The aim of the present study was to compare the clinical characteristics, treatment, and outcomes of women and men hospitalized with heart failure (HF) in a Middle-Eastern country. A retrospective analysis of all patients hospitalized with HF in the State of Qatar from 1991 through 2010 was made. The clinical characteristics, management, and outcomes of the patients with HF were compared according to gender. A subset analysis according to ethnicity was also done (Middle Eastern Arabs vs South Asians). During the 20-year period, 2,379 women and 4,689 men were hospitalized for HF. The women were older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment compared to the male patients. The women were less likely to be current smokers and to have ischemic heart disease compared to the men. Impaired left ventricular function was more common among men. The in-hospital mortality rates were comparable between the 2 groups (7.7% in women vs 8.2% in men; p = 0.4) and significantly improved with time in the 2 groups (p = 0.001). The mortality rates were comparable among the women, regardless of the ethnicity. In conclusion, overall improvement occurred in survival in patients hospitalized with HF in a Middle-Eastern country, regardless of gender. Women hospitalized with HF had mortality rates comparable to those of men.
Heart failure (HF) is a major cause of morbidity and mortality worldwide and has significant effects on the quality of life, cost, and longevity. An estimated 1 million hospitalizations for this syndrome occur annually in Europe and the United States each, and this number is expected to increase substantially during the next 2 decades. More women die every year of cardiovascular diseases (including coronary artery disease and HF) than of breast or uterine cancer. However, HF among women remains a poorly recognized and poorly understood syndrome. Although the prevalence of HF between women and men are equal, the vast majority of clinical trials of medical therapy for HF included few women. Moreover, to date, the vast majority of published studies on gender (post hoc analyses of trials and registries) were conducted in the developed world and included mainly white women. The aim of the present study was to compare the clinical characteristics, treatment, and outcome of women to men hospitalized with HF in a Middle-Eastern country during a 20-year period. Also, a subset analysis according to ethnicity was made (Middle-Eastern Arabs and South Asians).
Methods
Qatar is a small country with a population of around 600,000 (2001 census) and 1.6 million (2010 census), consisting of Qatari and other Middle-Eastern Arabs (<40%) and non–Middle-Eastern Arabs. The vast majority of non–Middle-Eastern Arabs are South Asians, mainly from India, Pakistan, Nepal, and Bangladesh. The present study was based at Hamad General Hospital, Doha, Qatar. This hospital provides in-patient and out-patient medical and surgical care for the residents of Qatar, both nationals and expatriates, at which >95% of cardiac patients in Qatar are treated, making it an ideal center for population-based studies.
The Cardiology and Cardiovascular Surgery Database at Hamad General Hospital was used for the present study. Data are entered for all patients admitted to Hamad General Hospital with cardiac illnesses. The Hamad Medical Review Board approved the investigation before the data analysis. The data were collected from the clinical records written by physicians at the patient’s discharge from the hospital, according to predefined criteria for each data point. These records have been coded and registered at the cardiology department since January 1991. With the described database, all patients presenting with HF requiring hospitalization during the 20-year period from 1991 to the end of 2010 were retrospectively identified. Patients with HF were compared according to gender.
HF was defined using the Framingham criteria. The simultaneous presence of ≥2 major criteria or 1 major criteria plus 2 minor criteria was required was required to establish a diagnosis of HF. The major criteria included paroxysmal nocturnal dyspnea or orthopnea, jugular venous distension, pulmonary rales, radiographic cardiomegaly, acute pulmonary edema, a third heart sound, central venous pressure >16 cm H 2 O, hepatojugular reflux, and weight loss of ≥4.5 kg within 5 days in response to HF treatment. The minor criteria included bilateral ankle edema, nocturnal cough, dyspnea on ordinary exertion, hepatomegaly, pleural effusion, and a heart rate of ≥120 beats/min. The minor criteria were acceptable only if they could not be attributed to any other medical condition (e.g., chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome).
Acute myocardial infarction was defined for the present study according to the World Heart Organization criteria. The presence of diabetes mellitus was determined by documentation in the patient’s previous or current medical record of a documented diagnosis of diabetes mellitus that had been treated with oral medication or insulin. The presence of hyperlipidemia was determined by the demonstration of a fasting cholesterol level >5.2 mmol/L in the patient’s medical record or any history of treatment of hyperlipidemia by the patient’s physician. Chronic renal impairment was defined as creatinine >1.5 of the upper normal range.
The presence of hypertension was determined by any documentation in the medical record of hypertension or if the patient was being treated for hypertension by the patient’s physician. Patients were divided into current cigarette smokers, past smokers (defined as >6 months’ abstinence from smoking), and those who had never smoked. The left ventricular ejection fraction was estimated or determined by echocardiography or ventriculography.
The patient characteristics are presented in percentages for categorical variables and as the mean ± SD for continuous variables. The frequencies of the categorical variables in the 2 populations (HF and non-HF and Middle-Eastern and South Asians) were compared using the chi-square test; continuous variables were compared using the 2-tailed Student t test. Variables influencing in-hospital mortality were assessed with the multiple logistic regression analysis enter method. Odds ratios, 95% confidence intervals, and p values are reported for significant predictors. p Values <0.05 were considered statistical significant. All p values were the results of 2-tailed tests. All data analyses were performed using the Statistical Package for Social Sciences, version 18.0 (SPSS, Chicago, Illinois).
Results
Overall, from 1991 to the end of 2010, 41,438 patients with acute cardiac disease were hospitalized. Of these patients, 7,066 were admitted with HF and 34,372 with other cardiovascular diagnoses and no HF. Of the 7,066 patients with HF, 2,379 were women and 4,689 were men.
Compared with men, the women were older and more likely to have diabetes mellitus, hypertension, dyslipidemia, and chronic renal impairment ( Table 1 ). The women were less likely to be current smokers and to have a history of myocardial infarction or HF as a complication of acute coronary syndrome compared to the men. Rheumatic heart disease was more common among the women than the men. Subanalysis according to ethnicity revealed that the South Asian women were significantly younger than their Middle-Eastern Arab counterparts (56.5 ± 11.7 vs 63 ± 11.8 years, p = 0.001).
| Variable | Women (n = 2,379) | Men (n = 4,689) | p Value |
|---|---|---|---|
| Patient characteristics at admission | |||
| Age (years) | 63 ± 12 | 61 ± 12.4 | 0.001 |
| Middle-Eastern Arabs | 88% | 66.7% | |
| South Asians | 7.5% | 23.7% | |
| Other | 4.3% | 9.6% | 0.001 |
| Hypertension | 69% | 50% | 0.001 |
| Diabetes mellitus | 66.6% | 52.4% | 0.001 |
| Current smoker | 1.3% | 20.5% | 0.001 |
| Chronic renal impairment | 9.7% | 8% | 0.02 |
| Dyslipidemia | 24% | 16% | 0.001 |
| Previous myocardial infarction | 24% | 35% | 0.001 |
| Previous coronary artery bypass grafting | 7% | 10% | 0.001 |
| Rheumatic heart disease | 0.8% | 0.3% | 0.001 |
| Acute coronary syndrome | 15% | 21% | 0.001 |
| Atrial fibrillation | 11% | 9% | 0.01 |
| Aortic stenosis | 2.5% | 2.4% | 0.69 |
| Mitral regurgitation | 6.7% | 4.3% | 0.001 |
| Pulmonary hypertension | 1.8% | 0.8% | 0.001 |
| Medication | |||
| β Blockers | 10.7% | 10.8% | 0.95 |
| Calcium channel blockers | 6.8% | 3.8% | 0.001 |
| Diuretics | 51.8% | 44% | 0.001 |
| Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker | 13.1% | 13.3% | 0.82 |
| Antiplatelet agents | 51% | 50% | 0.35 |
| Hydralazine | 2.1% | 1.0% | 0.001 |
| Nitrates | 7.3% | 7.5% | 0.77 |
| Left ventricular ejection fraction (%) | 40.3 ± 13% | 30.6 ± 12% | 0.001 |
At admission, the women were more likely to be taking diuretics, hydralazine, and calcium channel blockers compared to the men ( Tables 1 and 2 ). The women were less likely to be taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARB), and the use of antiplatelet agents, β blockers, and nitrates was comparable between the 2 groups.
| Variable | Women (n = 2,379) | Men (n = 4,689) | p Value |
|---|---|---|---|
| On admission | |||
| β Blockers | 14.5% | 15.9% | 0.12 |
| Calcium channel blockers | 12.8% | 7.4% | 0.001 |
| Diuretics | 83.9% | 82.3% | 0.08 |
| Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers | 52.1% | 57.4% | 0.001 |
| Hydralazine | 2.8% | 1.9% | 0.02 |
| Inotropes | 11.2% | 8.9% | 0.002 |
| At discharge | |||
| β Blockers | 13.9% | 15.9% | 0.03 |
| Calcium channel blockers | 18% | 10.7% | 0.001 |
| Diuretics | 83.3% | 81.4% | 0.05 |
| Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers | 54.8% | 59.9% | 0.001 |
| Clopidogrel | 8.5% | 11.9% | 0.001 |
| Aspirin | 65.7% | 69.7% | 0.01 |
| Warfarin | 9.9% | 12.8% | 0.001 |
Women were more likely to be treated with hydralazine, calcium channel blockers, and inotropes and less likely to be treated with ACEIs/ARB. Diuretic and β-blocker use were comparable between the 2 groups. The women were more likely prescribed calcium channel blockers than the men. The men were more likely prescribed ACEIs/ARB, antiplatelet agents, β blockers, and warfarin at discharge than were the women.
The in-hospital mortality rate (7.7% for the women vs 8.2% for the men, p = 0.4) and stroke rate (0.6% for the women vs 0.6% for the men, p = 0.7) were comparable between the 2 groups. Subset analysis of outcomes according to ethnicity revealed a comparable mortality rate between the women of South Asian and Middle-Eastern ethnicities (5.6% vs 7.8%; p = 0.5). In contrast to men with HF who had improved survival if they had preserved left ventricular function (p = 0.02), women with HF and preserved left ventricular function had mortality rates comparable to those of the women with HF and reduced left ventricular function (p = 0.12). During the 20-year period, an increase occurred in the percentage of women hospitalized with HF ( Table 3 ). Overall, the in-hospital mortality rate significantly decreased from 8.3% to 4.8%, regardless of gender ( Figure 1 ) .
| Variable | 1991–1994 (n = 1,089) | 1995–1998 (n = 1,445) | 1999–2002 (n = 1,261) | 2003–2006 (n = 1,804) | 2007–2010 (n = 1,469) | p Value |
|---|---|---|---|---|---|---|
| Age (years) | 61 ± 12.3 | 61.4 ± 12 | 61.3 ± 12.7 | 62 ± 11.9 | 62 ± 12.9 | 0.4 |
| Women | 28.7% | 36.3% | 33% | 36.5% | 32% | 0.001 |
| Mortality rate | 0.001 | |||||
| Total | 8.3% | 9% | 11% | 7.5% | 4.8% | |
| Men | 8.1% | 9.3% | 11.6% | 7.8% | 4.8% | |
| Women | 8.6% | 8.4% | 9.9% | 7.1% | 4.9% |
Advancing age, male gender, acute coronary syndrome presentation, and chronic renal impairment were associated with an increased risk of death. ACEI/ARB administration at admission was associated with a reduced risk of death ( Table 4 ).
| Variable | OR | 95% CI | p Value |
|---|---|---|---|
| Age | 1.02 | 1.01–1.02 | 0.001 |
| Male gender | 0.99 | 0.82–1.21 | 0.94 |
| Acute coronary syndrome | 2.88 | 2.4–3.5 | 0.001 |
| Diabetes mellitus | 0.98 | 0.81–1.2 | 0.83 |
| Hypertension | 0.62 | 0.52–0.75 | 0.001 |
| Chronic renal impairment | 1.38 | 1.04–1.92 | 0.03 |
| Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at admission | 0.05 | 0.28–0.41 | 0.001 |
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