*Women and DCM, a Fairy Tale?*

The mechanisms behind a prognostic benefit of female sex are still largely unknown. Indeed, in large clinical trials, women showed a variable response to medical treatment whereas the benefit in men was clear-cut [18]. Furthermore, large registry analysis, probably due to the short-term observation provided, failed to demonstrate a prognostic advantage of female sex in heart failure (HF) patients [19]. Our results provide novel prognostic insights into sex differences in patients with DCM. In the present analysis, we demonstrated that, despite previous hypotheses, there is no difference in response to standard heart failure treatment between sexes, with a similar rate of LVRR over time. However, despite the comparable rate of LVRR, male sex was confirmed as an important independent adverse prognostic factor in those patients (Figure 4). This finding suggests that the reason for this prognostic benefit in women might dwell in some intrinsic factors specifically related to the female sex. Furthermore, potential and yet unknown protective mechanisms might be present in female patients with DCM helping either to control the occurrence or to suppress life-threatening arrhythmic events, highlighting the protective role of female sex also in this setting. Whether different social or cultural behaviours associated with hormonal status or genetic background might have a role in this is still largely unknown and deserves further study [18,20–23].

**Figure 4.** Central Illustration Schematic representation of the main results of the study. The rate of LVRR is comparable between sexes; however, male sex is an independent adverse prognostic factor regardless of the occurrence of LVRR. Legend: Legend. HTx: Heart Transplantation; LVRR: Left Ventricular Reverse Remodelling; VAD: Ventricular Assist Device.
