Characteristics, management, and outcomes in women and men with congestive heart failure in 40 countries at different economic levels: an analysis from the Global Congestive Heart Failure (G-CHF) registry

BackgroundThere is a paucity of data on the clinical characteristics, management, and outcomes of women compared with men with heart failure in low-income and middle-income countries compared with high-income countries. We examined sex differences in risk factors, clinical characteristics, and treatments, and prospectively assessed the risk of heart failure hospitalisation and mortality in patients with heart failure in 40 high-income, middle-income, and low-income countries. MethodsParticipants aged 18 years or older with heart failure were enrolled from Dec 20, 2016, to Sept 9, 2020 in the prospective Global Congestive Heart Failure (G-CHF) study from 257 centres in 40 high-income, middle-income, and low-income countries. Participants were followed up until May 25, 2023. We recorded the demographic characteristics, medical history, and treatments of participants. We prospectively recorded data on heart failure hospitalisation and mortality by sex in the overall study, according to country economic status, and according to level of left ventricular ejection fraction (LVEF). Findings23341 participants (9119 [39 center dot 1%] women and 14222 [60 center dot 1%] men) were recruited and followed up for a mean of 2 center dot 6 years (SD 1 center dot 4). The mean age of women in the study was 62 years (SD 17) compared with 64 years (14) in men. Fewer women than men had an LVEF of 40% or lower (51 center dot 7% women vs 66 center dot 2% men). By contrast, more women than men had an LVEF of 50% or higher (33 center dot 2% women vs 18 center dot 6% men). Hypertensive heart failure was the most common aetiology in women (25 center dot 5% women vs 16 center dot 8% men), whereas ischaemic heart failure was the most common aetiology in men (45 center dot 6% men vs 26 center dot 6% women). Signs and symptoms of congestion were more common in women than men: 42 center dot 6% of women had a New York Heart Association functional class of III or IV compared with 37 center dot 9% of men. The use of heart failure medications and cardiac tests did not differ systematically between the sexes, although implantable cardioverter defibrillator (ICD) implantation was lower among women than men (8 center dot 7% women vs 17 center dot 2% men). The adjusted risk of heart failure hospitalisation was similar in women and men (women-to-men adjusted hazard ratio [HR] 0 center dot 99 [95% CI 0 center dot 92-1 center dot 05]). This pattern was consistent within groups of countries categorised by economic status, geographical region, and by LVEF level. However, women had a lower adjusted risk of mortality (women-to-men adjusted HR 0 center dot 79 [95% CI 0 center dot 75-0 center dot 84]) despite adjustments for prognostic factors-a pattern which was consistently observed across groups of countries irrespective of economic status, geography, and LVEF levels of patients. InterpretationThe underlying cause of heart failure and ejection fraction phenotype differ between women and men, as do the severity of symptoms. Heart failure treatments (except ICD use) were not consistently in favour of one sex. Paradoxically, while the rates of hospitalisations were similar among women and men, the risk of death was lower among women. These patterns were consistent regardless of the economic status of the countries. The higher mortality among men is unexplained and warrants further study