LAUSR

With the increasing longevity of ‘westernized’ populations, heart failure (HF) in the elderly has become a problem of growing scale and complexity. Affected individuals suffer impaired quality of life. Relatives as well as carriers suffer several years of distress and exhaustion. In addition, health services struggle to cope with the resource implications. Loss of ovarian hormones accelerates aging in women including mortality from cardiovascular disease.1 In the MESA (Multi-Ethnic Study of Atherosclerosis),2 testosterone as well as oestradiol levels were measured in the 2834 post-menopausal women. During 12.1 years of follow-up, the higher testosterone/oestradiol ratio was significantly associated with HF with reduced ejection fraction (HFrEF).2 Recently, special attention has been paid to HF in post-menopausal women. In this issue of the Journal, the paper by Chandramouli et al.3 addresses this issue and provides new insight into the relationship between diabetes mellitus (DM) and sex in HFrEF patients from the ASIAN-HF registry. They found that Asian women with HFrEF were more likely to have DM and more concentric left ventricular geometry compared to men. Furthermore, DM confers worse quality of life and a greater risk of adverse outcomes in women than men.3 Among HF patients, DM is a common co-morbidity and confers worse prognosis.4,5 Sex differences have been well-described in DM and HF separately. Women are often diagnosed with DM at a later age compared to men.6 Incident HF is two-fold higher in DM men and five-fold higher in DM women compared with their respective non-DM counterparts.7 Recent epidemiologic data have highlighted the large burdens of DM and HF, especially in Asia.8 Several important issues should be taken into account when interpreting the results from the ASIAN-HF registry.3 First, HF of ischaemic origin was highly included in the registry. If ischaemic HF was excluded, how would be the results? It would have been interesting to evaluate by sensitive analysis if ischaemic aetiology was a significant modifier of the relationship between DM and