International Journal of Clinical Medicine, 2011, 2, 254-259
doi:10.4236/ijcm.2011.23040 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)
Gender Effects on Acute Heart Failure
Arnon Blum1*, Rizak Sirchan1, Lital Keinan-Boker2,3
1Department of Medicine, Baruch-Padeh Poria Medical Center, Tiberias, Israel; 2Israel Center for Disease Control, Ministry of
Health, Jerusalem, Israel; 3School of Public Health, University of Haifa, Haifa, Israel.
Received March 10th, 2011; revised April 19th, 2011; accepted May 3rd, 2011.
ABSTRACT
Background: congestive heart failure is the leading cause of hospitalization in the elderly. Little is known about gender
effect on baseline characteristics and in-hospital outcome in patients admitted with acute heart failure. Our purpose
was to study the gender effect on in-hospital mortality in acute heart failure patients. Methods and Results: a prospec-
tive study [143 patients, 67 men (73.9 ± 13.8 years old) and 76 women (77.8 ± 10.1 years old) (p = 0.059)] followed
in-hospital outcome of patients with acute heart failure admitted to the hospital. Clinical parameters included body
mass index (BMI), ankle brachial index (ABI), left ventricular ejection fraction (LVEF), re-admissions within 1 year,
and in-hospital mortality. The gender effects that were studied included height, BMI, smoking, coronary artery disease,
LVEF and mortality: in total, 9 (6.3%) patients died, of them 8 (10.5%) women and 1 (1.5%) man. Women were shorter
(p < 0.001), had a higher BMI (p = 0.053), reported less frequently on current smoking (p < 0.001), had lower preva-
lence of coronary artery disease (p = 0.016), had a better LVEF (p = 0.02), but still, had a higher mortality rate (p =
0.026). The only variables independently affecting in-hospital mortality in women were height and recurrent admissions.
When we tested for the effect of height and recurrent admissions on mortality only among females by a multivariate
analysis height inversely and independently affected in-hospital mortality (p = 0.024), as well as recurrent admissions
(p = 0.031). Conclusions: in-hospital mortality was significantly higher in women compared with men admitted with
acute heart failure. Among females, the only independent variables that affected mortality were low stature and recur-
rent admissions.
Keywords: Gender, Heart Failure, in Hospital Death
1. Introduction
Congestive heart failure (CHF) is the leading cause of
hospitalizations in the elderly. Little is known about
gender differences in baseline characteristics and out-
comes in patients with acute co ng estive h eart failure. Th e
epidemic of cardiovascular disease in women has at-
tained increasing recognition.
The Framingham heart study reported an estimated
prevalence of heart failure of 0.8% in both genders
within the age group of 50 - 59 years. The prevalence
increases notably with advancing age, rising to 6.6% and
7.9% in men and women, respectively, aged 80 - 89
years [1]. A study from Olmsted County, Minnesota, has
evaluated the prevalence of “diastolic” heart failure. In
this survey of the population aged over 45 years, the
overall prevalence of heart failure was 2.2%, 44% of
heart failure cases had preserved systolic function (LVEF
> 50%). The prevalence of diastolic dysfunction was
higher in the older population and in those with a history
of hypertension, diabetes, coronary disease and previous
myocardial infarction. The prevalence of diastolic dys-
function was similar in both genders [2].
According to the Framingham study, the incidence of
heart failure was significantly higher in men compared to
women at all ages, with an age-standardised incidence
ratio of 1.67 [1]. Coronary artery disease was reported as
the etiological factor in 59% of men and 47% of women
for the period 1948- 1988. Va lvular diseas e, hyperten sion,
and diabetes were more common in women than in men
[1].
The incidence and prevalence of heart failure is lower
in women than men at all ages. However, due to the
steep increase in incidence with age, and the larger
population of elderly wo men in the d eveloped wor ld, the
total number of men and women living with heart failure
is similar. Heart failure with preserved systolic function
(“diastolic” dysfunction) is more common in women,
perhaps related to gender differences in the myocardial
response to injury, and the lower prevalence of coron ary

Gender Effects on Acute Heart Failure255
artery disease in women at all ages compared with men
[3].
In this prospective study we addressed some of the
questions that were raised about gender and acute heart
failure during in-hospital stay—clinical characteristics
and in hospital outcome. Our purpose was to study the in
hospital outcome of patients that were admitted with
acute heart failure.
2. Methods
This was a prospective, hospital-based study. The study
population included 143 consecutive patients that were
admitted with acute heart failure to the Medicine Ward
in the Baruch-Padeh Poria Medical Center during the
years 2008-2010.
The inclusion criteria included females and male pa-
tients older than 18 years old with no known chronic or
acute infectious, inflammatory or autoimmune disease.
The exclusion criteria included patients younger than 18
years old, patients who also had an active cancer or an
autoimmune, inflammatory or an infectious disease.
All had an exacerbation of a known heart failure and
were treated accordingly by beta blockers, angiotensin
converting enzyme inhibitors, and diuretics as needed.
On admission, all participants had their weight and
height measured and their body mass index (BMI) was
calculated. Their peripheral artery disease was evaluated
by measuring the ankle-brachial index (ABI); the ab-
dominal circumference served as a proxy for central
obesity, and the cardiac function was evaluated by
measuring the ejection fraction (echocardiography).
In addition, information on clinical parameters like
current smoking (self report), alcohol use, prevalence of
Atrial Fibrillation or other arrhythmias, Diabetes Melli-
tus type II, renal function, Hypertension, documented
Coronary Artery Disease (CAD), and Rheumatic Valvu-
lar Heart Disease (documented by echocardiography)
was collected.
Follow up continued during hospitalization.
The primary end point was to study the gender effect
on in-hospital mortality.
3. Statistical Analysis
Gender differences in categorical variables were as-
sessed by using the Chi-square test, and in continuous
variables, by using the independent sample T-test. Uni-
variate analyses, where in-hospital mortality served as
the dependent variable, were used to identify significant
correlates. Multivariate analyses, using logistic regres-
sion models, were stratified by gender and included
variables that significantly affected in-hospital mortality
in univariate analyses. P-value was set at 0.05, and all
analyses were two-tailed. The analyses were carried out
using the Statistical Package for Social Sciences (SPSS),
version 17.
4. Results
One hundred and forty three acute heart failure patients
were admitted to our Medicine Department. There were
67 men (mean age: 73.9 ± 13.8 years old; range: 23 - 99)
and 76 women (mean age: 77.8 ± 10.1 years old; range:
55 - 96) (p = 0.059). Men tended to report on current
smoking more frequently than women (31 men vs. 6
women; p < 0.001), were taller (mean height: 1.69 ± 0.1
meter vs. 1.58 ± 0.1; p < 0.001), and had a lower BMI
(mean BMI: 28.4 ± 5.9 vs. 30.8 ± 8.7; p = 0.053) (Table
1). Coronary artery disease was more prevalent among
men (42 [68%] vs. 36 [47%] in women; p = 0.016), and
their ejection fraction was lower (48.2 ± 15.7 vs. 55.1 ±
13.9 in women; p = 0.020) (Table 1).
No difference was observed between genders in rela-
tion to prevalence of diabetes mellitus, hypertension,
rheumatic valvular heart disease, abdominal circumfer-
ence and ankle brachial index (Table 1), but women had
a trend towards a higher prevalence of recurrent hospi-
talizations (8[11%] vs. 2[3%], p = 0.078), and a lower
prevalence of peripheral artery disease (ABI less than
0.9, 22[33%] among men, 18[24%] among women; p =
0.224) (Table 1).
There were 8 in-hospital deaths among women and
only 1 in-hospital death among men (p = 0.026) (Table
1). Variables that were significantly associated with
in-hospital mortality included gender (female), recurrent
hospitalizations, height (lower) and weight (lower) (Ta-
ble 2). Age, current smoking, BMI, LVEF, and preva-
lence of comorbidites (atrial fibrillation, diabetes melli-
tus, hypertension, coronary artery disease and valvular
rheumatic heart disease) did not seem to significantly
Table 1. Clinical characteristic s of the study population.
Total Males Femal es
p
-value
Gender 143 (100%) 67 (47%) 76 (53%)
Age 76.1 ± 12.0 73.9 ± 13.8 77.8 ± 10.1 0.059
Weight (Kg) 78.6 ± 20.1 80.9 ± 17.7 76.5 ± 21.8 0.187
Height (M) 1.63 ± 0.1 1.69 ± 0.1 1.58 ± 0.1 <0.001
BMI 29.6 ± 7.6 28.4 ± 5.9 30.8 ± 8.7 0.053
Abd Circ (cm) 108.4 ± 20.9108.3 ± 19.7 108.5 ± 22.00.951
ABI 0.97 ± 0.29 0.98 ± 0.33 0.97 ± 0.24 0.764
Smokers 37 (27%) 31 (50%) 6 (8%) <0. 001
DM type II 77 (56%) 35 (56%) 42 (55%) 0. 889
HTN 119 (86%) 51 (82%) 68 (89%) 0.221
CAD 78 (56%) 42 (68%) 36 (47%) 0.016
RHD 54 (39%) 21 (34%) 33 (43%) 0.253
A. Fibrillation 57 (42%) 24 (39%) 33 (43%) 0.630
LVEF (%) 51.9 ± 15.1 48.2 ± 15.7 55.1 ± 13.9 0.020
Recurrent
Admissions 10 (7%) 2 (3%) 8 (11%) 0.078
In-Hospital Death 9 (6%) 1 (2%) 8 ( 11%) 0.026

Gender Effects on Acute Heart Failure
256
Table 2. Correlates of in-hospital mortality—univariate
analyses.
Variable Mortality+ Mortality–
p
-value
Gender (n = 143)
Males 1 (1.5%) 66 (98.5%) 0.026
Females 8 (10.5%) 68 (89.5%)
Recurrent Hospitalizations (n = 143)
Yes 4 (40%) 6 (60%) <0.001
No 5 (3.8%) 128 (96.2%)
Continuous Variables
Height (M) (n=141) 1.50 ± 0.07 1.63 ± 0.08 <0.001
Weight (Kg) (n=140) 63.00 ± 24.55 79.41 ± 19.61 0.035
affect the outcome.
When stratified by gender, the only significant factor
in men was recurrent hospitalizations (p < 0.001). In
women, significant correlates affecting in-hospital mor-
tality included recurrent hospitalizations (p = 0.009),
low ABI < 0.9 (p = 0.006), and being shorter (p =
0.006).
We used a logistic regression model to assess the in-
dependent effect of each of these variables on in-hospital
mortality in women. Only height (OR = 0.000, 95% CI
0.000 - 0.116, p = 0.024) and recurrent admissions (OR
= 9.290, 95% CI 1.229 - 70.220, p = 0.031) remained
statistically significant (Table 3). The model was not
applied for men since only one man died.
5. Discussion
Of all the cardiovascular diseases, the prevalence of
heart failure is the only one that continues to increase in
the United States [4]. Heart failure affects mainly the
elderl y, the preval ence and incid ence of heart failur e are
expected to increase over the next several decades.
Gender differences in the syndrome of heart failure oc-
cur in etiology and pathophysiology and lead to differ-
ences in the clinical presentation and course of the syn-
drome. Hypertension and diabetes play a major role as
causes of heart failure in women [5]. Major risk factors
for heart failure have been evaluated in the past 50 years
in the Framingham heart study program. Hypertension
carried the largest population-attributable risk factor for
heart failure, underlying 59% of heart failure cases in
women and 39% in men with a hazard ratio of 3.35 in
women and 2.07 in men [6]. A particularly steep in-
crease in the prevalence of hypertension with increasing
Table 3. Logistic regression model to assess the independe nt
effect of each of these variables on in-hospital mortality in
women.
Variable OR 95% CI P-value
Recurrent patient (ref: no) 9.290 1. 22 9 - 70 .2 20 0.031
Height in cm (continuous) 0.000 0.000 - 0.116 0.024
age in women compared with men has also been ob-
served in a European WHO-MONICA cohort [7]. Myo-
cardial cell death, apoptosis, and cellular hypertrophy of
the remaining cells are more pronounced in the male
than in the female myocardium [8,9]. Female patients
with aortic stenosis exhibit relatively less ventricular
dilatation and less myocardial hypertrophy and have
better preserved left ventricular function at a comparable
degree of stenosis than male patients [9].
Adipose tissue produces inflammatory mediators that
increase the risk for cardiovascular disease and diabetes
[10]. Adipocytokines (interleukin-1 β, interleukin 6,
leptin, tumor necrosis factor α) and adiponectin levels
exhibit large sexual dimorphisms. Fat tissue expresses
aromatase, and conversion of testosterone to estrogen by
aromatase is one of the main sources for estrogen in
postmenopausal women [5].
The primary end point of our study was the gender
effect on in-hospital mortality, and the secondary end
points were to study the gender effect on recurrent hos-
pitalizations and peripheral artery disease (measured by
ABI of less than 0.9).
In our study there were much more in-hospital deaths
among women. Variables that were significantly associ-
ated with in-hospital mortality included gender (female
patients), recurrent ho spitalizations, height (lower height
—more deaths), and weight (lower weights—more
deaths). The on ly significant factor in men was recurrent
hospitalizations, while in women increased death rates
were affected by recurrent hospitalizations, peripheral
artery disease (ABI lower than 0.9) and a low stature.
After using a logistic regression analysis only height
remained statistically significant.
A prospective study evaluated gender differences
among 217 patients presenting with acute heart failure to
the emergency department in Switzerland. The primary
end point was all—cause mortality. Women were older
and had less pulmonary co-morbidity, more jugular ve-
nous pressure and higher diastolic blood pressure and
troponin level at presentation; however, the trend toward
lower survival in women seemed primarily related to
higher age rather than gender itself. Female sex was not
found as an independent predictor of long-term mortality
in acute heart failure [11]. Another study (a retrospective
one) did not find any significant gender differences in
the initial presentation, disposition, and diagnostic test-
ing of patients with acute heart failure admitted through
the emergency department [12].
The impact of gender was assessed in the beta blocker
evaluation of survival trial (BEST) which randomized 2
708 patients with NYHA class III/IV and LVEF less
than 35% to bucindolol versus placebo. Significant dif-
ferences in baseline clinical and laboratory characteris-

Gender Effects on Acute Heart Failure257
tics were found. Compared to men, women were
younger, more likely to be black, had a higher preva-
lence of non-ischemic etiology, had higher right and left
ventricular ejection fraction, higher heart rate, greater
cardiothoracic ratio, higher prevalence of left bundle
branch block, lower prevalence of atrial fibrillation, and
lower plasma nor-epinephrine level. Coronary artery
disease and LVEF appeared to be stronger predictors of
prognosis in women; however, in the non-ischemic pa-
tients, women had a significantly better survival rate
compared with men [13].
Obesity could be a factor in prognosis in heart failure
patients; however, studies have shown a better survival
in heart failure patients with decreased LVEF and a
higher BMI compared to those with a lower BMI
[14-19]. Another study has demonstrated an increased
mortality in patients with heart failure and preserved
systolic function and low BMI; however, with a BMI >
45 mortality increased, raising the possibility of a U
shaped relationship between BMI and survival [20]. A
meta-analysis of 9 retrospective studies (mean follow-up
of 2.7 years) found that compared to individuals without
elevated BMI, both overweight and obese patients had a
lower all-cause mortality and also lower cardiovascular
mortality. In a risk-adjusted sensitivity analysis, both
obesity and overweight remained protective against
mortality [21].
In our study a gender effect was observed on BMI;
women had a higher BMI compared with men (30.0 ±
8.7 vs. 28.4 ± 5.9, p = 0.053)—but such an effect should
have been a protective factor according to recent studies
on BMI and weight in patients with heart failure [20, 21],
but in our study obesity and overweight did not serve as
a protective factor against in-hospital mortality and had
no advan tag e for wo men.
Another interesting finding was the gender effect on
height; women were significantly shorter than men with
acute heart failure (1.58 ± 0.1 m vs. 1.69 ± 0.1 m, p <
0.001).
An autopsy Finish study evaluated coronary athero-
sclerosis among 599 females that died a sudden death
and found that 50% of women over 41 years old had
coronary lesions, 32% in women from 31 to 40 years,
17% in women from 21 to 30, and 6% in women under
20 years. Coronary atherosclerosis was correlated with
short stature as well as with BMI and abdominal fat [22].
A retrospective meta-analysis assessed the relationship
between short stature and coronary heart disease from 52
studies (3,012,747 individuals). The short ones were
below 160.5 cm and the tall ones over 173.9 cm on av-
erage. Among the shortest height category, the relative
risks were 1.35 for all-cause mortality, 1.55 for all car-
diovascular disease mortality, 1.49 for coronary heart
disease, and 1.52 for myocardial infarction when com-
pared with those within the highest height category.
Short stature was associated with increased cardiovas-
cular morbidity and mortality in both genders. No gen-
der effect was observed in this study. Only height was
the independent parameter that affected death [23]. On
the other hand, a prospective study of women hospital-
ized with acute coronary event (292 Swedish women,
aged 65 years or younger, follow-up 4.8 years) found
that independent of the confounding effects of other risk
factors of clinical importance for CHD the shortest 25%
of women (<160 cm) had a 2.1-fold increased rate of
developing adverse cardiac events compared with the
tallest 25% (>165 cm) [24].
To examine the influence of race and gender on hos-
pital outcome for patients with congestive heart failure a
retrospective study examined records on all 1995 New
York State hospital discharges assigned ICD-9-CM
codes indicative of this diagnosis. It was found that
45,894 patients (black women, 4750; black men, 3370;
white women, 21,165; white men, 16,609) had were
admitted with congestive heart failure. Blacks under-
went noninvasive cardiac procedures more often than
whites; procedure and specialty use rates were lower
among women than among men. After adjusting for
other patient characteristics and hospital type and loca-
tion, we found race to be an important determinant of
length of stay in the hospital (black, 10.4 days; white,
9.3 days; p = 0.0001), hospital charges (black, $13,711;
white, $11,074; p = 0.0001), mortality (black-to-white
odds ratio = 0.832; p = 0.003), and readmission
(black-to-white odds ratio = 1.301; p = 0.0001). Gender
was an important determinant of length of stay (women,
9.8 days; men, 9.2 days; p = 0.0001), hospital charges
(women, $11,690; men, $11,348; p = 0.02), and mortal-
ity (women-to-men odds ratio = 0.878; p = 0.0008). The
conclusion of that study was that race and gender affect
care process and hospital-based case outcomes for pa-
tients with CHF [25].
6. Conclusions
Our study has demonstrated a gender effect on in-hospi-
tal mortality among acute heart failure patients. The only
epidemiological data that could help explain our results
are studies that have demonstrated a link between short
stature and cardiovascular morbidity and mortality. Our
female population was about 10 cm shorter compared
with men, and this significant difference may explain our
results.
The novelty of our study was that it was a prospective
study that evaluated gender effect on in-hospital mortal-
ity in patients admitted with acute heart failure—unlike
any other study that examined these specific parameters

Gender Effects on Acute Heart Failure
258
in patients admitted with acute heart failure.
7. Study Limitation
The small sample size is limiting our ability to have
definite conclusions. We believe that by enlarging the
population of heart failure patients we will be able to
have more solid conclusions. Our plan is to continue
with this study and to recruit many more patients with
acute heart failure.
8. Conflict of Interest Disclosures
NONE for all authors.
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