Persistent sex gap in inpatient ICD utilization during HFrEF admissions: national trends 2018–2022
V Polana, V Godishala, S Tanna, S Karipineni, N Patel, D Nanavaty, S Singh, S ReddyAbstract
Background
Women with heart failure with reduced ejection fraction (HFrEF) have historically received less guideline-recommended device therapy. Contemporary national data on sex differences in inpatient primary-prevention implantable cardioverter-defibrillator (ICD) implantation during HFrEF hospitalizations remain limited.
Methods
Using the HCUP National Inpatient Sample (NIS) from 2018 to 2022, we identified adults hospitalized with a principal diagnosis of HFrEF. An “ICD-eligible proxy” cohort was established by excluding admissions with ventricular tachycardia/ventricular fibrillation, cardiac arrest, acute myocardial infarction, prior ICD presence, or palliative care. The primary outcome was new ICD implantation during hospitalization, identified via ICD-10-PCS generator insertion codes (ICD and CRT-D), excluding generator removal or revision procedures. Female sex was the exposure variable. Survey-weighted logistic regression adjusted for demographics, socioeconomic factors, clinical comorbidities (Elixhauser burden), admission characteristics, and hospital factors. A sex×year interaction term assessed temporal trends in disparities.
Results
Among 147,509 hospitalizations (37.8% female), weighted ICD implantation rates were lower in women than men (1.03% vs 1.26%). Adjusted analysis showed a trend toward lower odds of ICD implantation in women versus men (aOR 0.65, 95% CI 0.42–1.02, p=0.059). No significant temporal change in sex disparities was observed (female × year interaction p=0.589). Overall, ICD implantation rates declined in 2021 and 2022 compared with 2018 (2021: aOR 0.57, 95% CI 0.38–0.87, p=0.0089; 2022: aOR 0.56, 95% CI 0.36–0.86, p=0.0081).
Conclusions
In this national cohort of ICD-eligible HFrEF hospitalizations, women exhibited lower inpatient ICD implantation rates and a borderline reduced adjusted likelihood of receiving an ICD compared with men, with no evidence of improvement in this disparity from 2018 to 2022. These findings highlight persistent sex-based differences in the inpatient delivery of primary-prevention ICD therapy.