Background:
Despite recent advantages in therapy, chronic heart failure (HF) is still associated with high morbidity and mortality.

Purpose:
This study assessed the impact of sex on clinical presentation and outcomes in patients with advanced stages of heart failure.

Methods:
In total, 381 patients with advanced HF referred to a specialized outpatient clinic of a tertiary care hospital were prospectively enrolled from August 2015 until March 2018. Clinical characteristics, functional status measures (NYHA class and 6-minute walk test), cardiac and non-cardiac comorbidities (such as diabetes, hypercholesterolemia, prior transient ischemic attack/ischemic stroke, peripheral artery disease, chronic renal failure and COPD), echocardiographic measurements as well as current HF medication and device therapy (implantable cardioverter defibrillator and cardiac resynchronization therapy) were assessed at baseline. Age-adjusted Cox regression analyses in males vs. females were performed for all-cause mortality and, representing severe disease progression, a combined endpoint ‘death from any cause, heart transplantation or left ventricular assist device implantation'.

Results:
78.7% of included patients were male. Age, clinical characteristics (BMI, systolic blood pressure), type of cardiomyopathy, comorbidities, functional measures and echocardiographic parameters, as well as guideline-recommended medication and device therapy did not differ markedly between males and females (Table).
In a median follow-up of 3.3 years, 49 patients died, 14 patients underwent LVAD implantation and 6 patients heart transplantation; 25 patients were lost to follow-up. All-cause mortality was higher in males than females (3-year mortality 15.6% vs. 5.5%, p=0.061) with an age-adjusted hazard ratio of 2.98 (95% confidence interval 1.07-8.30, p=0.036). The combined endpoint was more often reached in males than females (20.0% vs. 6.9%, p=0.024, Figure).

Conclusion:
Male patients with advanced heart failure had a higher risk of death or cardiac replacement therapy than women. Sex differences in HF are a complex and multi-facetted issue, but the observed outcomes might suggest relevant differences in HF treatment response.