Gender related predictors of limited exercise capacity in heart failure (original) (raw)
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Frontiers in Cardiovascular Medicine, 2023
Background: We aimed to test the di erences in peak VO between males and females in patients diagnosed with heart failure (HF), using combined stress echocardiography (SE) and cardiopulmonary exercise testing (CPET). Methods: Patients who underwent CPET and SE for evaluation of dyspnea or exertional intolerance at our institution, between January and December , were included and retrospectively assessed. Patients were divided into three groups: HF with preserved ejection fraction (HFpEF), HF with mildly reduced or reduced ejection fraction (HFmrEF/HFrEF), and patients without HF (control). These groups were further stratified by sex. Results: One hundred seventy-eight patients underwent CPET-SE testing, of which % were females. Females diagnosed with HFpEF showed attenuated increases in end diastolic volume index (P =. for sex × time interaction), significantly elevated E/e' (P < .), significantly decreased left ventricle (LV) end diastolic volume:E/e ratio (P =. for sex × time interaction), and lesser increases in A-VO di erence (P =. for sex × time interaction), comparing to males with HFpEF. Females diagnosed with HFmrEF/HFrEF showed diminished increases in end diastolic volume index (P =. for sex × time interaction), mostly after anaerobic threshold was met, comparing to males with HFmrEF/HFrEF. This resulted in reduced increases in peak stroke volume index (P =. for sex × time interaction) and cardiac output (P =. for sex × time interaction). Conclusions: Combined CPET-SE testing allows for individualized non-invasive evaluation of exercise physiology stratified by sex. Female patients with HF have lower exercise capacity compared to men with HF. For females diagnosed with HFpEF, this was due to poorer LV compliance and attenuated peripheral oxygen extraction, while for females diagnosed with HFmrEF/HFrEF, this was due to attenuated increase in peak stroke volume and cardiac output. As past studies have shown di erences in clinical outcomes between females and males, this study provides an essential understanding of the di erences in exercise physiology in HF patients, which may improve patient selection for targeted therapeutics.
JAMA Cardiology, 2019
IMPORTANCE Sex differences in heart failure with preserved ejection fraction (HFpEF) have been established, but insights into the mechanistic drivers of these differences are limited. OBJECTIVE To examine sex differences in cardiometabolic profiles and exercise hemodynamic profiles among individuals with HFpEF. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted at a single-center tertiary care referral hospital from December 2006 to June 2017 and included 295 participants who met hemodynamic criteria for HFpEF based on invasive cardiopulmonary exercise testing results. We examined sex differences in distinct components of oxygen transport and utilization during exercise using linear and logistic regression models. The data were analyzed from June 2018 to May 2019. MAIN OUTCOMES AND MEASURES Resting and exercise gas exchange and hemodynamic parameters obtained during cardiopulmonary exercise testing. RESULTS Of 295 participants, 121 (41.0%) were men (mean [SD] age, 64 [12] years) and 174 (59.0%) were women (mean [SD] age, 61 [13] years). Compared with men, women with HFpEF in this tertiary referral cohort had fewer comorbidities, including diabetes, insulin resistance, and hypertension, and a more favorable adipokine profile. Exercise capacity was similar in men and women (percent predicted peak oxygen [O 2 ] consumption: 66% in women vs 68% in men; P = .38), but women had distinct deficits in components of the O 2 pathway, including worse biventricular systolic reserve (multivariable-adjusted analyses: ΔLVEF β = −1.70; SE, 0.86; P < .05; ΔRVEF β = −2.39, SE=0.80; P = .003), diastolic reserve (PCWP/CO: β = 0.63; SE, 0.31; P = .04), and peripheral O 2 extraction (C(a-v)O 2 β=-0.90, SE=0.22; P < .001). CONCLUSIONS AND RELEVANCE Despite a lower burden of cardiometabolic disease and a similar percent predicted exercise capacity, women with HFpEF demonstrated greater cardiac and extracardiac deficits, including systolic reserve, diastolic reserve, and peripheral O 2 extraction. These sex differences in cardiac and skeletal muscle responses to exercise may illuminate the pathophysiology underlying the development of HFpEF and should be investigated further.
Canadian Journal of Cardiology, 2015
Background. In heart failure (HF), females show better survival despite a comparatively low peak oxygen consumption (VO 2 ): this raises doubt about the accuracy of risk assessment by cardiopulmonary exercise testing (CPET) in females. Accordingly, we aimed to check: i) whether the predictive role of well-known CPET risk indexes, i.e. peak VO 2 and ventilatory response (VE/VCO 2 slope), is gender independent; ii) if gender-related characteristics that impact outcome in HF should be considered as associations which may confound the gender effect on survival.
Predictors of exercise capacity in heart failure
International Cardiovascular Forum Journal, 2015
Background and Aim: Compromised exercise capacity is a major symptom in patients with heart failure (HF) and reduced left ventricular (LV) ejection fraction (eF). six-minute walk test (6-MWt) is popular for the objective assessment of exercise capacity in these patients but is largely confined to major heart centres. the aim of this study was to prospectively examine functional parameters that predict 6-MWt in patients with HF and reduced LVeF. Methods: In 111 HF patients (mean age 60±12 years, 56% male), a 6-MWt and an echo-Doppler study were performed in the same day. In addition to conventional ventricular function measurements, global LV dyssynchrony was indirectly assessed by total isovolumic time-t-IVt [in s/min; calculated as: 60-(total ejection time-total filling time)], and tei index (t-IVt/ejection time). Also, LV and right ventricular function were assessed by mitral and tricuspid annular plane systolic excursion (MAPse and tAPse, respectively). Based on the 6-MWt distance, patients were divided into 2 groups: group I: ≤300m and group II: >300m. Results: the 6-MWt distance correlated with t-IVt and tei index (r=-0.37, p<0.001, for both), lateral and septal e' velocities (r=0.41, p<0.001, and r=0.46, p<0.001, respectively), e/e' ratio (r=-0.37, p<0.001) and tAPse (r=0.45, p<0.001), but not with the other clinical or echo parameters. group I patients had longer t-IVt, lower e/e'ratio, tAPse and lateral e' (p<0.001 for all) compared with group II. In multivariate analysis, tAPse [0.076 (0.017-0.335), p=0.001], e/e' [1.165 (1.017-1.334), p=0.027], t-IVt [1.178 (1.014-1.370), p=0.033] independently predicted poor 6-MWt performance (<300m). sensitivity and specificity for tAPse ≤1.9 cm were 66% and 77%, (AuC 0.78, p<0.001); e/e' ≥10.7 were 66% and 62% (AuC 0.67, p=0.002) and t-IVt ≥13 s/min were 64% and 60% (AuC 0.68, p=0.002) in predicting poor 6-MWt. Combined tAPse and e/e' had a sensitivity of 68% but specificity of 92% in predicting 6-MWt. Respective values for combined tAPse and t-IVt were 71% and 85%. Conclusion: In patients with HF, the limited exercise capacity assessed by 6-MWt, is multifactorial being related both to the severity of right ventricular systolic dysfunction as well as to raised LV filling pressures and global dyssynchrony.
Gender-Specific Physical Symptom Biology in Heart Failure
The Journal of cardiovascular nursing, 2014
There are several gender differences that may help explain the link between biology and symptoms in heart failure (HF). The aim of this study was to examine gender-specific relationships between objective measures of HF severity and physical symptoms. Detailed clinical data, including left ventricular ejection fraction and left ventricular internal end-diastolic diameter, and HF-specific physical symptoms were collected as part of a prospective cohort study. Gender interaction terms were tested in linear regression models of physical symptoms. The sample (101 women and 101 men) averaged 57 years of age and most participants (60%) had class III/IV HF. Larger left ventricle size was associated with better physical symptoms for women and worse physical symptoms for men. Decreased ventricular compliance may result in worse physical HF symptoms for women and dilation of the ventricle may be a greater progenitor of symptoms for men with HF.
2006
Background: Cardiopulmonary exercise testing (CPX) clearly holds prognostic value in the heart failure (HF) population. Studies investigating the prognostic value of CPX in individuals with HF have consistently examined predominantly male groups. The purpose of the present study was to examine the prognostic value of CPX in a female HF group. Methods: Seventy-five female and 337 male subjects diagnosed with HF participated in this study. The ability of peak oxygen consumption (VO 2 ) and the minute ventilation/carbon dioxide production (VE/VCO 2 ) slope to predict cardiac-related events were assessed. Results: In the year following CPX, the female group suffered 26 cardiac-related events (8 deaths/18 hospitalizations), while the male group suffered 89 cardiac-related events (20 deaths/69 hospitalizations). The hazard ratios for peak VO 2 and the VE/VCO 2 slope were 4.0 (95% confidence interval: 2.6 -6.1, p < 0.001) and 4.2 (95% confidence interval: 2.7 -6.6, p < 0.001) in the male group and 3.8 (95% confidence interval: 1.7 -8.5, p < 0.001) and 4.3 (95% confidence interval: 1.8 -9.8, p < 0.001) in the female group. In both the male and female groups, Cox multivariate analysis revealed VE/VCO 2 slope was the strongest predictor of cardiac-related events while peak VO 2 added significant predictive value and was retained in the regression.
Role of Gender in Heart Failure with Normal Left Ventricular Ejection Fraction
Progress in Cardiovascular Diseases, 2007
Heart failure with normal ejection fraction (HF-NEF) is frequently believed to be more common in women than in men. However, the interaction of gender and age has rarely been analyzed in detail, and knowledge of the distinction between pre-and postmenopausal women is lacking. Some of the studies that have described a higher prevalence of HF-NEF in women relied on clinical diagnoses of HF together with normal systolic function and did not measure diastolic function. This applies to the analysis of patients hospitalized for HF and some epidemiological investigations that agree on the greater prevelance of HF-NEF in women. Population-based studies with echocardiographic determination of diastolic function have suggested equal or greater prevelance of diastolic dysfunction in men. Major risk factors for HF-NEF include hypertension, aging, obesity, diabetes, and ischemia. Hypertension is more frequent in women and can contribute to left ventricular and arterial stiffening in a gender-specific way. Aging, obesity, and diabetes affect myocardial and vascular stiffness differently and lead to different forms of myocardial hypertrophy in women and men. In contrast, ischemia may play a greater role in men. Gender differences in ventricular diastolic distensibility, in vascular stiffness and ventricular/vascular coupling, in skeletal muscle adaptation to HF, and in the perception of symptoms may contribute to a greater rate of HF-NEF in women. The underlying molecular mechanisms include gender differences in calcium handling, in the NO system, and in natriuretic peptides. Estrogen affects collagen synthesis and degradation and inhibits the reninangiotensin system. Effects of estrogen may provide benefit to premenopausal women, and the loss of its protective mechanisms may render the heart of postmenopausal women more vulnerable. Thus, a number of molecular mechanisms can contribute to the gender differences in HF-NEF.
Role of gender, age and BMI in prognosis of heart failure
European Journal of Preventive Cardiology
The prognostic stratification of heart failure remains an urgent need for correct clinical management of the affected patients. In fact, due to the high mortality and morbidity rates, heart failure constantly requires an updated and careful management of all aspects that characterise the disease. In addition to the well-known clinical, laboratory and instrumental characteristics that affect the prognosis of heart failure, gender, age and body mass index have a different impact and deserve specific insights and clarifications. At this scope, the metabolic exercise cardiac kidney index score research group has produced several works in the past, trying to identify the role of these specific factors on the prognosis of heart failure. In particular, the different performances in the cardiopulmonary exercise test of specific categories of heart failure patients, such as women, elderly and obese or overweight individuals, have requested dedicated evaluations of metabolic exercise cardiac ...
Circulation, 2007
Background— We wished to test previous hypotheses that sex-related differences in mortality and morbidity may be due to differences in the cause of heart failure or in left ventricular ejection fraction (LVEF) by comparing fatal and nonfatal outcomes in women and men with heart failure and a broad spectrum of left ventricular ejection fraction. Methods and Results— We compared outcomes in 2400 women and 5199 men randomized in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program using multivariable regression analyses. A total of 1188 women (50%) had a low LVEF (≤0.40), and 1212 had a preserved LVEF (>0.40). Among the men, 3388 (65%) had a low LVEF, and 1811 had a preserved LVEF. A total of 1216 women (51%) and 3465 men (67%) had an ischemic cause of their heart failure. All-cause mortality was 21.5% in women and 25.3% in men (adjusted hazard ratio [HR], 0.77; 95% CI, 0.69 to 0.86; P <0.001). Fewer women (30.4%) than men (33.3%) e...