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Heart Failure in Women

Heart Failure in Women was developed to improve the care of women with heart failure via education, treatment, and research.

Our goal is to focus more attention on women in heart failure research so that we can eventually tailor therapy to meet individual needs.

"Nothing in life is to be feared, it is only to be understood."
-Marie Curie

"Something which we think is impossible now is not impossible in another decade."
- Constance Baker Motley

Heart Failure and Women

Heart failure affects about 2.5 million women in the United States. Despite the fact that women account for nearly 50% of all hospital admissions for heart failure, only 25% of women are involved in heart failure studies. Consequently, advances in heart failure therapies apply to most men, but have not been adequately studied in women.

Differences of women with heart failure as compared to men with heart failure:
  • Women tend to develop congestive heart failure at an older age than men.
  • Women tend to develop diastolic heart failure with a more normal ejection fraction than men. Ejection fraction is the measurement of how much blood is being pumped out of the left ventricle of the heart. Heart failure can occur due to a weakened heart muscle (systolic heart failure) or may be related to a stiff, inflexible heart muscle (diastolic heart failure). In some cases the ejection fraction can be normal, but due to the increased pressures inside the heart and lungs, the patient can have heart failure. Learn more
  • The causes of heart failure in women are often linked to high blood pressure, coronary artery disease, valvular disease, and diabetes mellitus.
  • Although rare, peripartum cardiomyopathy is a cause of heart failure unique to women. Peripartum cardiomyopathy is the rare development of heart failure within the last month of pregnancy, or within five months after delivery. Peripartum cardiomyopathy occurs without an identifiable cause.
  • Depression is frequently associated with heart failure and is more common in women than men.
  • Although the signs and symptoms of heart failure are the same among men and women, women tend to have more symptoms such as shortness of breath and more difficulty exercising than men. They also have swelling around their ankles more frequently than men.
  • In general, women survive longer than men with heart failure.
Clinical Trials
Heart Failure Clinical Trials and Women
Study Number of Women % Women/Total Patients
MERIT-HF 898 23
SOLVD Treatment 2568 20
SOLVD Prevention 548 13
RALES 446 27
EPHESUS 1918 29
DIG 1519 22
CIBIS II 515 19
COPERNICUS 469 20
CHARM - Overall 2400 32
CHARM - Preserved 1212 40
ELITE - II 966 31
Val-HEFT 1033 20
COMPANION 493 32
MIRACLE 145 32
MUSTIC 47 26
A-HEFT 421 40
V-HEFT 0 0
CARE-HF 216 27

Dr. Eileen Hsich, specialist in Women & Heart Failure

References
  1. AHA. Heart Disease and Stroke Stats-2009 Update. Dallas, Tx: AHA; 2009 *
  2. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA. 2003 Jan 8;289(2):194-202. *
  3. Vasan R, Larson M, Benjamin E, Evans J, Reiss C, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction. Journal of the American College of Cardiology. 1999; 33 (7): 1948-1955.*
  4. Masoudi F, Havranek E, Smith G; Fish R; Steiner J; Ordin D; Krumholz H. Gender, age, and heart failure with preserved left ventricular systolic function. Journal of the American College of Cardiology. 2003; 41 (2): 217-223.*
  5. Lund L, Mancini D. Heart failure in women. The Medical Clinics of North America. 2004; 88: 1321-1345.*
  6. Pearson G, Veille JC, Rahimtoola S; Hsia J, Oakley C, Hosenpud, J, Ansari A, Baughman KL. Peripartum Cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) Workshop Recommendations and Review. Journal of the American Medical Association. 2000; 283 (9): 1183-1188. *
  7. Gottlieb SS, Khatta M, Friedmann E, Einbinder L, Katzen S, Baker B, Marshall J, Minshall S, Robinson S, Fisher ML, Potenza M, Sigler B, Baldwin C, Thomas SA. The influence of age, gender, and race on the prevalence of depression in heart failure patients. Journal of the American College of Cardiology. 2004; 43: 1542-1549.*
  8. Johnstone D, Limacher M, Rousseau M, Liang CS, Ekelund L, Herman M, Stewart D, Guillotte M, Bjerken G, Gaasch W, et al. Clinical characteristics of patients in studies of left ventricular dysfunction (SOLVD). The American Journal of Cardiology. 1992; 70: 894-900.*
  9. Levy D, Kenchaiah S, Larson MG, Benjamin EJ, Kupka MJ, Ho KK, Murabito JM, Vasan RS. Long-term trends in the incidence of and survival with heart failure. N Engl J Med. 2002 Oct 31;347(18):1397-402. *
  10. Roger VL, Weston SA, Redfield MM, Hellermann-Homan JP, Killian J, Yawn BP, Jacobsen SJ. Trends in heart failure incidence and survival in a community-based population. Journal of the American Medical Association. 2004; 292: 344-350. *

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operator

written with Dr. Eileen Hsich, specialist in Women & Heart Failure

Diastolic Versus Systolic Heart Failure

Women develop diastolic heart failure more often than men, and more frequently than systolic heart failure. Diastolic heart failure occurs when the heart pumps normally, but the ventricles become stiff and doesn't relax properly. This causes the pressure to rise in the heart and lungs. Systolic heart failure occurs when the heart is weak and doesn't contract with enough force. In systolic heart failure there is not enough oxygen-rich blood being pumped throughout the body. The weak heart causes blood to accumulate, leading to a rise in pressure in the heart and lungs very similar to that seen in diastolic heart failure, but due to a different mechanism (ie. weak heart instead of stiff heart).

Causes of Heart Failure Unique to Women

The causes of heart failure in women are different than in men. Women with heart failure are more likely than men to have high blood pressure valvular disease, and diabetes mellitus, and less likely to have congestive heart failure due to prior heart attacks (ischemic cardiomyopathy).

However, women can still develop atherosclerosis (progressive narrowing of the arteries). In fact, although women with congestive heart failure develop coronary artery disease less often then men the frequency is still so high that it is the second leading cause for women with heart failure. It is important to remember that women often have atypical symptoms such as shortness of breath, as compared to men whose primary symptom is often chest pain. Therefore, women like men need to be evaluated for blockages in the arteries.

Women with breast cancer who have been treated with chemotherapy including doxorubicin (Adriamycin) can also develop congestive heart failure due to the toxic effects that these drugs can have on the heart muscle (called drug toxicity).

Another cause of congestive heart failure unique to women is peripartum cardiomyopathy. Peripartum cardiomyopathy is the rare development of heart failure within the last month of pregnancy or within five months after delivery. The cause of peripartum cardiomyopathy remains unknown.

References
  1. Masoudi FA, Havranek EP, Smith G, Fish RH, Steiner JF, Ordin DL, Krumholz HM. Gender, age, and heart failure with preserved left ventricular systolic function. J Am Coll Cardiol. 2003 Jan 15;41(2):217-23.
  2. Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol. 1999 Jun;33(7):1948-55.
  3. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK. The progression from hypertension to congestive heart failure.
    JAMA. 1996; 275:1557-1562.
  4. Philbin EF, DiSalvo TG. Influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure. Am J Cardiol. 1998 Jul 1;82(1):76-81.
  5. Jalal K. Ghali, MD; Ileana L. Piña, MD; Stephen S. Gottlieb, MD; Prakash C. Deedwania, MD; John C. Wikstrand, MD, PhD, on Behalf of the MERIT-HF Study Group. Metoprolol CR/XL in Female Patients With Heart Failure: Analysis of the Experience in Metoprolol Extended-Release Randomized Intervention Trial in Heart Failure (MERIT-HF). Circulation. 2002; 105: 1585-1591.*
  6. Lund LH, Mancini D. Heart failure in women. Med Clin North Am. 2004 Sep;88(5):1321-45.*
  7. Shindler DM, Kostis JB, Yusuf S, Quinones MA, Pitt B, Stewart D, Pinkett T, Ghali JK, Wilson AC. Diabetes mellitus, a predictor of morbidity and mortality in the Studies of Left Ventricular Dysfunction (SOLVD) Trials and Registry. Am J Cardiol. 1996; 77:1017-1020.*
  8. Perez EA. Doxorubicin and paclitaxel in the treatment of advanced breast cancer: efficacy and cardiac considerations. Cancer Invest. 2001; 19 (2): 155-164.*
  9. Pearson GD, Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, Ansari A, Baughman KL. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000 Mar 1;283(9):1183-8.*

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators

written with Dr. Eileen Hsich, specialist in Women & Heart Failure

Women and men should receive the same testing to diagnose heart failure and exclude other causes for their symptoms of heart failure.

The diagnosis for heart failure may include:

Medical History and Physical Exam

To diagnose heart failure, your doctor will first ask you questions about your symptoms and medical history. While diagnosing heart failure, your doctor will want to know:

  • If you have any other health conditions such as diabetes, kidney disease, angina, high blood pressure or other heart problems
  • If you smoke
  • If you drink alcohol and how much you drink
  • What medications you are taking
  • Your doctor will also perform a complete physical exam. Your doctor will look for signs of heart failure as well as any other illnesses that may have caused your heart to weaken.

Blood Tests:

Certain blood tests can help your doctor determine the cause and severity of heart failure. Blood tests may be done to evaluate kidney and thyroid function as well as to check cholesterol levels and the presence of anemia. Anemia is a blood disorder that occurs when there is not enough red blood cells in a person's blood.

B-type Natriuretic Peptide (BNP) blood test

When heart failure occurs or worsens, the pumping chambers, or ventricles, secrete a substance called BNP (pro-B type natriuretic peptide) in response to the accompanying changes in blood pressure. The BNP level rises when heart failure symptoms worsen, and it falls when the condition is stable. BNP helps determine if you have heart failure, rather than another condition that may cause similar symptoms. It also can help the doctor determine if your heart failure has worsened and more aggressive treatments are needed.

To test the BNP level, a small amount of blood is taken and placed in a machine that detects the level of BNP in your blood. The BNP level helps determine if you have heart failure. Usually, BNP levels below 100 pg/mL indicate no heart failure and levels above 100-300 suggest heart failure is present.

The BNP level also indicates if your heart failure condition has worsened and can provide information about your prognosis.

Chest X-ray

It shows the size of your heart and whether there is fluid build-up around the heart and lungs.

Echocardiogram

It is a graphic outline of the heart's movement. During an echo, a wand is placed on the surface of your chest. This wand sends ultrasound waves that provide pictures of the heart's valves and chambers so the pumping action of the heart can be studied. Echo can also find changes in the blood flow across the heart's valves and the pressure within the heart's chambers. It may also help estimate the blood pressure within the lungs.

Electrocardiogram

Records the electrical impulses traveling through the heart. During the test, small, flat, sticky patches called electrodes are placed on your chest. The electrodes are attached to an electrocardiograph monitor (EKG) that charts your heart's electrical activity on graph paper.

Ejection fraction (EF)

A test that determines how well your heart pumps with each beat. A normal EF is generally 50-55%. It is important for your doctor to know your EF. Your EF can go up and down, based on your heart condition and the effectiveness of the therapies that have been prescribed. It is important to have your EF measured initially and as needed, based on changes in your condition. Ask your doctor how often you should have your EF checked.

An EF of less than 50 percent usually confirms a diagnosis of systolic heart failure (a condition that occurs when the heart muscle doesn't contract with enough force, so there is not enough oxygen-rich blood to be pumped throughout the body). Diastolic dysfunction is a condition that occurs when the heart contracts normally, but the ventricle doesn't relax properly so less blood can enter the heart. People with diastolic dysfunction can have a normal EF or a low EF.

Other tests

Tests such as cardiac catheterization or stress tests , may be ordered by your doctor, depending on your condition.

Test Results

Although the same tests are used to diagnose heart failure in women and men, the results may not be the same. For instance, BNP blood levels are used to help diagnose heart failure and determine severity. However, the "normal" values for women are higher than for men.

There is also some evidence to suggest that the results of a metabolic stress test (which evaluates oxygen uptake during exercise - Peak VO2) are worse for women than men. The differences in results may be related to the adjustments made to the test results. The metabolic stress test results are adjusted for body weight but are not adjusted for lean body mass. This may explain the differences in results among men and women, since women usually have a higher percentage of body fat than men.

References
  1. Redfield MM, Rodeheffer RJ, Jacobsen SJ, Mahoney DW, Bailey KR, Burnett JC Jr.Plasma brain natriuretic peptide concentration: impact of age and gender. J Am Coll Cardiol. 2002 Sep 4;40(5):976-82.
  2. Alan H.B. Wu, Milton Packer, Andrew Smith, Rachel Bijou, Daniel Fink, Johannes Mair, Lars Wallentin, Nina Johnston, Carolyn S. Feldcamp, Doris M. Haverstick, Charaf E. Ahnadi, Andrew Grant, Normand Despres, Barry Bluestein, and Farooq Ghan. Analytical and Clinical Evaluation of the Bayer ADVIA Centaur Automated B-Type Natriuretic Peptide Assay in Patients with Heart Failure: A Multisite Study. Clin. Chem. 2004; 50: 867-873.
  3. Wang TJ, Larson MG, Levy D, Leip EP, Benjamin EJ, Wilson PW, Sutherland P, Omland T, Vasan RS. Impact of age and sex on plasma natriuretic peptide levels in healthy adults. Am J Cardiol. 2002 Aug 1;90(3):254-8.
  4. Richards DR, Mehra MR, Ventura HO, Lavie CJ, Smart FW, Stapleton DD, Milani RV. Usefulness of peak oxygen consumption in predicting outcome of heart failure in women versus men. Am J Cardiol. 1997 Nov 1;80(9):1236-8.
  5. Daida H, Allison TG, Johnson BD, Squires RW, Gau GT. Comparison of peak exercise oxygen uptake in men versus women in chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1997 Jul 1;80(1):85-8. *

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators

written with Dr. Eileen Hsich, specialist in Women & Heart Failure

With the right care, heart failure will not stop you from doing the things you enjoy. Your prognosis or outlook for the future will depend on how well your heart muscle is functioning, your symptoms, and how well you respond to and follow your treatment plan.

In general, women with heart failure survive longer than men with heart failure but remain symptomatic (ie. shortness of breath) and functionally more limited. Women with heart failure also require hospitalization more frequently than men.

Your health care team will help you manage your condition and help you stay on track with your heart failure treatment plan.
It is important to keep regular follow-up appointments with your health care team, as well as to take your medications as prescribed, make dietary changes and live an active and healthy lifestyle.

Everyone with a chronic illness, such as heart failure, should discuss their desires for extended medical care with their doctor and family. An "advance directive" or "living will" is one way to let everyone know your wishes. A living will expresses your desires about the use of medical treatments to prolong your life. This document is prepared while you are fully competent in case you are unable to make these decisions at a later time.

References

With the right care, heart failure will not stop you from doing the things you enjoy. Your prognosis or outlook for the future will depend on how well your heart muscle is functioning, your symptoms, and how well you respond to and follow your treatment plan.
In general, women survive longer than men with heart failure 1-2 but remain symptomatic (ie. shortness of breath) and functionally more limited 3-4.

  1. Levy D, Kenchaiah S, Larson MG, Benjamin EJ, Kupka MJ, Ho KK, Murabito JM, Vasan RS. Long-term trends in the incidence of and survival with heart failure. N Engl J Med. 2002 Oct 31;347(18):1397-402. * .
  2. Roger VL, Weston SA, Redfield MM, Hellermann-Homan JP, Killian J, Yawn BP, Jacobsen SJ. Trends in heart failure incidence and survival in a community-based population. Journal of the American Medical Association. 2004; 292: 344-350.
  3. Riedinger MS, Dracup KA, Brecht ML, Padilla G, Sarna L, Ganz PA. Quality of life in patients with heart failure: do gender differences exist? Heart and Lung. 2001; 30: 105-116.*
  4. Friedman MM. Gender differences in the health related quality of life of older adults with heart failure. Heart and Lung. 2003; 32:320-327.*

Everyone with a chronic illness, such as heart failure, should discuss their desires for extended medical care with their doctor and family. An "advance directive" or "living will" is one way to let everyone know your wishes. A living will expresses your desires about the use of medical treatments to prolong your life. This document is prepared while you are fully competent in case you are unable to make these decisions at a later time. Learn More.

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators

written with Dr. Eileen Hsich, specialist in Women & Heart Failure

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