Gender differences in survival in advanced heart failure - Insights from the FIRST study

Background-Previous natural history studies in broad populations of heart f ailure patients have associated female gender with improved survival, parti cularly in patients with a nonischemic etiology of ventricular dysfunction. This study investigates whether a similar survival advantage for women wou ld be evident among patients with advanced heart failure. Methods and Results-The study analysis is based on the Flolan international Randomized Survival Trial (FIRST) study which enrolled 471 patients (359 m en and 112 women) who had evidence of end-stage heart failure with marked s ymptoms (60% NYHA class IV) and severe left ventricular dysfunction (left v entricular ejection fraction 18+/-4.9%). A Cox proportional-hazards model, adjusted for age, gender, 6-minute walk, dobutamine use at randomization, m ean pulmonary artery blood pressure, and treatment assignment, showed a sig nificant association between female gender and better survival (relative ri sk of death for men versus women was 2.18, 95% CI 1.39 to 3.41; P<0.001). A lthough formal interaction testing was negative (P=0.275), among patients w ith a nonischemic etiology of heart failure, the relative risk of death for men versus women was 3.08 (95% CI 1.56 to 6.09, P=0.001), whereas among th ose with ischemic heart disease, the relative risk: of death for men versus women was 1.64 (95% CI 0.87 to 3.09, P=0.127). Conclusions-Women with advanced heart failure appear to have better surviva l than men. Subgroup analysis suggests this finding is strongest among pati ents with a nonischemic etiology of heart failure.