Table 1:
Data on Outcomes of HFrEF by Race and Gender
| Demographics | Outcomes | |
|---|---|---|
| Exercise training (cardiac rehabilitation) | ||
| Race/Ethnicity, and Gender | HF-ACTION (2003–2007) multicenter clinical trial: Median age of enrolled patients, 59 years (28% female and 32% African Americans) [15]. |
After adjustment for prognostic factors, exercise training demonstrated modest significant reductions in all-cause mortality, cardiovascular mortality, and HF hospitalization; subgroup post hoc analysis demonstrated greater benefits in women than men [15]. |
| Transcatheter Mitral Valve Repair (TMVr/Mitraclip) | ||
| Race | NIS database (2012–2016) analysis of TMVr utilization and outcomes in the US: Of 7940 TMVr performed, only 8.6% were performed in African Americans [37]. Compared to African Americans, White recipients of Mitraclip were older (77.7±10.8 vs 67.2±14.28, p<0.001) and less likely to be women (45.3% vs 60.3%, p < 0.001) [37]. |
Whites had higher in-hospital mortality than African Americans [4.7% vs 1.6%; OR: 3.10 (95% CI:1.61–5.97); p<0.001] [37] Whites also had higher in-hospital cardiac arrest and pacemaker implantation compared to African Americans [37]. |
| Gender | In the NIS database (2012–2016), White women were less likely than African American women to receive Mitraclip (45.3% vs 60.3%, p<0.001) [37, 38]. | Women and men had similar in-hospital survival except for lower incidence of ventricular arrhythmias (4.1% vs 7.2%; p=0.01) in women and higher incidence of pacemaker implantation in women (1.7% vs 0.4%; p=0.01) [38]. |
| Cardiac Resynchronization Therapy (CRT) | ||
| Race/Ethnicity and Gender | NIS database (2002–2010) analysis of CRT utilization trends in the US: Of the 374 202 CRT procedures recorded, Whites received 79.6% of which 71.4% were male recipients [6]. Predominant age group of CRT recipients was 64–84 years which accounted for 64.6% of procedures recorded) [6]. |
Women, particularly age<85, have slightly better in-hospital mortality than men (0.71% vs 0.93%) [6]. Women have more adverse outcomes with CRT-D compared to men including hemothorax and pneumothorax (4.4% vs 0.9%) and infection requiring reoperation (2.5% vs 0.6%), and fewer appropriate shocks [4, 6]. Gender disparities in utilization are widening despite greater benefit in women [82]. |
| VAD/Transplant | ||
| Race/Ethnicity | Analysis of the UNOS registry (2008–2018) for trends on LVAD implantation as a bridge to heart transplant in the US: 14 324 patients (64% Whites; 26% African Americans; 7% Hispanics; and 3% other races) received cLVAD as a bridge to heart transplant [57]. |
African Americans had the lowest incidence of heart transplantation, and African American race was a predictor of waitlist mortality and delisting for worsening clinical status post VAD [57]. VAD survival and hospitalization benefits are similar across race and ethnicity [83]. |
| OPTN/SRTR 2018 heart transplant waitlist composition (as of December 2018): Whites (61.1%), African Americans (26.5%), Hispanics (8.9%), Asians (2.7%) [14]. In 2018, Whites received 64.2% versus 22.0% (African Americans), 8.8% (Hispanics), 4.1% (Asian), and 0.8% (other/unknown) of heart transplants, respectively [14]. |
African Americans have worst 5-year post heart transplant mortality across race/ethnicity [14]. | |
| Gender | NIS database (2004–2016) analysis on temporal trends in LVAD utilization and post-LVAD mortality by sex demonstrated a decrease in LVAD implantation from 25.8% (2004) to 21.9% (2016) [84]. Men comprise 80% of the destination VAD population [84]. |
With contemporary cLVAD, women have similar complications (post cVAD in-hospital mortality, time to infection, bleeding, and device malfunction) to men [17, 84]. Stroke risk post VAD is greater in women than men [adjusted hazard’s ratio: 1.44(95% CI: 1.05–1.96); p=0.002]) [17]. |
| Men comprise 75.8% of patients on heart transplant waitlist and 71.7% of heart transplant recipients [14]. | Women receiving cLVAD while listed had lower chances of heart transplant than men, increased risk of waitlist mortality, and delisting for worsening clinical status at 2-years post implantation. Women have higher adjusted waitlist mortality & are less likely than men to be transplanted urgently (UNOS status1A) [14]. | |
HFrEF indicates heart failure with reduced ejection fraction; NIS, National Inpatient Sample; INTERMACS, Interagency Registry of Mechanically Assisted Circulatory Support; HF-ACTION, UNOS, United Network for Organ Sharing; OPTN/SRTR, US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients; Heart Failure- A Controlled Trial Investigating Outcomes of Exercise Training; cVAD, continuous flow ventricular assist device; LVAD, left ventricular assist device; CRT-D, cardiac resynchronization therapy- defibrillator; CMS, Centers for Medicare and Medicaid Services.