Treatment and Diagnosis of Valvular Heart Disease Should Be Gender-specific
Key findings
- Although no gender differences exist in the prevalence of valvular heart disease, important sex differences exist in the diagnosis, treatment and outcomes
- Women with severe mitral regurgitation have unique valvular pathology, present with more advanced disease and suffer from delayed referral for surgical interventions with less favorable outcomes
- Women are more likely than men to have high-risk phenotypes of aortic stenosis, however, they have a more favorable prognosis and improvement in mortality after transcatheter aortic valve replacement
- All women with suspected or diagnosed valvular heart disease should undergo preconception planning by a multidisciplinary team and specialty care throughout pregnancy
- Future clinical guidelines should address known gender differences to help guide the timely diagnosis and treatment of the growing population of women with valvular heart disease
Valvular heart disease, which affects 2.5% of the U.S. population, can be the primary driver of ventricular dysfunction and heart failure (HF). The most common valvular lesions in the U.S., mitral regurgitation and aortic stenosis, are equally prevalent in women and men, but there are important gender differences in their management.
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In an issue of Heart Failure Clinics that is devoted to heart failure in women, Daniela R. Crousillat, MD, and Malissa J. Wood, MD, co-director of Massachusetts General Hospital's Corrigan Women's Heart Health Program, review gender differences in the diagnosis and treatment of mitral regurgitation (MR), aortic stenosis (AS) and tricuspid regurgitation (TR), and discuss the management of valvular heart disease in pregnancy.
Mitral Regurgitation
Overall, women present with less severe MR than men do, the authors explain, but they have unique challenges to routine mitral valve (MV) repair. These include increased leaflet thickening, anterior or bileaflet MV prolapse, a higher prevalence of MV calcification and a predilection for rheumatic MV disease.
Because of the absence of indexed values for size and the prevalence of smaller left ventricular dimensions among women, echocardiographic parameters often underestimate the severity of MR in women.
For that reason and because of their atypical presentation, women with severe MR who undergo surgery are usually at higher risk than men are because by the time they are referred, they are older and have more comorbid conditions including atrial fibrillation and HF.
Dr. Crousillat and Dr. Wood suggest considering cardiac magnetic resonance imaging for patients, particularly women, whose symptoms and echocardiographic findings are discordant. However, as with echocardiography, no sex-specific guidelines exist for a referral to MV intervention.
For some individuals with MR, a new treatment option that is effective in women is a transcatheter edge-to-edge MV leaflet coaptation clip. It is approved in the U.S. for patients with severe, symptomatic degenerative MR who are not candidates for surgery, and a recent observational study found no gender differences in outcomes. The treatment option has recently shown similar efficacy in the treatment of symptomatic heart failure with moderate to severe secondary MR.
Aortic Stenosis
Women with AS tend to present for treatment later in the disease course than men do, Drs. Crousillat and Wood state. In general, they have higher rates of symptomatic HF and concomitant moderate to severe MR than men do, and they are more likely to have paradoxical low-flow, low-gradient AS, a higher-risk phenotype.
Because of the technical limitations of echocardiography, the latest research is focusing on multidetector computed tomography (MDCT). The degree of aortic valve load by MDCT is now known to correlate well with the echocardiographic severity of AS, and gender-specific calcium scores have been defined for diagnosis of AS.
However, the American Heart Association/American College of Cardiology (AHA/ACC) has not yet incorporated MDCT into its guidelines because of the need for more definitive evidence.
The use of transcatheter aortic valve replacement (TAVR) is also on the rise, and women represent half of the patients who undergo the procedure in the U.S. Multiple studies have shown improved survival after TAVR, compared with surgical aortic valve replacement (SAVR), in women. However, the optimal strategy for women remains to be determined, Dr. Crousillat and Dr. Wood say.
Tricuspid Regurgitation
TR is particularly frequent in women. Tricuspid valve interventions are still associated with higher rates of morbidity and mortality, compared with left-sided valvular interventions, and are rarely performed for isolated TR.
According to Dr. Crousillat and Dr. Wood, the emerging transcatheter treatment options for severe TR make it essential that research defines perioperative risk factors and optimal surgical timing for both sexes.
Pregnancy and Valvular Heart Disease
The hemodynamic changes accompanying pregnancy increase the risk of HF in women who have advanced valvular heart disease. Women with severe, stenotic left-sided lesions are at the highest risk of developing HF and having poor maternal and neonatal outcomes. The authors emphasize the guidance from the ACC, which recommends that all women with suspected or diagnosed valvular heart disease should undergo preconception planning by a multidisciplinary team and have specialty care throughout pregnancy.
Better Guidelines Needed
The prevalence of HF among women is increasing rapidly, the authors say in conclusion. Gender-specific guidelines for timely diagnosis and referral of women would go a long way toward mitigating their risks