In a recent study published in Open European Heart Journala group of researchers investigated the effect of sex on cardiac magnetic resonance (CMR) estimation of left ventricular filling pressure (LVFP) in the diagnosis of heart failure (HF).
Record
There is a critical need for distinct strategies to improve the diagnosis and treatment of heart disease in women. Heart failure is a growing global health problem, with more than 64 million people affected.
Women suffer disproportionately from heart failure with preserved ejection fraction (HFpEF) due to factors such as aging and hypertension. The ejection fraction (EF) method of classifying HF has limitations, leading to fewer treatment options for HFpEF compared to HF with reduced EF (HFrEF). Women are less likely to receive HF-specific care or optimally guided therapy, resulting in poorer quality of life.
Gender differences in cardiac imaging and biomarkers have been noted. CMR-derived pulmonary capillary wedge pressure (PCWP) shows prognostic utility, but current noninvasive methods require improvement. Further research is needed to improve gender-specific diagnostic models and improve the accuracy and effectiveness of the diagnosis and treatment of heart failure in women.
About the study
The present study diagnosed heart failure in participants based on European Society of Cardiology guidelines, which require symptoms such as dyspnea, clinical signs such as peripheral edema, and evidence of cardiac dysfunction.
Two cohorts were included: an origin cohort from the Assessing the Spectrum of Pulmonary Hypertension Identified at a Referral Center (ASPIRE) registry in Sheffield, United Kingdom (UK) and a validation cohort from Leeds, UK.
The ASPIRE registry included patients with suspected pulmonary hypertension who underwent imaging and right heart catheterization (RHC) within 24 hours. The validation cohort included patients with newly diagnosed heart failure recruited between 2018 and 2020 and evaluated by CMR.
Interventional studies used a thermodilution catheter to record PCWP. CMR studies included acquisition of cine images with General Electric High Definition X (GE HDx) and Siemens Magnetom Prisma scanners. Blank image analysis was performed using GE Advantage Workstation and Circle Cardiovascular Imaging version 42 (cvi42) software. Cardiac volumes, left ventricular mass (LVM) and peak left atrial volume (LAV) were calculated.
The derivation cohort included 835 subjects, and a sex-specific CMR-derived PCWP equation was developed. The validation cohort, consisting of 434 individuals, applied this equation.
Outcomes were assessed for major adverse cardiovascular events (MACE) and heart failure hospitalization. Statistical analysis included t-test, X-test2 tests, multivariate regression, Receiver Operating Characteristic (ROC) analysis and Kaplan–Meier and Cox models. Statistical significance was set at P < 0.05.
Study results
In the study, the origin cohort included 835 participants, 60% of whom were women. Mean age was similar between sexes (66 ± 13 years, P = 0.84). Females had significantly lower mean body surface area (BSA) than males (1.8 ± 0.2 vs. 2.0 ± 0.2 m², P < 0.0001) and higher systolic blood pressure (146 ± 28 vs. 140 ± 24 mmHg, P < 0.001). Women also had a slightly higher mean heart rate than men (72 ± 15 vs 70 ± 16 bpm, P = 0.02) and had a lower prevalence of COPD (9% vs 15%, P = 0.005). HFpEF was more common in women than in men (62% vs 40%, P <0.001), whereas men had more heart failure with mid-range EF (7% vs 2%, P <0.001). There was no significant difference in intraoperative mean PCWP between women and men (14.0 ± 6 vs. 13.7 ± 6 mmHg, P = 0.52).
In CMR assessment, women had lower left ventricular end-diastolic volume (LVEDV) and left ventricular end-diastolic volume (LVESV), resulting in smaller left ventricular volume (LVSV) and higher left ventricular ejection fraction (LVEF) than men. Males showed higher LVM and LAV. In the right ventricle (RV), females had lower right ventricular end-diastolic volume (RVEDV), right ventricular end-diastolic volume (RVESV) and right ventricular stroke volume (RVSV), but higher total right ventricular ejection fraction (RVEF). Overall CMR-derived PCWP values were significantly higher in men (14.7 ± 4.0 vs. 13.0 ± 3.0 mmHg, P < 0.001) compared with women.
Gender, LAV, and LVM were used as input variables in stepwise multivariate regression to develop a CMR-derived PCWP equation, with age as a weighted variable. The unindexed equation was chosen for better goodness of fit (R-value 0.571) compared to the indexed values. Internal cross-validation showed that the new model for gender maintained its independent association with invasively measured PCWP, whereas the general CMR-derived model did not (beta = 1, standard error = 0.005, P < 0.0001, partial r = 0.57). The general equation underestimated PCWP in women and overestimated it in men, while the sex-specific CMR equation showed no significant difference compared with invasive assessment.
During a mean follow-up of 2.4 ± 1.2 years in the validation cohort, 56 patients (12.3%) experienced MACE. Multivariable Cox proportional hazard regression showed that only the sex-specific model was independently associated with MACE (beta = 0.92, standard error = 0.23, P = 0.001, HR 2.5, 95% CI 1.4–4, 3). Kaplan-Meier analysis confirmed that sex-derived CMR PCWP predicted MACE (X2 = 11.4, P = 0.0007). CMR-derived PCWP remained predictive of MACE and HF hospitalizations, independent of LVEF, across all HF classifications.
conclusion
This study demonstrated that a sex-specific LVFP CMR model improves the accuracy of PCWP estimation and enhances prognostic performance in patients with heart failure.
