Gender differences in clinical outcome and primary prevention defibrillator benefit in patients with severe left ventricular dysfunction: A systematic review and meta-analysis

Background

Women are underrepresented in primary prevention implantable cardioverter-defibrillator (ICD) trials, and data on the benefit of ICD therapy in this subgroup are controversial.

Objective

The purpose of this study was to better evaluate the benefit of prophylactic ICD in women by performing a meta-analysis of primary prevention ICD trials that assessed gender differences on the end-points of total mortality, appropriate ICD intervention, and survival benefit of ICD compared with placebo.

Methods

PubMed, CENTRAL, and other databases were searched in October 2009. Studies were included only if they examined gender differences in the specified end-points, providing the hazard ratio (HR) obtained in multiple Cox regression analyses, and adjusted for all confounding variables.

Results

We retrieved five studies (MADIT-II, MUSTT, SCD-HeFT, DEFINITE, COMPANION) that enrolled 7,229 patients (22% women) with dilated cardiomyopathy (74% ischemic). Compared to men, women had no significant difference in overall mortality (HR 0.96, 95% confidence interval [CI] 0.67–1.39, P = .84) but experienced significantly less appropriate ICD interventions (HR 0.63, 95% CI 0.49–0.82, P ≤.001). The benefit of ICD on mortality was significantly higher in men (HR 0.67, 95% CI 0.58–0.78, P <.001) but did not reach statistical significance in women (HR 0.78, 95% CI 0.57–1.05, P = .1).

Conclusion

Women enrolled in primary prevention ICD trials have the same mortality compared to men while experiencing significantly less appropriate ICD interventions, thus suggesting a smaller impact of sudden cardiac death on overall mortality in women with dilated cardiomyopathy. These findings may explain the smaller ICD survival benefit among women.

Keywords: Dilated cardiomyopathy, Gender differences, Implantable cardioverter-defibrillator, Sudden cardiac death

Abbreviations: CI, confidence interval, DCM, dilated cardiomyopathy, HR, hazard ratio, ICD, implantable cardioverter-defibrillator, LVEF, left ventricular ejection fraction, SCD, Sudden cardiac death