Heart Failure in Women--Insights from the Framingham Heart Study

Abstract

In the latter half of the 20th century, among participants of the Framingham Heart Study, incidence of heart failure (HF) has declined by about a third in women but not in men and survival after the onset of HF has improved in both sexes; however, HF remains highly lethal with over 50% dying within 5 years after onset of HF. Overall, the 8-year relative risk of HF is 24% lower in women compared with men. The 8-year incidence rates of HF with preserved ejection fraction (HFPEF; EF >45%) and HF with reduced EF (HFREF; EF ≤ 45%) in women and HFPEF in men are similar; however, men have a 2-fold higher cumulative incidence of HFREF than HFPEF. The lifetime risk of HF is about 20% in both women and men at 40, 50, 60, 70, and 80 years of age. Contribution of hypertension and diabetes mellitus to the risk of HF was more prominent in women than in men. Serum levels of several biomarkers were distinctly different in women compared with men and had differential effects on left ventricular structure and function; however, the strength and direction of the association between biomarkers levels and HF risk were generally similar in women and men. In individuals with HF, about two-thirds of the underlying cause of death and about one-half of the immediate cause of death were due to cardiovascular causes. Non-cardiovascular underlying and immediate causes of death were more evident in HFPEF.

Fig. 1

Temporal trends in age-adjusted survival after the onset of heart failure among women (a) and men (b). Values were adjusted for age (<55, 55 to 64, 65 to 74, 75 to 84, and ≥85 years). Estimates are shown for participants who were 65 to 74 years of age. Source: Levy D et al. New Engl J Med. 2002;347:1397–1402

Fig. 2

Cumulative incidence of heart failure with preserved ejection fraction (HFPEF) versus reduced ejection fraction (HFREF) in women (a) and men (b). Source: Ho JE et al. Circulation. Heart failure. 2013;6:279–286

Fig. 3

Cumulative risk for heart failure at selected index ages for women (a) and men (b). Lifetime risk for heart failure for given index age is cumulative risk through age 94 years. Source: Lloyd-Jones DM et al. Circulation. 2002;106:3068–307

Fig. 4

Underlying causes of death in women and men with heart failure according to status of left ventricular ejection fraction. HFREF denotes heart failure with reduced ejection fraction. HFPEF denotes heart failure with preserved ejection fraction. CHD denotes coronary heart disease. CVD denotes cardiovascular disease. Source: Lee DS et al. Circulation. Heart failure. 2011;4:36–43