Heart failure affects 26 million people globally. It is a leading cause of hospitalisations and early deaths and a major economic burden, making up 1-2% of the NHS budget. A common cause is dilated cardiomyopathy, a heart muscle condition that affects up to 1 in 250 people, or 240,000 people in the UK. Unfortunately, despite best treatment, mortality for this relatively young population (median age 40) remains high. We urgently need to improve how we care for patients with this condition.
Biological sex (being male or female) may play a critical role in disease. My research shows that:
(i) Dilated cardiomyopathy affects twice as many men as women. Either men are more at risk or women are protected.
(ii) The hearts of men and women with dilated cardiomyopathy differ - women have smaller hearts and better heart function.
(iii) Women get twice as many complications after the age of 50 whilst men have the same number of complications regardless of age. This suggests that women are more at risk of complications despite a 'milder' disease and this risk increases after menopause.
Despite these observations, we currently treat men and women exactly the same.
Women experience a number of unique life events linked to major hormonal changes such as menopause. However, we do not know the impact of menopause on dilated cardiomyopathy or its complications. Determining how and why dilated cardiomyopathy differs in men and women will help us to make sense of the range of health outcomes that patients experience.
Background: Dilated cardiomyopathy is a leading cause of heart failure, affects up to 1/250 people, and has a 20% 5 year mortality. The contribution of biological sex is poorly understood.
Aim: To evaluate the impact of menopause on dilated cardiomyopathy prognostic risk.
Objective: Evaluate whether menopause is associated with an increased risk of adverse cardiovascular outcomes amongst patients with dilated cardiomyopathy.
Methodology:
Self -controlled case series of women with dilated cardiomyopathy pre and post menopause (exposure variable- menopause), adjusting for hormone replacement therapy use, socioeconomic status, heart failure medication use (ACE inhibitors, beta blockers, ARNIs, aldosterone antagonists, diuretics), GP practice and comorbidities of diabetes and hypertension and follow up for non-fatal adverse cardiovascular outcomes (heart failure hospitalisation, non-fatal myocardial infarction, atrial fibrillation, stroke, non-fatal cardiac arrest). Observation periods will be divided according to age groups. Cases will be determined using CPRD data as well as HES admitted patient care data. As an additional analysis to explore the effect of age as opposed to menopause itself on outcomes, a similar study in the male cohort will be conducted using a dummy variable at the median age of onset of menopause (age 51).
This work will lead to improved understanding of the effect of sex specific variables as cardiomyopathy risk factors to improve diagnostic strategies and identification of previously unrecognised at-risk populations (e.g. perimenopausal women).
Non fatal cardiovascular outcomes of: heart failure hospitalisation, non fatal myocardial infarction, atrial fibrillation, stroke, non fatal cardiac arrest
Upasana Tayal - Chief Investigator - Imperial College London
Upasana Tayal - Corresponding Applicant - Imperial College London
Constantinos Kallis - Collaborator - Imperial College London
Emily Graul - Collaborator - Imperial College London
Jennifer Quint - Collaborator - Imperial College London
HES Admitted Patient Care;ONS Death Registration Data;Practice Level Index of Multiple Deprivation