSE Study
Linde C JACC 2008
610 pts NYHA class I or II
Effect of CRT on LVESVI
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?
Bleeker GB PACE 2005
Response based on improvement in NYHA class
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
Lilli A 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
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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
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
Ghali JK JACC 2003
2708 pts(28%omenRandomized to Bucindolo or Placebo
Left ventricular Ejection Fractionin Women and Men with Congestive Heart Failure
Hsich EM JACC 2009
Heart Failure in Women :A Need for Prospective Data
Myocardial Response to Pressure Overload
Women Men
Sex-Related Differences in Myocardial Remodeling
Piro M et al JACC 2010
Echocardiographic characteristics of patients with aortic stenosis
Left ventricular geometry and function in patients with aortic stenosis: gender differences
Kostkiewicz M Int J Cardiol 1999
Placebo E2
van Eickels M Circulation 2001TAC Transverse Aortic Constriction
Myocyte Death in the Failing Human Heart Is Gender Dependent
Guerra S Circulation Research 1999
Jessup, M. J Thorac Cardiovasc Surg 2004
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.
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
Conclusioni