Gender differences in clinical profiles, management, and outcomes of valvular heart disease: insights from a nationwide cohort

Background Valvular heart disease (VHD) exhibits significant regional and gender differences globally. While degenerative VHD dominates in developed countries, rheumatic heart disease remains prevalent, especially in Oceania, Africa, and Asia. The ESC-EORP VHD II survey highlighted sex differences in etiology and treatment, but data on moderate to severe VHD in Chinese adults are limited. Objective To compare the distribution, etiology, treatment patterns, and 2-year outcomes of moderate to severe VHD between men and women in China. Methods This study prospectively enrolled patients with moderate to severe VHD from 46 centers. Clinical data, interventions, and outcomes (all-cause mortality, cardiovascular death, hospitalization for heart failure [HHF], major adverse cardiovascular events [MACE]) were compared. Kaplan-Meier survival curves, logistic regression, and Cox regression were used for analysis. Results Among 13,917 patients (45.2% women), rheumatic (22.67%), degenerative (22.71%), and functional (27.18%) diseases were most common. Functional VHD was more prevalent in men (28.89% vs. 25.11%), while rheumatic VHD was more common in women (31.89% vs. 15.67%). Men had higher aortic regurgitation (AR) prevalence (15.67% vs. 6.62%), and women had higher tricuspid regurgitation (TR) prevalence (31.89% vs. 15.05%). Clinically, women had higher atrial fibrillation/flutter (33.82% vs. 26.55%), preserved LVEF (79.40% vs. 66.53%), and palpitations (38.01% vs. 30.17%), while men had more comorbidities and bicuspid aortic valves (5.35% vs. 2.87%). The overall intervention rate was 31.72%, with no gender difference (men: 31.26% vs. women: 32.27%). Women were more likely to undergo valve repair (17.69% vs. 12.90%, p<0.001). In AR patients, men had higher intervention rates (46.98% vs. 32.61%, p<0.001), and women were less likely to receive intervention (OR: 0.6, 95% CI: 0.4–0.91, p=0.002). The 2-year survival rate was 90.85%, with no gender difference (men: 90.41% vs. women: 91.38%, p=0.086). Valve intervention improved survival to 97.0%, with no gender disparity. In AR, men had higher survival (96% vs. 93%, p=0.023); in MVHD, women had higher survival (87.94% vs. 85.33%, p=0.031) and lower adverse events. Age-gender interaction showed patients ≥70 years had higher risks of MACE, cardiovascular death, and HHF. Multivariate Cox regression confirmed no significant gender effect across age groups (p>0.05), with renal insufficiency, NYHA class III–IV, and pulmonary hypertension as common risk factors and valve intervention as a protective factor. Conclusions Significant gender differences exist in VHD etiology and subtypes in China. Women had more rheumatic VHD and valve repairs, while men had more degenerative and functional VHD. Intervention improved survival, with no gender disparity. Age and VHD subtype influenced intervention rates and prognosis, supporting individualized, sex- and age-stratified management strategies.Different VHD Subtypes by Gender Two-Year Survival Curves