Sex differences in clinical profile, management, and outcomes in heart failure: results from the Spanish SEC-Excelente National Registry

Introduction

The prognosis of women with heart failure (HF) has been evaluated in multiple studies, yielding inconsistent and sometimes contradictory results. This study aimed to describe the clinical characteristics, management, and outcomes of women with HF followed in specialized HF units in Spain, and to compare them with male patients.

Methods

This was a prospective, multicentre, national study conducted in accredited HF units in Spain between 2019 and 2023. Baseline clinical characteristics were analysed according to sex. Clinical outcomes, including all-cause mortality and HF-related hospitalizations, were assessed during 1 year of follow-up. Survival analyses were performed using Kaplan–Meier methods, and the association between sex and the composite endpoint of all-cause death or HF hospitalization was evaluated using Cox proportional hazards regression.

Results

A total of 2,245 patients were included, 802 (35.7%) women. Women were older (74.1 ± 12.0 vs 69.4 ± 12.1 years; p<0.001) and had a higher prevalence of dementia (4.9% vs 2.8%; p=0.013), prior stroke (11.9% vs 9.2%; p=0.048), anaemia (35.1% vs 31.1%; p=0.049), and atrial fibrillation (57.0% vs 49.9%; p=0.001). Valvular heart disease (22.1%) and tachycardiomyopathy (19.0%) were the most frequent HF aetiologies in women. Median left ventricular ejection fraction (LVEF) was higher in women (45% [IQR 33–60] vs 35% [27–47]; p<0.001).

Women received prognostic HF therapies less frequently than men, including sacubitril/valsartan (30.7% vs 47.6%; p<0.001), BB (78.4% vs 82.9%; p=0.009), MRAs (52.1% vs 64.1%; p=0.001), SGLT2i (43.5% vs 59.0%; p=0.001), and ICDs (4.4% vs 9.9%; p<0.001). Conversely, women were more often treated with diuretics (84.4% vs 79.5%; p=0.003) and ACEi/ARBs (38.6% vs 32.9%; p=0.001). Among patients with reduced LVEF, women were less likely to receive quadruple therapy (42.8% vs 49.7%; p=0.003).

Women were less frequently included in multidisciplinary HF care programmes (75.4% vs 80.2%; p=0.009) and cardiac rehabilitation programmes (7.3% vs 11.2%; p=0.003). During follow-up, the mean number of HF hospitalizations was similar between men (0.28 ± 0.83) and women (0.33 ± 1.03). No significant sex-related differences in event-free survival were observed (Figure 1). Cox regression analysis showed no association between sex and the composite endpoint of all-cause death or HF hospitalization (Table 1).

Conclusions

Women with HF present with a higher burden of comorbidities and are more likely to have HF with preserved ejection fraction. Despite receiving fewer evidence-based therapies and being less frequently referred to structured HF programmes and cardiac rehabilitation, their clinical outcomes are comparable to those of men. Sex was not independently associated with prognosis in this cohort of patients.Table 1For image description, please refer to the figure legend and surrounding text.Figure 1For image description, please refer to the figure legend and surrounding text.