Heart failure affects 5,1 million people in the united states, and almost half are

women. In 2010, 32,847 deaths in women were due to heart failure, which accounted
for more deaths in women than in men. The prevalence of heart failure increases with
age, with more women than men having heart failure after 79 years of age. Although
the lifetime risk for the development of heart failure in a 40 year old individual is not
different between the sexes, the lifetime risk for the development of heart failure in a
40 years old individual without a preceding myocardial infarction is 1 in 6 for women
versus 1 in 9 for men.

The risk factors associated with heart failure and its underlying pathophysiology
differ by sex. Women with heart failure have more hypertension, valvular heart
disease and thyroid disorders than men do but are less likely to have obstructive
coronary artery disease. Even though obstructive coronary artery disease is less
frequent in women, it is a stronger risk factors in women include cardiac toxicity from
the chemotherapeutic drugs used for the treatment of breast cancer and peripartum
cardiomyopathy. Women with acute decompensated heart failure are twice as likely
as men to have preserved left ventricular function or heart failure with a preserved
ejection fraction. Even women with an impaired left ventricular ejection fraction will
have a higher left ventricular ejection fraction than men do. Notably, women with
heart failure have a lower quality of life, lower depression. Nonetheless, overall
survival is better for women than for men with heart failure. This finding not only
results from women having more heart failure with a preserved ejection fraction
because mortality rates from heart failure do not relate to preserved or impaired
ejection fraction in either sex, altough those with ischemic cardiomypathy have a
worse prognosis.

Peripartum cardiomyopathy

Peripartum cardiomyopathy cause impaired left ventricular ejection fraction in

the last month of pregnancy or within 5 months postpartum, with no preexisting
cardiac disease and no identifiable cause. Its incidence is estimated to be 1 in 4000
pregnancies, and it is associated with certain risk factors, including advanced maternal
age, african descent, high parity, twin pregnancy, use of tocolytics and poverty. After
the diagnosis left ventricular ejection fraction recovers in approximately half within 6
months, but 20% deteriorate and either die or require heart transplantation. Recovery
appears to be related to a less severe decline in left ventricular ejection fraction. The
risk during subsquent pregnancies is not entirely clear, but in a retrospective analysis
of 44 patients with peripartum cardiomyopathy in a preceding pregnancy, left
ventricular ejection fraction declined in the next pregnancy both in those who had
recovered left ventricular function and in those with persistent impairment of left
ventricular ejection fraction.

Diagnosis gagal jantung

In terms of diagnosing acute heart failure, the studies of left ventricular

dysfunction demonstrated that women with an impaired systolic left ventricular
ejection fraction were more likely than men to have edema, elevated jugular venous
pulsation and an s3 gallop. In contrast, acute decompensated heart failure national
registry showed no sex diferrences in the initial signs and symptoms of acute heart
failure and the study included 54,674 women, who accounted for more than half of
the number in the registry. The differences in this study versus othes may be related to
how acute decompensated heart failure national registry was specifically looking at
acute decompensated heart failure rather than chronic symptoms. There is a sex
differences in the biomarker brain natriuretic peptide, which is used to diagnose heart
failure. Baseline brain natriuretic peptide values are higher in women than in men, but
brain natriuretic peptide higher than 500 pg/mL appears to be a stronger predictor of
death in women with heart failure than in men. Further studies are needed to delineate,
understand and use sex differences in these biomarkers.

Terapi gagal jantung

Treatment of heart failure may benefit both sexes esqually, but the
underrepresentation of women in heart failure trials and the more prevalent heart
failure with a preserved ejection fraction in women contribute to our lack of evidance
regarding treatment of heart failure in women. The candesartan in heart failure :
Assesment of reduction in mortality and morbidity trials, along with others, showed
that women were more likely to have preserved left ventricular function 50% than
men were 35%. Overall, evidence base heart failure therapies are underused in both
sexes, and although women are less likely than men to received them, this disparity
did not translate into a higher rate of hospitalization for heart failure or mortality.
Women are less likely to receive vasoactive agent, but men and women have equal
length of hospitalization and age adjusted in hospital heart failure mortality rate.

Primary and secondary prevention of sudden cardiac death in heart failure with
the use of implantable cardioverter defibrilator devices demonstrate sex differences.
Cairdioverter defibrilator devices are underuse in both sex. Particularly so in women.
Eligible women, especially black women are less likely than men to receive a
cardioverter defibrilator devices. Cardioverter defibrilator devices use increase
overtime, and the racial diparities disappear by 2009, but the sex disparities have
persisted none of the randomized trials for cardioverter defibrilator devices and rolled
sufficient numbers of women to permit analysis of sex differences. All studies to date
are underpowered to detect sex differences, but cardioverter defibrilator devices do
not clearly demonstrate a mortality benefit in women. Women have similiar
implantation rate but they also have greater complication rate both at 45 days and 1
year. Although there were no sex differences in mortality. Early complication
consisted of lead repositioning in men and lead replacement in women, and late
complication for both sexes included pocket infection and electrical strorm. In
addition women were less likely to receive appropriate therapy via shock or
antitachycardia pacing than men were. These differences may result from sex
differences in body size. Delay evaluation in women or simply innate differences in
respons to disease.

Cardiac resynchronization therapy is of benefit in both women and men with

heart failure and wide QRS complex. In the comparizon of medical therapy pacing
and defibrilation in heart failure study, women who underwent cardiac
resynchronization therapy had a greater reduction in the combined endpoint of total
mortality of hospital stay fo any cause than death women receiving jsut medical
therapy. Although few studies have reported any specific data, these same findings
have been confirmed in aretrospective analysis of the cardiac resynchronization heart
failure study.

Cardiac transplantation

Heart transplantation occures far less frequently in women than in men, with only
28% of heart transplant in the United State in 2011 occuring in women. This may
result from the older age of women with heart failure and differences in choices
related to transplantation. Survival after transplantation does appeared to be slightly
worse in women than in men, with the survival gap increaseng slightly with time.

Aritmia and sudden cardiac date

Important sex differences in cardiac electrophysiology have an impact on

arhytmia and sudden cardiac death. Starting women have higher resting heart rates
than men do. They also have longer QT intervals and a greater risk for drug induced
torsade the pointes. TABEL 77-2 depicts sex differences in this supraventricular
tachycardia. Atrioventricular nodal reentrant tachycardia is twice as common in
women as in men. In contrast to atrioventricular reentrant tachycardia, as seen in wolf
parkinson wide syndrome, which is more common in men. When coompare with men,
women with atrial fibrilation have a higher risk for stroke are less likely to received
anticoagulation and ablation procedur. Women have an overall lowe risk for sudden
cardiac death are less likely to have obstructive coronary artery disease at the time of
sudden cardiac death.

Prevention of cardiovascular disease

Guideline for prevention of cardiovascular disease in women are based on the

effectiveness based guidline for the prevention of cardiovascular disease in women
2011 update: a guideline from the American Heart Association and the 2013 ACC/AH
guideline on the assesment of cardiovascular risk, which rely on evidence base studies
but also include “real world” observation. Women with a ten year predicted risk for
cardiovascular disease of 7,5% or greater are now considered eligible for statin lipid
lowering therapy. Prior women specific guidelines suggest that women with a 10% or
greater risk are consider rate high risk. Lifestyle recomendation are part of any
cardiovascular disease prevention strategy for women and include specific exercise
recommendation. Current guideline encourage at least 150 minutes of moderate
exercise on 75 minute of vigorous exercise per week. In addition the guidline
emphasize greater cardiovascular disease benefit with more exercise and death
women who need to lose weight should accumulate a minimum of 60 to 90 minutes of
at least moderate intensity psysical activity on most and preverably all days of the
week. Women are adiviced to sustain areobic activuty at least 10 minutes. During
each exercise session. Resistance and straightening exercise at least 2 days per week
are also recomended for all women. Along with exercise the guidelines give specific
dietary recomendation for all women base on the diatery approaches to stop
hypertension diet. These recomendation include fruit and vegetable 4,5 cups per day,
fiber 30gram per day ; whole grains, 3 servings per day ; sugar 5 or fewer servings per
week ; nuts 4 serving or more per week ; saturated fat, less than 7% of total energy
intake ; cholesterol, less than 150 mg per day ; and sodiom, less than 1500 mg per day.
Women are advised to consume 2 servings of oily fish per week. The guideline advise
that women should not smoke and should avoid environmental tobacco smoke. These
guideline recommend aspirin therapy (75 to 325 mg/ day) for high risk women with
coronary heart disease are less contraindicated. Aspirin at the same dose range is
reasonable in women with diabetes mellitus. If a high risk women has an indication
for but is intolerance of aspirin therapy, clopidogrel should be substituted. Aspirin is
useful for primary prevention in women 65 years or older (81mg daily or 100mg
every other day). if blood control to reduce the risk for ischemic stroke. It may be
reasonable to consider aspirin therapy in women younger than 65 year for prevention
of ischemic stroke if they have high risk for stroke. Figure 77-6 outline the guidline
for primary and secondary prevention of cardiovascular disease. This algorhytm
includes specific recommendation for prevention of stroke in women with atrial
fibrilation.

Certain specific therapy list as class III intervention, are advised against, either as
a result of no demonstrated benefit of effectiveness or when the risk outweigh any
potential benefit. Such treatment includes hormon replacement therapy outside the
indication for menopausal symptoms, antioxidant vitamin supplement, folic acid
supplement, and routine use of aspirin in healthy women younger than 65 years.

Cardiac rehabilitation reverse to coordinated, multifaceted intervention designed

to optimized a cardiac patient physical, psychological, and social functioning, in
addition to stabilizing, slowing or event reversing the progression of the underlying
atherosclerotic processes. Cardiac rehabilitation consistently improves objective
measure of functional capacity, decreases anginal symptoms, facilitates reduction of
risk for cardiovascular disease, and improves psychosocial well being in both sexes.
This intervention also improves quality of life and medication compliance and reduce
morbidity and mortality. Cardiac rehabilitation is underused in United State with an
estimated participation rate of just 10% to 20% of eligible patient with women
particularly being underrefered and less likely to complete cardiac rehabilitation even
if they enroll.

Conclusion

The sex and gender differencess in cardiovascular disease epidemiology, clinical

features, therapies, and outcomes reviewed in this chapter highlight several reasons
why all practitioners should remain cognizant of these disparities and strive to
overcome them. The information should arm health care providers to diagnose
cardiovascular disease in women more effectively and to provide evidenced based
management strategies for both sexes