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Sex differences in heart failure patients assessed by combined echocardiographic and cardiopulmonary exercise testing
Zach Rozenbaum1,2, Yoav Granot1, Ben Sadeh1
1Cardiology Division, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv-Yafo, Israel.
Insights
Female heart failure patients exhibit lower exercise capacity than males due to distinct physiological differences. This study highlights sex-based variations in heart failure exercise physiology, informing targeted treatments.
Area of Science:
- Cardiology
- Exercise Physiology
- Sex Differences in Medicine
Background:
- Heart failure (HF) management requires understanding sex-specific exercise physiology.
- Peak oxygen uptake (VO2) differences between males and females with HF are not fully elucidated.
- Combined stress echocardiography (SE) and cardiopulmonary exercise testing (CPET) offer a comprehensive approach.
Purpose of the Study:
- To investigate sex-based differences in peak VO2 among patients with heart failure.
- To compare exercise physiology between males and females across different HF subtypes (HFpEF, HFrEF/HFmrEF) and controls.
- To utilize combined CPET-SE for detailed, individualized, non-invasive assessment.
Main Methods:
- Retrospective analysis of 178 patients undergoing CPET and SE for dyspnea or exertional intolerance (2013-2017).
- Patients categorized into HF with preserved ejection fraction (HFpEF), HF with mildly reduced/reduced ejection fraction (HFmrEF/HFrEF), and control groups.
- Stratification by sex within each group to analyze physiological responses.
Main Results:
- Females with HFpEF showed attenuated increases in end-diastolic volume index and A-VO2 difference, with elevated E/e' compared to males.
- Females with HFmrEF/HFrEF exhibited diminished increases in end-diastolic volume index, leading to reduced peak stroke volume and cardiac output compared to males.
- Forty percent of the study population were females, highlighting the need for sex-specific analysis.
Conclusions:
- Combined CPET-SE effectively reveals sex-specific exercise physiology in HF patients.
- Female HF patients demonstrate lower exercise capacity due to impaired left ventricular compliance and peripheral oxygen extraction (HFpEF) or reduced cardiac output augmentation (HFmrEF/HFrEF).
- Understanding these sex differences is crucial for optimizing therapeutic strategies and improving clinical outcomes in heart failure.
Background:
We aimed to test the differences in peak VO2 between males and females in patients diagnosed with heart failure (HF), using combined stress echocardiography (SE) and cardiopulmonary exercise testing (CPET).
Methods:
Patients who underwent CPET and SE for evaluation of dyspnea or exertional intolerance at our institution, between January 2013 and December 2017, were included and retrospectively assessed. Patients were divided into three groups: HF with preserved ejection fraction (HFpEF), HF with mildly reduced or reduced ejection fraction (HFmrEF/HFrEF), and patients without HF (control). These groups were further stratified by sex.
Results:
One hundred seventy-eight patients underwent CPET-SE testing, of which 40% were females. Females diagnosed with HFpEF showed attenuated increases in end diastolic volume index (P = 0.040 for sex × time interaction), significantly elevated E/e' (P < 0.001), significantly decreased left ventricle (LV) end diastolic volume:E/e ratio (P = 0.040 for sex × time interaction), and lesser increases in A-VO2 difference (P = 0.003 for sex × time interaction), comparing to males with HFpEF. Females diagnosed with HFmrEF/HFrEF showed diminished increases in end diastolic volume index (P = 0.050 for sex × time interaction), mostly after anaerobic threshold was met, comparing to males with HFmrEF/HFrEF. This resulted in reduced increases in peak stroke volume index (P = 0.010 for sex × time interaction) and cardiac output (P = 0.050 for sex × time interaction).
Conclusions:
Combined CPET-SE testing allows for individualized non-invasive evaluation of exercise physiology stratified by sex. Female patients with HF have lower exercise capacity compared to men with HF. For females diagnosed with HFpEF, this was due to poorer LV compliance and attenuated peripheral oxygen extraction, while for females diagnosed with HFmrEF/HFrEF, this was due to attenuated increase in peak stroke volume and cardiac output. As past studies have shown differences in clinical outcomes between females and males, this study provides an essential understanding of the differences in exercise physiology in HF patients, which may improve patient selection for targeted therapeutics.
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