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      Sex Differences in Comorbidity, Therapy, and Health Services’ Use of Heart Failure in Spain: Evidence from Real-World Data

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          Heart failure (HF) is becoming increasingly prevalent and affects both men and women. However, women have traditionally been underrepresented in HF clinical trials. In this study, we aimed to analyze sex differences in the comorbidity, therapy, and health services’ use of HF patients. We conducted a cross-sectional study in Aragón (Spain) and described the characteristics of 17,516 patients with HF. Women were more frequent (57.4 vs. 42.6%, p < 0.001) and older (83 vs. 80 years, p < 0.001) than men, and presented a 33% lower risk of 1-year mortality ( p < 0.001). Both sexes showed similar disease burdens, and 80% suffered six or more diseases. Some comorbidities were clearly sex-specific, such as arthritis, depression, and hypothyroidism in women, and arrhythmias, ischemic heart disease, and COPD in men. Men were more frequently anti-aggregated and anti-coagulated and received more angiotensin-converting-enzyme (ACE) inhibitors and beta-blockers, whereas women had more angiotensin II antagonists, antiinflammatories, antidepressants, and thyroid hormones dispensed. Men were admitted to specialists (79.0 vs. 70.6%, p < 0.001), hospital (47.0 vs. 38.1%, p < 0.001), and emergency services (57.6 vs. 52.7%, p < 0.001) more frequently than women. Our results highlight the need to conduct future studies to confirm the existence of these differences and of developing separate HF management guidelines for men and women that take into account their sex-specific comorbidity.

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          Most cited references 41

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          Heart failure: preventing disease and death worldwide

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            Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure.

            We studied the impact of noncardiac comorbidity on potentially preventable hospitalizations and mortality in elderly patients with chronic heart failure (CHF). Chronic HF disproportionately affects older individuals, who typically have extensive comorbidity. However, little is known about how noncardiac comorbidity complicates care in these patients. This was a cross-sectional study of 122,630 individuals age >/=65 years with CHF identified through a 5% random sample of all U.S. Medicare beneficiaries. We assessed the relationship of the 20 most common noncardiac comorbidities to one-year potentially preventable hospitalizations and total mortality. Preventable hospitalizations were determined by admissions for ambulatory care sensitive conditions using predefined criteria. Sixty-five percent of the sample had at least one hospitalization, of which 50% were potentially preventable. Exacerbations of CHF accounted for 55% of potentially preventable hospitalizations. Nearly 40% of patients with CHF had >/=5 noncardiac comorbidities, and this group accounted for 81% of the total inpatient hospital days experienced by all CHF patients. The risk of hospitalization and potentially preventable hospitalization strongly increased with the number of chronic conditions (both p < 0.0001). After controlling for demographic factors and other diagnoses, comorbidities that were associated consistently with notably higher risks for CHF-preventable and all-cause preventable hospitalizations, and mortality, included chronic obstructive pulmonary disease/bronchiectasis, renal failure, diabetes, depression, and other lower respiratory diseases (all p < 0.01). Noncardiac comorbidities are highly prevalent in older patients with CHF and strongly associate with adverse clinical outcomes. Cardiologists and other providers routinely caring for older patients with CHF may improve outcomes in this high-risk population by better recognizing non-CHF conditions, which may complicate traditional CHF management strategies.
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              Trends in comorbidity, disability, and polypharmacy in heart failure.

              Comorbidity, disability, and polypharmacy commonly complicate the care of patients with heart failure. These factors can change biological response to therapy, reduce patient ability to adhere to recommendations, and alter patient preference for treatment and outcome. Yet, a comprehensive understanding of the complexity of patients with heart failure is lacking. Our objective was to assess trends in demographics, comorbidity, physical function, and medication use in a nationally representative, community-based heart failure population. Using data from the National Health and Nutrition Examination Survey, we analyzed trends across 3 survey periods (1988-1994, 1999-2002, 2003-2008). We identified 1395 participants with self-reported heart failure (n=581 in 1988-1994, n=280 in 1999-2002, n=534 in 2003-2008). The proportion of patients with heart failure who were ≥80 years old increased from 13.3% in 1988-1994 to 22.4% in 2003-2008 (P <.01). The proportion of patients with heart failure who had 5 or more comorbid chronic conditions increased from 42.1% to 58.0% (P <.01). The mean number of prescription medications increased from 4.1 to 6.4 prescriptions (P <.01). The prevalence of disability did not increase but was substantial across all years. The phenotype of patients with heart failure changed substantially over the last 2 decades. Most notably, more recent patients have a higher percentage of very old individuals, and the number of comorbidities and medications increased markedly. Functional disability is prevalent, although it has not changed. These changes suggest a need for new research and practice strategies that accommodate the increasing complexity of this population. Copyright © 2011 Elsevier Inc. All rights reserved.

                Author and article information

                Int J Environ Res Public Health
                Int J Environ Res Public Health
                International Journal of Environmental Research and Public Health
                23 March 2020
                March 2020
                : 17
                : 6
                [1 ]Research Group on Heart Failure, IIS Aragón, Internal Medicine Service, Hospital General de la Defensa, 50009 Zaragoza, Spain; agraciagut@
                [2 ]EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, REDISSEC, Miguel Servet University Hospital, 50009 Zaragoza, Spain; bpoblador.iacs@ (B.P.-P.); sprados.iacs@ (A.P.-T.)
                [3 ]Research Group on Heart Failure, Faculty of Medicine, Internal Medicine Service, Lozano Blesa University Hospital, 50009 Zaragoza, Spain; fruizl@
                Author notes
                [* ]Correspondence: agimenomi.iacs@ ; Tel.: +34-976-765-500 (ext. 5375)

                These authors contributed equally to this work and served as senior co-authors.

                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (


                Public health

                heart failure, epidemiology, comorbidity, medication, health services use, gender, sex


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