Prognostic Stratification of Women With Chronic Heart Failure Referred for Heart Transplantation: Relevance of Gender as Compared With Gender-related Characteristics

Background: Few studies are available regarding prognostic stratification of women with severe chronic heart failure (CHF). Although women seem to have a better outcome than men, this may be due to favorable baseline characteristics. Methods: We analyzed a cohort of CHF patients referred for heart transplantation (HT) who underwent clinical/laboratory/instrumental evaluation. Women and men were frequency matched for baseline age (53 ± 14 vs 53 ± 9 years, p = 0.92), left ventricular ejection fraction (33 ± 10 vs 31 ± 8%, p = 0.90) and ischemic etiology (17 vs 22%, p = 0.50). Results: A total of 198 patients were analyzed (109 women matched to 89 men). In addition to matching parameters, prevalence of severe symptoms, diabetes and hypertension were also comparable (p ≥ 0.25). After 3 years, cardiovascular death or need for HT (CD/HT) event-free survival was 78 ± 4% in women and 50 ± 6% in men (p = 0.005). On multivariate analysis, female gender was associated with a lower risk of CD/HT (relative risk [RR] 0.52; 95% confidence interval [CI] 0.30 to 0.89; p = 0.017), independently of symptoms, blood pressure (BP), left ventricular end-diastolic diameter (LVEDD) and mitral regurgitation (MR). Nevertheless, CD/HT event-free survival at 3 years was 49 ± 9% for women with New York Heart Association (NYHA) Class III or IV status, who presented with either severe MR, mean BP ≤60 mm Hg or LVEDD ≥35 mm/m2. Conclusions: In advanced CHF, women patients seem to have a better prognosis irrespective of baseline characteristics, supporting the hypothesis that female gender is protective against myocardial injury. However, women with severe symptoms accompanied by either hypotension, severe left ventricular enlargement or MR are at high risk and deserve cautious follow-up and consideration for HT.