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Sex Differences in Pharmacotherapy and Long-Term Outcomes in Patients With Ischaemic Heart Disease and Comorbid Left
Misha Dagan1, Diem T Dinh2, Julia Stehli3
1Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia. Electronic address: http://www.twitter.com/misha_dagan.
Insights
Women with heart conditions receive similar guideline-directed medical therapy (GDMT), but less secondary prevention. Adjusted analysis shows no difference in long-term mortality, emphasizing risk factor optimization for women with ischaemic heart disease and LV dysfunction.
Area of Science:
- Cardiology
- Clinical Medicine
- Public Health
Background:
- Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) significantly impact women's health.
- Women often experience delayed diagnosis and reduced access to guideline-directed medical therapy (GDMT) compared to men.
- Understanding sex-based differences in treatment and outcomes is crucial for cardiovascular disease management.
Purpose of the Study:
- To compare the utilization of GDMT and secondary prevention strategies between men and women post-percutaneous coronary intervention (PCI).
- To investigate the association between sex, GDMT, and long-term mortality in patients with reduced LV ejection fraction (<50%).
- To identify factors influencing long-term outcomes in women with IHD and LV dysfunction.
Main Methods:
- Analysis of prospectively collected data from a multicentre registry (2005-2018) involving 13,015 patients with LV ejection fraction <50%.
- GDMT defined as beta-blocker, ACE inhibitor/ARB ± MRA; long-term mortality assessed via Australian National Death Index linkage.
- Comparison of treatment patterns and mortality rates between sexes, with adjusted analyses for confounding factors.
Main Results:
- Women constituted 20% of the cohort, presenting with higher comorbidity rates (hypertension, diabetes, renal dysfunction, stroke, rheumatoid arthritis) and older age.
- GDMT rates were similar between sexes (73% vs 72%), but women received less ACE inhibitor/ARB, statin, and dual antiplatelet therapy.
- Unadjusted long-term mortality was higher in women (25% vs 19%), but adjusted analysis revealed no significant sex-based difference (HR 0.99; 95% CI 0.87-1.14).
Conclusions:
- High rates of GDMT for LV dysfunction were observed in both sexes, yet women were undertreated with secondary IHD prevention.
- The initial higher mortality observed in women was mitigated by adjusted analyses, suggesting baseline risk factors play a significant role.
- Optimizing baseline risk factors in women with IHD and comorbid LV dysfunction is essential to improve long-term cardiovascular outcomes.
Background:
Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) are common among women. However, women tend to present later and are less likely to receive guideline-directed medical therapy (GDMT) compared with men.
Methods:
We analysed prospectively collected data (2005-2018) from a multicentre registry on GDMT 30 days after percutaneous coronary intervention in 13,015 patients with LV ejection fraction <50%. Guideline-directed medical therapy was defined as beta blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker±mineralocorticoid receptor antagonist. Long-term mortality was determined by linkage with the Australian National Death Index.
Results:
Women represented 20% (2,634) of the total cohort. Mean age was 65±12 years. Women were on average >5 years, with higher body mass index and higher rates of hypertension, diabetes, renal dysfunction, prior stroke, and rheumatoid arthritis. Guideline-directed medical therapy was similar between sexes (73% vs 72%; p=0.58), although women were less likely to be on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80% vs 82%; p=0.02). Women were less likely to be on statin therapy (p<0.001) or a second antiplatelet agent (p=0.007). Women had higher unadjusted long-term mortality (25% vs 19%; p<0.001); however, there were no differences in long-term mortality between sexes on adjusted analysis (hazard ratio 0.99; 95% confidence interval 0.87-1.14; p=0.94).
Conclusions:
Rates of GDMT for LV dysfunction were high and similar between sexes; however, women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality in women was attenuated in adjusted analysis, which highlights the need for optimisation of baseline risk to improve long-term outcomes of women with IHD and comorbid LV dysfunction.
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