No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Global Health and Economic Burden of Hospitalizations for Heart Failure Lessons Learned From Hospitalized Heart Failure Registries
Abstract
Heart failure is a global pandemic affecting an estimated 26 million people worldwide and resulting in more than 1 million hospitalizations annually in both the United States and Europe. Although the outcomes for ambulatory HF patients with a reduced ejection fraction (EF) have improved with the discovery of multiple evidence-based drug and device therapies, hospitalized heart failure (HHF) patients continue to experience unacceptably high post-discharge mortality and readmission rates that have not changed in the last 2 decades. In addition, the proportion of HHF patients classified as having a preserved EF continues to grow and may overtake HF with a reduced EF in the near future. However, the prognosis for HF with a preserved EF is similar and there are currently no available diseasemodifying therapies. HHF registries have significantly improved our understanding of this clinical entity and remain an important source of data shaping both public policy and research efforts. The authors review global HHF registries to describe the patient characteristics, management, outcomes and their predictors, quality improvement initiatives, regional differences, and limitations of the available data. Moreover, based on the lessons learned, they also propose a roadmap for the design and conduct of future HHF registries. (C) 2014 by the American College of Cardiology Foundation
... Residual congestion at discharge affects up to 50% of patients hospitalized with ADHF and is linked to increased risk of rehospitalization and mortality within six months, regardless of the underlying condition [12,13]. Current guidelines lack defined target levels for congestion at discharge, highlighting a gap in current management strategies [4]. ...
... In a study involving 2061 patients with HFrEF, Ambrosy et al. evaluated a comprehensive congestion score that included dyspnea, orthopnea, asthenia, crackles, edema, and jugular venous distention. Their findings demonstrated that elevated congestion scores were significantly associated with increased mortality and higher rates of heart failure readmissions, emphasizing the clinical impact of persistent congestion [13]. ...
... This phenomenon reflects an attenuated natriuretic response despite the use of appropriate or escalating doses of loop diuretics. This phenomenon is driven by multiple factors, including impaired renal perfusion, elevated venous pressures, neurohormonal activation, and tubular remodeling-particularly in the distal nephron-where enhanced sodium reabsorption blunts the diuretic effect [13,23,44,45,128]. These mechanisms shift the dose-response curve, making higher doses necessary to achieve a meaningful response [17]. ...
Congestion represents a defining hallmark of heart failure (HF) leading to increased morbidity and mortality in HF patients. While it was traditionally viewed as a simple and uniform state of volume overload, contemporary understanding has emphasized its complexity, distinguishing between intravascular, interstitial, and tissue congestion. Congestion contributes to overt clinical manifestation of HF. However, subclinical congestion often goes undetected, increasing the risk of adverse outcomes. Residual congestion, in particular, remains a frequent and challenging issue, with its persistence at discharge being strongly linked to rehospitalization and poor prognosis. Clinical evaluation often fails to reliably identify the resolution of congestion, highlighting the need for supplementary diagnostic methods. Improvement in imaging modalities, including lung ultrasound, venous Doppler, and echocardiography, have significantly enhanced the detection of congestion. Moreover, biomarkers such as natriuretic peptides, bioactive adrenomedullin, soluble CD146, and carbohydrate antigen 125 offer valuable, complementary insights into fluid distribution and the severity of HF congestion. Therefore, a comprehensive, multimodal strategy that integrates clinical evaluation with imaging and biomarker data is crucial for optimizing the management of congestion in HF. Future approaches should prioritize personalized decongestive therapy, addressing both intravascular and tissue congestion, while aiming to preserve renal function and limit neurohormonal activation. Refinement of these strategies holds promise for improving long-term outcomes, reducing rehospitalizations, and enhancing overall patient prognosis.
... Suy tim vẫn luôn là vấn đề sức khỏe đáng quan tâm không chỉ ở Việt Nam mà còn trên cả thế giới. Ước tính có khoảng hơn 26 triệu bệnh nhân mắc phải và tỷ lệ này ngày càng tăng chủ yếu ở người lớn tuổi [1]. Suy tim cấp là bệnh lý đặc trưng bởi các dấu hiệu và/hoặc triệu chứng của suy tim tiến triển nhanh chóng hoặc có thể diễn tiến một cách từ từ nhưng khiến người bệnh cần hỗ trợ y tế khẩn cấp hoặc cần nhập viện điều trị cấp cứu hoặc cần khám chữa bệnh sớm. ...
... Những đợt cấp của suy tim góp phần gia tăng tỷ lệ tử vong nội viện cũng như ngoại viện và nguy cơ tái nhập viện. Tỷ lệ tử vong nội viện dao động khoảng 6%-10%, tỷ lệ tử vong sau 30 ngày là 6,5 % và sau 1 năm xuất viện là 30% [1,2]. ...
Bệnh viện Trung ương Huế Y học lâm sàng Bệnh viện Trung ương Huế-Tập 17, số 3-năm 2025 33 Nghiên cứu nồng độ CA 125 ở bệnh nhân suy tim mất bù cấp Ngày nhận bài: 16/02/2025. Ngày chỉnh sửa: 28/03/2025. Chấp thuận đăng: 07/04/2025 Tác giả liên hệ: Đoàn Chí Thắng. Kết quả: Nồng độ CA 125 ở nhóm bệnh nhân suy tim cấp là 126,2 ± 12,3 U/mL cao hơn có ý nghĩa so với nhóm suy tim mạn 17,6 ± 1,6 U/mL, nhóm bệnh nhân không suy tim 11,2 ± 1,3 U/mL (p < 0,001). Nhóm có các triệu chứng lâm sàng của suy tim cấp lúc vào viện như phù, tĩnh mạch cổ nổi, khó thở, gan lớn có nồng độ CA 125 cao hơn có ý nghĩa so với nhóm không có các biểu hiện lâm sàng của suy tim cấp, phân độ NYHA càng cao thì nồng độ CA 125 càng cao (p < 0,05). Có mối tương quan thuận có ý nghĩa thống kê với p < 0,05 giữa nồng độ CA 125 lúc vào viện với các chỉ số sinh hoá CKMB, hs-TroponinT, Creatinine, Ure, NT-proBNP. Riêng NT-proBNP, nồng độ CA 125 có mối tương quan thuận lúc vào viện và sau 7 ngày điều trị với r lần lượt là 0,749 và 0,558 (p < 0,05). Kết luận: CA 125 là xét nghiệm có giá trị đánh giá tình trạng sung huyết ở bệnh nhân suy tim mất bù cấp Từ khóa: CA 125, suy tim mất bù cấp, sung huyết. Objective: To evaluate the relationship between CA 125 levels and congestion, expressed through clinical and paraclinical aspects of patients with acute decompensated heart failure. Methods: The study was conducted on 80 patients admitted to These patients were divided into three groups: Group 1: 25 patients were calculated to have decompensated heart failure, Group 2: 31 patients with stable heart failure, hospitalized for other reasons, Group 3: 24 patients without heart failure. The study was conducted using a cross-sectional study method. The sampling method was convenient. Results: CA 125 levels in the group of patients with acute heart failure was 126.2 ± 12.3 U/mL, significantly higher than that in the group of patients with chronic heart failure 17.6 ± 1.6 U/mL, and the group of patients without heart
... Heart failure (HF) is a complex syndrome in which congestion plays a central role in disease progression and clinical outcomes. Characterized by extracellular fluid accumulation, congestion is the leading cause of hospitalizations and readmissions, affecting patients across various HF phenotypes, from de novo HF to acute decompensation and advanced HF [1][2][3]. ...
... It is not solely the heart that suffers but rather the entire body, as the effects of congestion propagate across organ systems. Acknowledging and understanding the systemic repercussions of congestion is essential to developing more effective therapeutic strategies and improving patient outcomes in heart failure management [2,15,89]. ...
Congestion is a key clinical feature of heart failure (HF), contributing to hospitalizations, disease progression, and poor outcomes. While traditionally considered a hemodynamic issue, congestion is now recognized as a systemic process affecting multiple organs. Renal dysfunction arises from impaired perfusion and sodium retention, leading to maladaptive left ventricular remodeling. Hepatic congestion contributes to cholestatic liver injury, while metabolic disturbances drive anemia, muscle wasting, and systemic inflammation. Additionally, congestion disrupts the intestinal barrier and immune function, exacerbating HF progression. Given its widespread impact, effective congestion management requires a shift from a cardiovascular-centered approach to a comprehensive, multidisciplinary strategy. Targeted decongestive therapy, metabolic and nutritional optimization, and immune modulation are crucial in mitigating congestion-related organ dysfunction. Early recognition and intervention are essential to slow disease progression, preserve functional capacity, and improve survival. Addressing HF congestion through personalized, evidence-based strategies is vital for optimizing long-term care and advancing treatment paradigms.
... HF is a major health, social, and economic problem affecting about 2% of the world population. 13 In the U.S. alone, the costs related to HF are expected to reach 70 billion U.S. dollars by 2030, an increase of 130% on current costs. 1416 The 30day read mission rate is a key indicator of hospital performance. ...
Patients with heart failure with preserved ejection fraction (HFpEF) often experience dyspnea, fatigue, and exercise intolerance, which are closely linked to skeletal muscle dysfunction and structural abnormalities. The only proven intervention to enhance exercise capacity and quality of life in these patients is regular endurance exercise training. However, its long-term effectiveness is often limited due to poor patient adherence and mobility restrictions caused by sarcopenia, cachexia, or frailty. Therefore, novel therapeutic approaches targeting these unmet needs are urgently required. Sauna-HFpEF is an academic-led, mechanistic, prospective, single-arm, single-center pilot study designed to assess the safety, feasibility, and efficacy of intermittent hyperthermia (sauna therapy) in improving exercise capacity and quality of life in patients with heart failure with preserved ejection fraction (HFpEF), as well as to explore the underlying mechanisms. A total of 18 clinically stable outpatients with HFpEF were enrolled and participated in twice-weekly sauna sessions at 60°C over a 10-week period. Assessments were conducted at baseline and after the intervention, including: echocardiography, cardiopulmonary exercise testing, six-minute walk test, body composition analysis to assess skeletal muscle mass and fat tissue, isokinetic skeletal muscle strength measurement of the quadriceps, daily physical activity monitoring using wearable accelerometers for one week, blood biomarkers, including NT-proBNP, renal function, and inflammatory markers (GDF-15, IL-6), and quality-of-life questionnaires (SF-36, HADS, EQ-5D). Furthermore, to explore the underlying mechanisms of a potential sauna-induced effect, patients underwent two ultrasound-guided punch biopsies of the musculus vastus lateralis in the right quadriceps - one before and one after the intervention. The collected samples were analyzed for structural, metabolic, and mitochondrial changes to gain further insights into the physiological adaptations. Sauna-HFpEF is the first study to investigate the safety and efficacy of sauna therapy using a comprehensive bed-to-benchside approach within the same patient population. This study aimed to address the existing knowledge gap while providing a foundation for the design of a future randomized controlled trial.
... Heart failure (HF) is a leading cause of hospitalisation and death [1]. Atrial fibrillation (AF) is frequent in patients with HF, and their coexistence is associated with substantially increased morbidity and mortality [2,3]. ...
Background
Dynamic chest radiography (DCR) can estimate haemodynamic parameters in patients with heart failure (HF). Atrial fibrillation (AF) often coexists with HF; however, owing to its sometimes paroxysmal nature and minimal or absent symptoms, many patients with AF remain undiagnosed. Additional tools for AF diagnosis may be beneficial; therefore, we evaluated the ability of DCR to distinguish patients with HF in sinus rhythm (SR) from those with AF.
Methods
In this small-sample pilot study, 20 patients with HF (median age, 67 years; males, 85%) underwent 12-lead electrocardiography and DCR on the same day. Aortic arch (Ao), right atrial (RA), right and left pulmonary artery (PA), and left ventricular (LV) apex pixel values (PVs) were measured. Seventeen patients were in SR and three demonstrated AF on 12-lead electrocardiography before DCR.
Results
The PV and PV change rate waveforms of the Ao, RA, PAs, and LV apex were regular in SR and irregular with AF. The difference between patients in SR and those with AF was particularly clear in the LV apex PV change rate waveforms. In addition, the heart rates (HRs) of patients in SR and with AF could be calculated from the PV change rate waveforms and were similar to those calculated by 12-lead electrocardiography.
Conclusions
DCR can detect AF in patients with HF and may be able to infer HR.
Graphical abstract
... (2) La IC es una pandemia a nivel mundial, con más de 64 millones de personas afectadas y más de 1 millón de internaciones anuales en Estados Unidos y Europa. (3,4) Se estima que los costos directos de la IC suponen 1-2% del presupuesto sanitario de los países desarrollados. (5) Describir la IC de una región es una necesidad desde el punto de vista epidemiológico y sanitario. ...
Introducción: La insuficiencia cardíaca es una verdadera pandemia, con más de 64 millones de personas con este síndrome en todo el mundo. Realizamos un registro de insuficiencia cardíaca en Santa Cruz de la Sierra – Bolivia, el REGISTRO SEPE-HF. Objetivos: determinar las características epidemiológicas, clínica, evaluación, tratamiento y pronóstico de la insuficiencia cardíaca en nuestra región. Material y métodos: Desde enero 2023 hasta abril 2024 fueron incluidos pacientes con historia de insuficiencia cardíaca internados por dicha causa en 7 centros participantes. Resultados: Se incluyeron 418 pacientes, el 49% hombres, con una media de edad de 67,4 ± 13,1 años. Tenía antecedentes de hipertensión arterial el 64%, de diabetes mellitus el 21%, de fibrilación auricular un 20%, de cardiopatía isquémica el 12%. La predominante fue la chagásica (37%). En el ecocardiograma transtorácico el 51% presentaba fracción de eyección ventricular izquierda menor de 40%. La incidencia de mortalidad cardiovascular fue del 5,5%. Se observaron similitudes en cuanto a nues-tra incidencia en muchos factores epidemiológicos, comorbilidades, perfil clínico y ecocardiograma con el Registro argentino de internación por insuficiencia cardíaca ARGEN-IC. Conclusión: El registro SEPE refleja las características y evolución de los pacientes internados por insuficiencia cardíaca en Santa Cruz de la Sierra, Bolivia. La etiología chagásica es responsable de más de un tercio de los casos, lo que hace imprescindible avanzar en el desarrollo de medidas que favorezcan el diagnóstico precoz de la afección y la erradicación de la endemia.
... The prevalence was 1%-3% in the adult population (Ruiz-García et al. 2023;Wang, Chai, et al. 2021), while it was much higher, from 6% to 14% in those aged over 60 years (Gorodeski et al. 2018). Heart failure was also confirmed to have a strong relationship with a poor prognosis, including a decline in quality of life, disability, depression, hospitalisation, high mortality within 1 year of admission and a low survival rate in 5 years (Dick and Epelman 2016;Ambrosy et al. 2014), leading to enormous caregiving and financial burdens on healthcare systems. ...
Aims
To explore the conceptualisation of social frailty and discuss its role in shaping the disease trajectory of heart failure. Based on the discussion, recommendations on how to prevent and manage social frailty in this clinical cohort are delineated.
Design
A discursive paper.
Methods
This paper searched two databases, PubMed and Google Scholar, for a narrative review of the literature related to social frailty and heart failure from 2008 to 2024.
Findings
By integrating the conceptualisation of social frailty from different theoretical paradigms, social frailty is a multi‐domain construct that relies on a balance between the availability of environmental resources, social interactions and an individual's ability to maintain and acquire these resources to enhance their well‐being. Substantial evidence showed the prognostic impact of social frailty on patient‐reported, functional and clinical outcomes of patients with heart failure. The underlying mechanism is still under‐investigated, but heart failure‐related self‐care may mediate its impact. Based on this evidence, improving social frailty may rely on a diagnostic protocol to enhance the person‐centred care planning on ways to optimise the social resources to support complex self‐care.
Conclusion
Social frailty poses a greater risk to health outcomes in patients with heart failure. Further research is needed to explore determinants and interventions for social frailty in this population.
Implications
This paper increases the awareness of social frailty in heart failure patients and provides important insights on how to combat this social determinant of poor health outcomes among this clinical cohort. A dual‐purpose approach of improving social resources and self‐care behaviours may have great promise in reducing their social frailty, and this postulation will need to be investigated in future research.
Patient or Public Contribution
There is no involvement of patients or the public in the design or writing of this discursive paper.
... Advanced age, low systolic blood pressure, a history of hypertension, electrolyte imbalances, elevated brain natriuretic peptide (BNP) levels, and speci c ECG abnormalities have consistently been linked to a heightened risk of mortality (8). Furthermore, factors like previous heart failure hospitalization, high blood urea nitrogen (BUN), anemia, and history of percutaneous coronary intervention have previously been found as independent predictors of adverse short-term outcomes, de ned as death and rehospitalization within 60 days (9).Although these known predictors exist, previous research has shown not only the need for hospital-based studies to move beyond traditional endpoints like hospitalization and mortality by incorporating patient-centered outcomes-such as quality of life impairments and functional limitations-but also the importance of leveraging readily available clinical data at the time of admission to improve risk assessment, guide early therapeutic interventions, and inform targeted care strategies for high-risk patients (10,11). ...
Background. Acute decompensated heart failure (ADHF) with reduced ejection fraction (HFrEF) remains a critical cause of hospitalization, characterized by high short-term mortality and significant functional impairment. Early identification of patients at risk using readily available clinical parameters is essential for optimizing management and improving outcomes. Objectives. This study aimed to identify independent clinical, laboratory, and electrocardiographic predictors of in-hospital mortality and severe functional limitation, as defined by New York Heart Association (NYHA) class IV, in patients admitted with ADHF. Methods. In this retrospective cross-sectional study, 100 patients hospitalized with HFrEF were evaluated. Demographic data, comorbidities, clinical signs, laboratory biomarkers, and ECG parameters were analyzed. Multivariate logistic regression models were employed to determine independent predictors of in-hospital mortality and NYHA class IV status. Results. The in-hospital mortality rate was 16%, and 45% of patients were classified as NYHA class IV prior to admission. Multivariate analysis identified female sex (OR: 8.11; p = 0.023), elevated jugular venous pressure (OR: 12.40; p = 0.025), anemia (OR: 9.11; p = 0.034), prolonged QTc interval (OR: 1.03 per ms; p = 0.029), increased heart rate (OR: 1.04 per bpm; p = 0.048), and leukocytosis (OR: 1.46; p = 0.025) as independent predictors of in-hospital mortality. Severe functional impairment (NYHA class IV) was independently associated with pulmonary rales/wheezing/rhonchi (OR: 4.40; p = 0.026), tricuspid or mitral valve murmurs (OR: 3.26; p = 0.020), and reduced serum alkaline phosphatase levels (OR: 0.994; p = 0.014). Conclusion. Simple, bedside-accessible clinical and paraclinical markers—including JVP elevation, QTc prolongation, anemia, leukocytosis, and pulmonary auscultation findings—serve as robust predictors of early mortality and functional decline in ADHF. These findings advocate for the integration of routine clinical assessments and basic investigations into early risk stratification frameworks to enhance acute heart failure management, particularly in resource-limited settings.
... Nevertheless, in real-world, population-level analyses, overall mortality has remained essentially unchanged, while the rate of HF readmissions has arguably increased [3,4]. Approximately 50% of patients will experience at least one readmission within 6 months of an index hospitalization, and, on average, 30% die within 12 months of their first HF admission [5]. Despite the high-cost disincentives, HF remains among the top three causes of hospitalization in the United States and one of the most reimbursed Medicare Severity Diagnosis Related Group families (MS-DRG) [6]. ...
Unplanned admissions for worsening heart failure (WHF) are the largest resource cost in heart failure (HF) management. Despite advances in pharmacological agents and interventional therapy, HF remains a global epidemic. One crucial—and costly—gap in HF management is the inability to obtain objective information to identify and quantify congestion and personalize treatment plans to effectively manage WHF events without resorting to expensive, invasive methods. Although the causes of WHF are varied and complex, the universal effect of HF decompensation is the significant decline in quality of life due to symptoms of hypervolemic congestion and the resultant reduction in cardiac output, which can be quantified via increased pulmonary venous congestion due to high intracardiac filling pressures. Accessible and reliable markers of congestion could more precisely quantify the severity of WHF events and stabilize patients earlier by interrupting and reversing this process with timely introduction or modification of evidence-based treatments. Pulmonary artery and cardiac pressure sensing tools have gained evidential credence and increased clinical uptake in recent years for the prevention and treatment of WHF, as studies of implantable hemodynamic devices have iteratively and reliably demonstrated substantial reductions in WHF events. Recent advances in sensing technologies have ranged from single-parameter invasive pulmonary artery monitors to completely non-invasive multi-parameter devices incorporating multi-sensor concept technologies aided by machine learning or artificial intelligence, although many remain investigational. This review aims to evaluate the potential for novel pulmonary artery and cardiac pressure sensing technology to reshape the management of WHF from within the hospitalized and ambulatory care environments.
... In the past few decades, the incidence of HF has been on the rise; Currently, the global prevalence of HF is 1-3%, with over 64 million people affected by HF [2]. Despite advances in diagnosis and treatment plans, the prognosis for heart failure patients is not optimistic, with studies showing a 10-year mortality rate of 50% [3]. Based on this situation, it is imperative to evaluate the long-term prognosis of the HF population. ...
Backgrounds Previous studies have found a significant correlation between the estimated glucose disposal rate (eGDR) and cardiovascular disease (CVD). However, little is known about the relationship between eGDR and the prognosis of heart failure patients. Methods The study included 1632 participants from the UK biobank who were diagnosed with heart failure before December 2010 and had no history of cancer and diabetes. The formula used to calculate eGDR is as follows: 21.158- (0.09 * waist circumference [cm]) - (3.407 * hypertension) -0.551 * HbA1C (%). Participants were divided into four groups based on baseline eGDR:<4, 4-5.99, 6-7.99, and ≥ 8 mg/kg/min. The outcome is the all-cause mortality rate of heart failure patients. The Cox proportional hazards regression model examined the association between eGDR and event outcomes. Results During a 13-year follow-up, the UK Biobank recorded 612 deaths. The Kaplan‒Meier analyses revealed that the mortality rate of heart failure in the group with the lowest eGDR was significantly higher (log-rank p < 0.01). The mortality rate of heart failure patients with eGDR ≥ 8 mg/kg/min is lower than that of heart failure patients with eGDR < 4 mg/kg/min, with a hazard ratio (HR) of 0.63 [95% confidence interval (CI) 0.41,0.97]. Conclusions This study suggests that a decrease in eGDR is associated with an increase in mortality after heart failure. Therefore, eGDR can serve as a new indicator for evaluating the prognosis of heart failure patients.
... Heart failure (HF) is a growing global health challenge, affecting approximately 64 million people [1] and is associated with high hospitalization rates, with 30-day readmission rates between 20% and 30% [2][3][4]. HF also imposes a significant economic burden, with the direct medical costs in the United States reaching billions of dollars annually [5]. Beyond financial impacts, HF adversely affects patients' quality of life (QoL), functional status, and productivity often leading to disability. ...
Background
The concurrent presence of iron deficiency (ID) and heart failure (HF) can worsen prognosis and reduce the quality of life for affected individuals. This study aimed to explore the effects of incorporating iron sucrose into standard HF treatments for patients with acute decompensated HF and ID.
Methods
We prospectively enrolled 65 hospitalized HF patients, all with a left ventricular ejection fraction of ≤40% and ID, defined as ferritin levels below 100 ng/mL or ferritin levels between 100 and 299 ng/mL with transferrin saturation below 20%. Patients were randomized into two groups: the iron sucrose group, who received intravenous iron sucrose in addition to the standard HF treatment; a control group who received standard HF treatment alone serum ferritin, iron, transferrin saturation, and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores were measured at baseline and a 4-week follow-up.
Results
Baseline characteristics, iron profiles, and KCCQ scores were comparable between the two groups. At 4 weeks, patients in the iron sucrose group possessed significantly higher serum ferritin levels than those in the control group (ferritin 485.3 ± 269.7 ng/mL vs. 225.5 ± 162.5 ng/mL, p < 0.001; Δferritin 382.2 ± 243.5 ng/mL vs. 97.4 ± 143.0 ng/mL, p < 0.001, respectively). Only 9.1% of patients in the iron sucrose group remained within the ID criteria, compared to 36.7% in the control group (p = 0.012). The ΔKCCQ score was 10.6 points higher (27.8 ± 19.5 vs. 17.1 ± 17.8 points, p = 0.031) in the iron sucrose group than in the control group.
Conclusions
Post-discharge intravenous iron sucrose may improve iron levels and quality of life in HF patients with ID.
Clinical trial registration
NCT06703411, https://clinicaltrials.gov/expert-search?term=NCT06703411.
... Chronic heart failure (CHF) is a complex clinical syndrome caused by abnormal changes in cardiac structure and function or dysfunction of ventricular contraction and relaxation, which is the late stage of various heart diseases [1]. There are approximately 26 million people with heart failure worldwide [2][3], and there were about 8.9 million individuals with heart failure in China [4][5][6]. CHF is associated with high morbidity, mortality, and readmission rates, which increase medical expenses and caregiver burden. ...
Background
Good self-management behaviors can improve the physical function and quality of life of patients with heart failure and reduce hospitalization, mortality, and medical expenses. While the overall self-management level among patients with chronic heart failure (CHF) in China is low, previous studies have often used a cross-sectional design, and few have followed up on patients’ self-management beyond 6 months after discharge. This study aimed to explore the factors influencing and the changes in the self-management level of patients with CHF and provide a basis for the timing and choice of interventions within 1 year after discharge.
Methods
A longitudinal study was conducted from December 2021 to June 2022, including patients with CHF who met all the inclusion criteria. Data on demographics, disease-related details, social support, self-efficacy, and other information were collected during hospitalization (T0) and reevaluated at 1 month (T1), 3 months (T2), 6 months (T3), and 12 months (T4) after discharge.
Results
A total of 213 patients were enrolled at T0, with 206, 201, 189, and 173 patients completing follow-up at T1, T2, T3, and T4, respectively. The self-management score was lowest at T0, highest at T1, began to decline at T2, and stabilized at T3; however, T3 remained higher than T0. Social support, self-efficacy, disease course, medication type, education level, and personal monthly income were identified as factors influencing self-management.
Conclusions
The study findings indicate that self-management is a dynamic process of change. The level of self-management was at a high level 3 months after the patients were discharged from the hospital, but showed a decreasing trend from 6 months, which was related to numerous factors. This study helps to provide a theoretical basis for the timing and content of self-management intervention for patients with CHF by clinical healthcare professionals.
... CRS encompasses a spectrum of disorders in which acute or chronic dysfunction in either the heart or kidneys leads to dysfunction in the other organ, exacerbating clinical outcomes [4,5]. Patients with both HF and AKI face significantly higher risks of hospitalization, prolonged intensive care stays, and increased mortality compared to those with either condition alone [6][7][8].The growing burden of cardiovascular and renal diseases, coupled with an aging population and increasing prevalence of comorbidities such as diabetes and hypertension, underscores the need for a comprehensive analysis of mortality trends associated with HF and AKI. ...
Background
Heart failure (HF) and acute kidney injury (AKI) are leading contributors to morbidity and mortality in the United States, often coexisting as part of the cardiorenal syndrome. Understanding long-term mortality trends is crucial for guiding healthcare policies and interventions. This study analyses national trends in HF- and AKI-related mortality from 1999 to 2020, with a focus on age-adjusted mortality rates (AAMR) and disparities across gender, race/ethnicity, urbanization, and geographic regions.
Methods
We conducted a retrospective analysis using the CDC WONDER database, extracting mortality data for adults aged 25–85 years. HF- and AKI-related deaths were identified using ICD-10 codes. Temporal trends in AAMR were evaluated using Joinpoint regression, and subgroup analyses were performed to assess disparities.
Results
A total of 219,243 HF- and AKI-related deaths were recorded. The overall AAMR increased from 3.56 per 100,000 in 1999 to 5.30 in 2020 (AAPC: 1.52%; p < 0.001). Males had a higher AAMR than females (5.80 vs. 3.84). NH Black individuals exhibited the steepest rise in mortality, whereas NH White and Asian populations showed stabilization. Nonmetropolitan areas had higher AAMRs compared to metropolitan regions. State-level disparities revealed that North Dakota and West Virginia had the highest mortality rates, whereas Florida and Arizona had the lowest.
Conclusion
HF- and AKI-related mortality has risen significantly over the past two decades, with pronounced disparities across demographic and geographic subgroups. These findings underscore the need for targeted interventions to address healthcare inequities and improve outcomes in high-risk populations.
... HFpEF patients were older than the ones with reduced LVEF, whereas this subgroup included more women than men. The aforementioned findings come in agreement with similar studies [16], and relevant population-based epidemiological data [5,17,18]. Chronic HF phenotyping across our sample is further detailed by several comorbid conditions. Interestingly, HFpEF cases had higher rates of preexisting hypertension, AF, COPD, and OSAS. ...
Purpose
Heart failure (HF) burden and care varies significantly across different countries. We aimed to illustrate the clinical characteristics and HF-related care among cardiology inpatients in Greece.
Methods
We collected information about all cardiology inpatients on the 3rd of March 2022. The current analysis focuses on acute or chronic HF.
Results
Among a total of 923 participants, 280 (30%) concerned cases of acute HF whereas 351 patients (38%), (median age 79 ± 12 years, male gender 63.8%) had a history of chronic HF, with their majority presenting with multiple comorbidities and previous HF hospitalizations. 173 (49%) of chronic HF participants had reduced LVEF. Ischemic heart disease was the predominant HF etiology (182, 51.9%). Prior to the index admission, chronic HF cases were receiving diuretics, beta blockers, ACEi/ARBs, ARNI, MRAs, and SGLT2i at 79.8%, 74.4%, 43.3%, 10.8%, 40.7%, and 14%, respectively. Independent predictors of lower prescription rates of Guideline Directed Medical Therapy (GDMT) included advanced age (p < 0.001), chronic kidney disease (RASi OR 0.392, p = 0.008, MRA OR 0.523 p = 0.097), and lack of follow-up in dedicated HF clinics (p = 0.006). No regional differences with regards to GDMT were identified.
Conclusion
In this nation-wide real-world snapshot study, patients with chronic and acute HF accounted for a significant proportion of cardiology inpatients, while ischemic heart disease was the leading HF cause. GDMT and device therapy can be improved. Follow-up in dedicated HF units was related with increased prescription rates of GDMT, whereas this was not affected by geographical region.
Graphical Abstract
Chronic heart failure regional distribution (regional density of participants visualized on a map with person-shaped markers), comorbidities, and pharmacotherapy. HECMOS
... 2 Pharmacotherapy is regarded as the cornerstone of HF treatment, which has been shown to reduce mortality, prevent recurrent hospitalizations, and improve clinical status, functional capacity, and quality of life. [2][3][4][5] For a significant number of HF patients who receive guideline-directed medical therapy, it is possible not only to stabilize symptoms, but often to observe significant improvements in myocardial function. 6 ejection fraction (HFimpEF). ...
Aims
The necessity of lifelong treatment and polypharmacy in chronic heart failure (HF) patients with improved myocardial function remains debated. This systematic review aims to synthesize current literature regarding this issue.
Methods and results
A systematic literature search was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from the inception to 18 October 2024. Seven studies ( n = 552) reporting minimization or withdrawal of pharmacotherapy in chronic HF patients with improved ejection fraction or stable New York Heart Association status were included. Findings were heterogeneous due to variations in study design and protocols. Loop diuretic withdrawal was favoured by one non‐randomized study ( n = 26) and one randomized controlled trial (RCT) ( n = 188). Minimization of angiotensin receptor–neprilysin inhibitors ( n = 77) or withdrawal of mineralocorticoid receptor antagonists (MRA) ( n = 70) was not favourable. Carvedilol monotherapy was favoured by one small‐sample RCT ( n = 60). One RCT ( n = 51) reported a high overall relapse rate (65%) following multiple drug withdrawal in recovered patients with dilated cardiomyopathy. Another RCT ( n = 80) found a low occurrence of cardiac dimensional deterioration (7.5%) following multiple drug withdrawal in post‐cardiac resynchronization therapy patients with normalized ejection fraction. However, 28% required drug re‐initiation due to cardiac comorbidities.
Conclusion
The existing evidence on minimizing or withdrawing oral pharmacotherapy in chronic HF patients with improved myocardial function remains very limited and heterogeneous, supporting only loop diuretic withdrawal and possibly carvedilol monotherapy, but not the minimization or withdrawal of renin–angiotensin system inhibitors, MRA, or the combination of HF medications. Large RCTs are needed to determine the appropriate treatment strategy.
... Suy tim là một vấn đề sức khỏe cộng đồng với tỷ lệ mắc bệnh cao, đặc biệt ở người lớn tuổi [1]. Hiện nay có nhiều chất chỉ điểm sinh học giúp chẩn đoán và tiên lượng suy tim như peptid lợi niệu BNP (Brain Natriuretic Peptid) hoặc NT-proBNP, galectin-3 và gần đây là CA125 [2]. ...
Đặt vấn đề: CA125 được xem là một dấu ấn sinh học phổ biến, sự thay đổi của CA125 liên quan với mức độ nghiêm trọng của bệnh trong bối cảnh mất bù cấp tính và kết cục lâm sàng ở bệnh nhân suy tim. Mục tiêu nghiên cứu: Khảo sát nồng độ CA125 và một số yếu tố tương quan ở bệnh nhân suy tim mạn mất bù cấp có phân suất tống máu thất trái giảm. Đối tượng và phương pháp nghiên cứu: Nghiên cứu mô tả, cắt ngang với 110 bệnh nhân được chẩn đoán suy tim mạn mất bù cấp có phân suất tống máu thất trái giảm tại khoa Tim mạch can thiệp – Thần kinh Bệnh viện Trường Đại học Y Dược Cần Thơ và khoa Nội tim mạch Bệnh viện Đa khoa Trung ương Cần Thơ từ 9/20243/2025. Kết quả: Nồng độ trung bình của CA125 là 48,45 (21,1-126,8) U/ml. Có 68 (61,8%) bệnh nhân gia tăng nồng độ CA125 huyết tương. Mối tương quan có ý nghĩa thống kê mạnh giữa nồng độ CA125 với thời gian mắc suy tim (r=0,461, p<0,001), huyết áp tâm thu (r=-0,216, p=0,023), số lượng bạch cầu (r=-0,312, p<0,001) và thông số đường kính tĩnh mạch chủ dưới (IVC) (r=0,213, p=0,026). Mối liên quan có ý nghĩa thống kê giữa sự gia tăng nồng độ CA125 với sự xuất hiện của triệu chứng tràn dịch màng phổi với OR=2,907 (1,125-7,513), p=0,024 và triệu chứng phù ngoại vi ở bệnh nhân suy tim với OR=5 (1,952-12,806), p<0,001. Kết luận: Nồng độ CA125 trung bình là 48,45 U/ml (21,1-126,8). Có 61,8% bệnh nhân có mức CA125 tăng cao. Nghiên cứu cho thấy gia tăng CA125 có mối tương quan thuận với thời gian mắc suy tim, đường kính tĩnh mạch chủ dưới và có mối liên quan chặt chẽ với triệu chứng sung huyết tĩnh mạch hệ thống và phổi.
... 1,2 HF is the leading cause of hospitalization, with projected health-care costs reaching about $70 billion annually by 2030. 3 In addition to a high mortality risk, patients with HF experience physical and emotional symptoms such as dyspnea, edema, difficulty sleeping, fatigue, and depression, which can markedly worsen health status. 4,5 A patient-reported outcome (PRO) is any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else. ...
Heart failure is a growing health-care concern affecting tens of millions of individuals globally. Although traditional therapeutic strategies have focused on reducing the risk for hospitalization and mortality, the importance of patient-reported outcomes (PROs) in patients with heart failure is increasingly being recognized. Regulatory agencies consider PROs part of their evaluation of drugs and devices, and professional society guidelines may recommend interventions that improve PROs. However, for several reasons, the effect of interventions on PROs reported in heart failure trials currently is difficult to interpret. There is no consensus on the timing and frequency of PRO assessments. Moreover, it has been difficult to establish a minimal clinically important difference, that is, the minimal change in a PRO score that is meaningful to a patient. In addition, traditional methods of analyzing and reporting PROs such as comparison of mean differences across groups or responder analysis are prone to statistical artifacts and misinterpretation. This article presents an in-depth discussion of these issues, with the Kansas City Cardiomyopathy Questionnaire used as an example, to facilitate the use of PROs in heart failure research, regulatory, and clinical settings.
... Currently, over 1 million hospitalizations annually are related to HF in the US and Europe. In the US, approximately 10-51% of HF inpatients are admitted to ICU [6,7]. AKI is more prevalent among HF patients in the ICU [8]. ...
Background
The combination of heart failure (HF) and acute kidney injury (AKI) increases the mortality of patients. It is critical to identify HF patients who may have a high risk for AKI. Albumin-corrected anion gap (ACAG) is a new indicator, but there are no studies on ACAG and the risk of AKI in HF patients.
Methods
Data for HF patients was obtained from the MIMIC-IV database. Receiver operating characteristic (ROC) analysis and decision curve analysis (DCA) were employed to evaluate the clinical value of ACAG in predicting AKI risk. Logistic regression analysis and restricted cubic spline (RCS) curve were conducted to explore the relationship between ACAG and AKI. A competing risk model was developed to further investigate the relationship between ACAG on AKI.
Results
The study analyzed 5,972 HF patients, with 49.82% (2886/5972) suffering from AKI. The prediction performance of ACAG on AKI was good (AUC:0.656). Continuous ACAG was associated with AKI after adjusting for various significant variables (Model 1: OR = 1.094, 95%CI: 1.078–1.110; Model 2: OR = 1.150, 95%CI: 1.133–1.166; Model 3: OR = 1.035, 95%CI. 1.017–1.054). All High ACAG groups showed a higher risk of AKI (all P < 0.001). ACAG was also linked to in-hospital mortality (P < 0.001). The competing risks model revealed that high ACAG was still a risk factor for AKI when in-hospital mortality served as a competing risk event (P < 0.001).
Conclusion
High ACAG was associated with the risk of AKI in HF patients. Clinicians can risk-stratify HF patients by combining ACAG levels.
... Hospitalizations due to worsening heart failure (HF) continue to pose significant challenges, adversely affecting patient outcomes and placing substantial strain on healthcare systems [1]. Traditional methods, such as weight monitoring and symptom-based evaluations, are limited by low sensitivity and often identify decompensation in late stages [2]. ...
ZOLL Heart Failure Management System (ZOLL HFMS) is a non-invasive, remote monitoring device that employs radiofrequency signals transmitted through an adhesive patch embedded with integrated sensors to evaluate lung fluid levels. By analyzing trends in lung fluid status and related parameters, ZOLL HFMS may facilitate the early detection of heart failure (HF) decompensation and enable timely interventions. Insights from the recent BMAD trial (Impact of heart failure management using thoracic fluid monitoring from a novel wearable sensor: Results of the Benefits of Microcor [µCor™] in Ambulatory Heart Failure) highlight its promise in those with recent HF hospitalization, demonstrating a reduction in time to first HF readmission and improvement in quality of life. In this review, we summarize data on the ZOLL HFMS, with a focus on its lung fluid analysis mechanism for early HF decompensation detection and the accuracy of its measurements compared to other modalities. Then, we examine key outcomes from the recent BMAD trial, highlighting their clinical relevance and identifying gaps that warrant further investigation in future clinical trials. Lastly, we outline potential directions for integrating this technology into routine HF management.
... Previous foreign systematic evaluations have shown that the 30-day readmission rate of heart failure patients is around 20%, and has risen in recent years; whereas data on 30-day readmission for heart failure in China are scarce, a retrospective study showed that readmission occurs within 30 days for about 22.8% of heart failure patients [4,5]. Frequent readmissions seriously affects patients' prognosis and quality of life and need to be controlled or avoided by early risk identification and intervention [6][7][8]. However, it's widely acknowledged that predicting the rate of unplanned readmissions in heart failure patients is more challenging than predicting mortality rates, because unplanned readmissions may be the result of a complex interplay between clinical disease factors, psychological behaviors, and socioenvironmental influences [9,10]. ...
Background
Heart failure imposes a significant healthcare burden, with early unplanned readmissions post-discharge linked to poor outcomes. Identifying risk factors and their predictive value is crucial for targeted interventions.
Objective
To investigate gender differences in cumulative hazard function and the factors influencing 30-day unplanned readmissions in heart failure patients, and to compare their predictive value.
Methods
A prospective study of heart failure patients hospitalized in Beijing Hospital from October 2023 to March 2024. Patients’ nutritional status was assessed using the Mini-Nutritional Assessment Scale Short Version (MNA-SF), frailty was evaluated using the Groningen Frailty Index (GFI), and the Appendicular Skeletal Muscle Mass Index (ASMI) was calculated. Multifactorial Cox regression analysis was conducted, and ROC curves were plotted for predictive modeling.
Results
A total of 121 heart failure patients (60.3% males), aged (69.87 ± 11.9) years were included. With a median follow-up duration of 30 days, 25 (20.7%) patients with readmission. COX regression analysis stratified by gender showed that age, regular smoking, nutritional status, left ventricular ejection fraction(LVEF), brain natriuretic peptide(BNP), GFI, and ASMI were independent predictors of readmission within 30 days in patients with heart failure (P < 0.050). ROC curve analysis showed that age, BNP, ASMI, smoking status, LVEF, nutritional status, and GFI individually as well as in combination predicted readmission within 30 days in patients with heart failure; the joint model performed optimally, with an AUC value reaching 0.877 (95%CI 0.801 ∼ 0.952, P < 0.001), with a sensitivity of 0.920 and a specificity of 0.729.
Conclusion
A multifactorial approach including age, BNP, ASMI, smoking status, LVEF, nutritional status, and GFI predicts 30-day readmission risk, offering a basis for clinical intervention strategies to improve patient outcomes.
... The term describes left ventricular dysfunction (LVD) resulting from significant CAD; clinical trials and recent registries have attributed worse outcomes to ICM compared with non-ischemic etiologies [2,3]. The management of patients with CAD and reduced left ventricular ejection fraction (LVEF) poses a significant clinical and public health challenge [4]. ...
Ischemic cardiomyopathy remains a leading cause of heart failure, yet the optimal revascularization approach for patients with reduced left ventricular function remains uncertain. This review synthesizes current evidence on coronary revascularization strategies, emphasizing real-world applicability and individualized treatment. It critically evaluates the benefits and limitations of coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI], highlighting key knowledge gaps. Findings from the STICH trial demonstrate that CABG improves long-term survival despite an elevated early procedural risk, particularly in patients with extensive multivessel disease. In contrast, the REVIVED-BCIS2 trial suggests that PCI enhances quality of life but does not significantly reduce mortality compared to optimal medical therapy, making it a viable alternative for high-risk patients ineligible for surgery. This review underscores the role of advanced imaging techniques in myocardial viability assessment and emphasizes the importance of comprehensive risk stratification in guiding revascularization decisions. Special attention is given to managing high-risk patients unsuitable for CABG and the potential benefits of PCI in symptom relief despite uncertain survival benefits. A stepwise algorithm is proposed to assist clinicians in tailoring revascularization strategies, reinforcing the need for a multidisciplinary Heart Team approach to optimize outcomes.
... Heart failure (HF), which develops predominantly as a consequence of coronary artery disease and chronic hypertension, is currently recognized as a global pandemic (Ambrosy et al., 2014). The most prominent functional symptom of heart failure is exercise intolerance, which is caused mainly by an impairment of the heart as a pump, resulting in decreased cardiac output and limited oxygen supply to tissues, in turn leading to energy deficiency in the locomotory muscles (Karwi et al., 2019;Takada et al., 2022). ...
Introduction
There is growing body of evidence that an enhanced concentration of branched-chain amino acids (BCAAs), as a consequence of an impaired myocardial oxidative metabolism, is involved in the occurrence and progression of heart failure (HF). The purpose of this study was to examine the effect of 8 weeks of spontaneous wheel running (8-sWR) (reflecting low-to-moderate intensity physical activity) on the myocardial [BCAAs] and mitochondrial oxidative metabolism markers, such as tricarboxylic acid (TCA) cycle intermediates (TCAi), mitochondrial electron transport chain (ETC) proteins and mitochondrial DNA copy number (mtDNA/nDNA) in a murine model of HF.
Methods
Adult heart failure (Tgαq*44) and wild-type (WT) mice were randomly assigned to either the sedentary or exercising group. Myocardial concentrations of [TCAi] and [BCAAs] were measured by LC-MS/MS, ETC proteins were determined by Western immunoblotting and mtDNA/nDNA was assessed by qPCR.
Results
Heart failure mice exhibited decreased exercise performance capacity as reflected by a lower total distance covered and time of running in wheels. This was accompanied by impaired TCA cycle, including higher citrate concentration and greater [BCAAs] in the heart of Tgαq*44 mice compared to their control counterparts. No impact of disease at its current stage i.e., in the transition phase from the compensated to decompensated stage of HF on the myocardial mitochondrial ETC, proteins content was observed, however the altered basal level of mitochondrial biogenesis (lower mtDNA/nDNA) in the heart of Tgαq*44 mice compared to their control counterparts was detected. Interestingly, 8-sWR significantly decreased myocardial citrate content in the presence of unchanged myocardial [BCAAs], ETC proteins content and mtDNA copy number.
Conclusion
Moderate-intensity physical activity, even of short duration, could be considered an effective intervention in heart failure. Our results suggest that central metabolic pathway - TCA cycle appears to be more sensitive to moderate-intensity physical activity (as reflected by the lowering of myocardial citrate concentration) than the mechanism(s) regulating the BCAAs turnover in the heart. This observation may have a particular importance in heart failure, since an improvement of impaired myocardial oxidative metabolism may contribute to the upgrading of the clinical status of patients.
... A U.S. study reported that the incidence of new heart failure cases rises with age, affecting 1.3% of men and 0.7% of women in their 60s, and 8.3% of men and 7.8% of women in their 80s 5) . The global aging population has contributed to what is now termed a "heart failure pandemic", with 26 million people worldwide affected 6) . In Japan, the number of patients with chronic heart failure is estimated to rise significantly due to the aging population and the increasing prevalence of ischemic heart disease. ...
Purpose] To examine whether functional independence measure scores and effectiveness at discharge can be predicted using N-terminal pro-B-type natriuretic peptide concentrations at admission in postoperative patients aged ≥75 years with proximal femur fractures. [Participants and Methods] This study included 35 patients who were admitted for rehabilitation after proximal femur fracture surgery between April 1, 2020 and September 20, 2023 and were discharged by November 30, 2023. The primary outcomes were the functional independence measure scores and effectiveness at discharge. The explanatory variables analyzed using multiple regression included demographic data; N-terminal pro-B-type natriuretic peptide concentration, estimated glomerular filtration rate, and geriatric nutritional risk index at admission; functional ambulation categories before injury; and motor, cognitive, and total functional independence measure scores at admission. [Results] The motor functional independence measure score at admission and N-terminal pro-B-type natriuretic peptide concentration were significant explanatory variables for the motor functional independence measure score at discharge. The N-terminal pro-B-type natriuretic peptide concentration was a significant explanatory variable in total and motor functional independence effectiveness. [Conclusion] This study, which excluded cognitively impaired patients and focused on individuals aged ≥75 years, suggests that N-terminal pro-B-type natriuretic peptide concentration at admission affects the functional independence measure scores and effectiveness at discharge.
... Population-based investigations of individuals with decompensated HF have revealed a significant occurrence of concurrent conditions such as AF/atrial flutter (30-46%), valvular heart disease (44%) and dilated cardiomyopathy (25%). 17,21 Moreover, patients admitted to hospital with acute decompensated HF typically exhibit advanced age (71-75 years) and a prior diagnosis of HF (65-87%), with the majority also presenting with coronary artery disease (50-68%) and hypertension (53-72%). 22 It is advised that patients be evaluated using an approach that focuses on assessing the severity of their condition rather than its underlying cause. ...
Congestion is the hallmark and the main therapeutic target in patients with decompensated heart failure (HF). Residual clinical congestion is defined as a high left ventricular diastolic pressure associated with signs and symptoms of HF, such as dyspnoea, rales and oedema, persisting despite guideline-directed medical treatment. Residual congestion in the predischarge and early post-discharge phase is the major risk factor for HF readmission and mortality. Therefore, prompt recognition of congestion and rapid optimisation of medical and device therapy are crucial to induce remission in this malignant process. In this paper we discuss the definitions, prevalence and prognosis of HF decompensation; the significance of assessing residual congestion in HF patients; the results of observational and randomised clinical trials to detect and treat residual congestion; and the current guidelines to prevent recurrent HF decompensation in the context of residual congestion. Strategies to detect and address residual congestion are crucial to stopping readmissions after an acute HF hospitalisation and improving long-term prognosis.
... It is characterized by the heart's inability to supply sufficient blood flow to meet the body's needs, leading to symptoms such as fatigue, breathlessness, and fluid retention [1]. HFrEF poses a significant challenge within the global health landscape, affecting millions worldwide and markedly impacting morbidity, mortality, and healthcare systems [2]. The economic burden of HFrEF on healthcare systems is substantial, with the estimated average cost of hospitalization for HFrEF ranging from USD 3780 to USD 34,233 [3]. ...
Background: Heart failure with reduced ejection fraction is a complex condition that necessitates adaptive, patient-specific management strategies. This study aimed to evaluate the effectiveness of a time-adaptive machine learning model, the Passive-Aggressive classifier, in predicting heart failure with reduced ejection fraction severity and capturing individualized disease progression. Methods: A time-adaptive Passive-Aggressive classifier was employed, using clinical data and Brain Natriuretic Peptide levels as class designators for heart failure with reduced ejection severity. The model was personalized for individual patients by sequentially incorporating clinical visit data from 0–9 visits. The model’s adaptability and effectiveness in capturing individual health trajectories were assessed using accuracy and reliability metrics as more data were added. Results: With the progressive introduction of patient-specific data, the model demonstrated significant improvements in predictive capabilities. By incorporating data from nine visits, significant gains in accuracy and reliability were achieved, with the One-Versus-Rest AUC increasing from 0.4884 with no personalization (zero visits) to 0.8253 (nine visits). This demonstrates the model’s ability to handle diverse patient presentations and the dynamic nature of disease progression. Conclusions: The findings show the potential of time-adaptive machine learning models, particularly the Passive-Aggressive classifier, in managing heart failure with reduced ejection fraction and other chronic diseases. By enabling precise, patient-specific predictions, these approaches support early detection, tailored interventions, and improved long-term outcomes. This study highlights the feasibility of integrating adaptive models into clinical workflows to enhance the management of heart failure with reduced ejection fraction and similar chronic conditions.
... Another important observation emerging from our data is that a significant exclusion criterion both for vericiguat and OM was an LVEF over the established trials cutoffs. Indeed, data from large registries have indicated that only approximately 50% of patients were classified with HFrEF [75][76][77]. Preliminary studies pointed out conflicting results on the role of these drugs in patients with preserved LVEF requiring further large-scale investigations with longer follow-up [78][79][80]. Moreover, we should emphasize the potential role that vericiguat and OM could play in certain high-risk subcategories of CHF patients, such as advanced NYHA class or subjects with CKD, as suggested by recent evidence [81]. ...
Background: Several drugs are emerging as potential therapeutic resources in the context of chronic heart failure (CHF), although their impact on daily clinical practice remains unknown. The objective of this study was to investigate the theoretical eligibility for vericiguat and omecamtiv mecarbil (OM) in a real-world outpatient setting. Methods: A cross-sectional observational study was conducted, enrolling all patients with CHF who had at least one visit between January 2023 and January 2024 in a dedicated outpatient clinic of a tertiary referral center. Theoretical eligibility for vericiguat and OM in our population was assessed by adopting the criteria of the respective phase III clinical trials (VICTORIA trial for vericiguat and GALACTIC-HF trial for OM). Results: In 350 patients with CHF, the rate of individuals eligible was 2% for vericiguat and 4% for OM. A value for left ventricular ejection fraction (LVEF) over the clinical trials’ cutoffs was observed in 41% of cases for vericiguat and 69% for OM. The absence of a recent heart failure (HF) worsening was found in 78% of cases for vericiguat and 72% for OM. Conclusions: Only a small proportion of CHF patients would be eligible for vericiguat and OM in a real-world outpatient setting. The absence of a recent HF worsening and an LVEF over the established trials’ cutoffs are the main causes of non-eligibility. Further studies are required to assess the efficacy of these drugs in a wider population in order to increase the candidates for these beneficial treatments.
Aims
Loop diuretics alleviate symptoms in heart failure (HF), but despite recommendations for dynamic dosing, implementation in practice remains challenging. The EASY‐STOP trial investigated whether ambulatory urinary sodium monitoring using a point‐of‐care sensor could guide diuretic down‐titration.
Methods and results
This prospective, single‐centre study enrolled 50 euvolaemic HF patients on stable guideline‐directed medical therapy for ≥3 months and receiving maintenance loop diuretic (≥20 mg furosemide equivalent daily). After a 1‐week baseline phase of daily self‐measured first‐void and post‐diuretic urinary sodium assessment, loop diuretics were gradually reduced by 50% and discontinued when ≤20 mg furosemide equivalents. Urinary monitoring continued for another 3 weeks. Successful down‐titration was defined as remaining congestion‐free (no rise in New York Heart Association class ≥I, oedema, pleural effusion, ascites, rise in right ventricular systolic pressure ≥10 mmHg, or worsening diastolic dysfunction ≥1 grade). Investigators and patients were blinded for urinary sodium analysis during the study. Patients were 75 (68–79) years old, had left ventricular ejection fraction 46 (± 11)%, estimated glomerular filtration rate 47 (35–65) ml/min and N‐terminal pro‐B‐type natriuretic peptide 899 (326–2558) ng/L. Among the 50 patients, 62 diuretic down‐titrations were performed, of which 34 (55%) were successful. Baseline urinary sodium before loop diuretic down‐titration was similar between groups. However, patients who successfully achieved down‐titration exhibited a significant increase in first‐void urinary sodium following down‐titration (53–74 mmol/L, p < 0.001), whereas those requiring reinitiation showed no significant change (56–58 mmol/L, p = 0.331). A 10 mmol/L increase predicted successful down‐titration with 79.4% sensitivity and 78.6% specificity (area under the curve = 0.851).
Conclusions
Point‐of‐care urinary sodium monitoring may represent a non‐invasive and personalized approach to diuretic titration in HF management. Further trials are warranted to validate its clinical utility and long‐term benefits.
Background and Aims
Outpatient cardiology follow-up is the cornerstone of heart failure (HF) management, requiring adaptation based on patient severity. However, risk stratification using administrative data is scarce, and the association between follow-up and prognosis according to patient risk has yet to be described at a population level. This study aimed to describe prognosis and management across different strata using simple criteria, including diuretic use and prior HF hospitalization (HFH).
Methods
This nationwide cohort included all French patients reported as having HF in the previous 5 years and alive on 1 January 2020. Patients were categorized into four groups: (i) HFH within the past year (HFH ≤ 1y), (ii) HFH 1–5 years ago (HFH > 1y), (iii) not hospitalized using loop diuretics (NoHFH/LD+), and (iv) not hospitalized without loop diuretics (NoHFH/LD−). Between-group associations, all-cause mortality (ACM), and cardiology follow-up were analysed using survival models.
Results
The study included 655 919 patients [80 years (70–87), 48% female]. One-year ACM risk was 15.9%, ranging from 8.0% (NoHFH/LD−) to 25.0% (HFH ≤ 1y). Mortality risk was 1.61-fold higher for NoHFH/LD+, 1.83-fold for HFH > 1y, and 2.32-fold for HFH ≤ 1y compared to NoHFH/LD− (P < .0001). During the first year of follow-up (2020), cardiology consultation rates were similar across groups, with 40% of patients lacking an annual visit. Compared to no consultation, a single cardiology visit in the previous year (2019) was associated with a 6%–9% absolute reduction in 1-year ACM during the following year (2020) across all groups. The number needed to consult (NNC) to prevent one modelled death was 11–16. Additional visits showed greater benefit with increasing HF severity, with NNC ranging from 55 (NoHFH/LD−) to 20 (HFH ≤ 1y). The optimal follow-up to minimize the number of deaths without increasing the total number of consultations was 1 annual visit for NoHFH/LD−, 2–3 visits for NoHFH/LD+ and HFH > 1y, and 4 visits for HFH ≤ 1y patients.
Conclusions
Despite having a HF diagnosis, 40% of patients do not see a cardiologist annually, regardless of disease severity. Simple stratification based on hospitalization history and diuretic use effectively predicts outcomes. Tailoring the annual number of HF consultations according to this stratification could optimize resource use and reduce avoidable modelled deaths.
Background: There is recent evidence for the medical treatment of heart failure (HF) with mildly reduced ejection fraction (EF) and preserved EF (HFmrEF/HFpEF). However, in real-world settings, information on how cardiologists treat patients with HFmrEF/HFpEF, especially those with chronic, mild, and stable HF or newly diagnosed HF, is lacking. In other words, we do not know when cardiologists should start and intensify medical treatment, which drugs they should choose, or why. To answer these questions, we will conduct an observational study of HFmrEF/HFpEF. Here, we describe the rationale and protocol of this observational study.
Methods and Results: This study will explore the therapeutic status of approximately 4,200 patients who were diagnosed or newly diagnosed with chronic HFmrEF/HFpEF (LVEF >40%) at approximately 70 cardiology clinics and hospitals. After enrolment, physicians will check whether the current medical therapy is appropriate for each patient and initiate or intensify HF medical therapy appropriately. The primary endpoints will be: (1) the proportion of patients within the categories of reasons for changing prescriptions at visit 1 of HF medical therapy and (2) a composite of unexpected HF hospitalization and all-cause death in a 2-year follow-up.
Conclusions: This registry will uniquely confirm the current treatment status of patients with HFmrEF/HFpEF in real-world settings.
Background/Objectives: Heart failure (HF) poses a significant global health burden. In Spain, its prevalence rises annually, contributing significantly to cardiovascular-related hospitalizations and deaths. Through a broad and integrative perspective, the CARABELA-HF initiative seeks to improve the organization and delivery of HF care in Spain, addressing the key challenges identified across the care continuum. Methods: CARABELA-HF involved four phases: characterization of HF care models, validation of improvement areas, potential solutions and healthcare quality indicators, refinement of results from a regional perspective, and local dissemination and implementation. Ten pilot centers participated, and nine variables were identified to characterize operating HF care models. Results: Four HF care models were identified based on the degree of coordination between departments and resource availability. Structure, quality of care, and transformation indicators were used to evaluate these models, revealing improvement areas. Overall, this process identified solutions for generating a comprehensive and integrated HF care model, highlighting enhanced coordination, digital transformation, enhanced nursing roles, professional training and patients’ education, accredited HF care models, resource accessibility, and data-based evaluation. Conclusions: CARABELA-HF provides insights into current HF care models in Spain and identifies healthcare quality indicators for future improvement efforts. It strives to enhance patient outcomes, raise healthcare standards, and improve overall system efficiency through the promotion of a comprehensive and integrated HF care pathway.
The Get With the Guidelines-Heart Failure program was developed in 2005 with the goal of bringing evidence-based guidelines in heart failure management into widespread clinical practice. The program includes workshops, webinars, tool kits, chart abstraction, performance benchmarking, and achievement awards to drive quality improvement at participating hospitals. Two decades after its inception, the program has grown to include over 600 participating institutions across the United States. Linking registry data to Centers for Medicare and Medicaid Services claims has also allowed for the evaluation of longitudinal outcomes. Get With the Guidelines-Heart Failure has helped improve the quality of care for patients and has contributed substantially to the understanding of clinical science and optimal management of heart failure. This narrative review provides an overview of the indelible impact of the Get With the Guidelines-Heart Failure program on quality heart failure care over the past 20 years and highlights future challenges and directions.
Aims
The prevalence and impact of cardiovascular, kidney, and metabolic (CKM) overlap on physical function and prognosis in older patients with heart failure (HF) remain unclear. This study aimed to assess the impact of overlapping CKM conditions on physical function and prognosis in older patients with HF.
Methods
This post-hoc analysis of the FRAGILE-HF (main cohort) and SONIC-HF (validation cohort), both prospective multicentre studies, included patients aged ≥65 years who were hospitalised for HF. CKM overlap was defined as the presence of one or more of the following comorbidities: atherosclerotic cardiovascular disease, chronic kidney disease, or type 2 diabetes mellitus. The primary outcome was a composite of all-cause death and HF readmission within 2 years. Physical function was assessed using gait speed, five-time chair stand test (5CST), short physical performance battery (SPPB), and 6-min walk test (6MWT). To validate the prognostic association of CKM overlap, we conducted an external validation using the SONIC-HF cohort, an independent prospective study with identical inclusion criteria
Results
Of 1,113 patients (mean age: 80±8 years, 58.1% male), 193 (17.3%) had no CKM conditions, 370 (33.2%) had one, and 550 (49.5%) had two or three. A multivariable logistic regression model, adjusted for age, sex, comorbidities, and New York Heart Association functional class, showed that two or three CKM conditions were independently associated with lower physical function (5CST: odds ratio [OR]=1.91, P<0.001; SPPB: OR=1.87, P=0.001; 6MWT: OR=1.84, P=0.003). Kaplan–Meier analysis demonstrated a significant stepwise association between CKM overlap and the primary outcome in both the FRAGILE-HF and SONIC-HF cohorts (Log-rank: P < 0.001). Adjusted Cox analysis demonstrated that the overlapping CKM conditions were associated with the primary outcome, with two or more CKM conditions showing a statistically significant association in the FRAGILE-HF cohort (HR = 1.64, P = 0.003). Similarly, although statistical significance was not reached in the SONIC-HF cohort, a stepwise increase in HR was observed (2–3 CKM conditions: HR = 1.90, 95% CI: 0.97–3.73, P = 0.063).
Conclusion
Older patients with HF who have greater CKM overlap exhibited significantly poorer physical function and prognosis.
Background and Objective
In a tertiary care hospital in India, investigators evaluated the efficacy and safety of vericiguat, a new oral soluble guanylate cyclase stimulator in patients with worsening symptoms of heart failure and reduced ejection fraction (HFrEF).
Methods
A retrospective assessment was conducted on patients with HFrEF and deteriorating symptoms who received either guideline-directed medical therapy (GDMT) or vericiguat, in addition to GDMT. The main result was a combination of death and hospitalization for heart failure (HF). Other measured results included systolic and diastolic blood pressure (DBP), left ventricular ejection fraction (LVEF), levels of N-terminal probrain natriuretic peptide (NT-pro BNP), kidney function, and sodium and potassium levels in the body.
Results
After 6 months, 11 patients in the vericiguat group (22%) and 25 patients in the GDMT group (50%) experienced a primary composite event of death or hospitalization for HF. The administration of vericiguat resulted in a notable enhancement of the clinical indicators of HF, such as LVEF and NT-proBNP levels ( P < 0.001). Administration of vericiguat at a dosage of 10 mg once a day, in conjunction with GDMT, did not have any negative effects on systolic or DBP, renal function, or electrolyte balance compared to GDMT alone.
Conclusion
In patients experiencing deteriorating HF, the administration of vericiguat resulted in a notable decrease in cardiovascular mortality or hospitalization for HF compared with those who only received GDMT. This study emphasizes the efficacy and safety of vericiguat therapy in Indian patients with deteriorating HF.
Heart Failure (HF) impacts approximately 64 million people globally. While overall incidence of HF is relatively stable across countries, the overall number of HF patients is increasing due to aging populations. Many articles examine the microbiome in HF, however, studies from humans have not been analyzed systematically. The aim of this meta-analysis is to bridge this gap by analyzing previously published data on human HF patients with untargeted metabolomics to understand whether microbially-mediated metabolites are consistently important for HF status. A systematic survey of the literature identified 708 articles discussing HF, the microbiome, and metabolomics. Of these, 82 were primary studies of HF patients, 61 studied human adults, 23 included an untargeted metabolomics measure, and 3 studies had data that was usable and publicly accessible. These studies include a GCMS study from stool, NMR of saliva and exhaled breath condensate, and LCMS from left ventricle of HF patients undergoing transplantation and unused donor hearts. Significant differences were observed from PCA between HF and controls for stool and left ventricle, but not saliva or EBC samples. OPLS-DA was conducted for stool and ventricle samples, and further revealed significant group differences. Univariate testing with FDR correction revealed 8 significant microbially-relevant metabolites (p < 0.005 after correction), most notably asparagine from left ventricle and 2-methylbutyryl carnitine from stool. Though there is much discussion of the microbiome in health outcomes in HF, there is limited research from human populations. Some microbial co-metabolites from both stool and heart were significantly associated with HF.
Despite major advances in recent years, the timely detection and prevention of incipient congestion in patients with chronic heart failure remains challenging. Most approaches are either invasive or require the acquisition of additional hardware. Leveraging voice analysis for the purposes of diagnosing, predicting risks, and telemonitoring clinical outcomes of patients with heart failure represents a promising, cost-effective, and convenient alternative compared with hitherto deployed methods. To expand this field, close collaboration of several disciplines of medicine and computer science is an obligatory requirement. The current review aims to lay out the state-of-the-art in this quickly advancing area of research. It elucidates the foundation for voice feature extraction, describes the prospective capabilities of this evolving technology, and outlines the challenges involved in identifying vocal biomarkers both in general and in the context of heart failure.
Background
Although the assessment of in-hospital mortality risk among heart failure patients in the intensive care unit (ICU) is crucial for clinical decision-making, there is currently a lack of comprehensive models accurately predicting their prognosis. Machine learning techniques offer a powerful means to identify potential risk factors and predict outcomes within multivariable clinical data.
Methods
This study, based on the MIMIC-III database, extracted demographic characteristics, vital signs, laboratory test values, and comorbidity information of heart failure patients using structured query language. LASSO regression was employed for feature selection, and various machine learning algorithms were utilized to train models, including logistic regression (LR), random forest (RF), and gradient boosting (GB), among others. An ensemble learning model based on a soft voting mechanism was constructed. Model performance was evaluated using accuracy, recall, precision, F1 score, and AUC values through cross-validation and on an independent test set.
Results
In five-fold cross-validation, the soft voting ensemble learning model demonstrated the best overall performance, with accuracy and AUC values both at 0.86. Additionally, RF and GB models also performed well, with RF achieving an accuracy of 0.79 and an AUC of 0.79 on the independent test set, while the GB model achieved an accuracy of 0.77 and an AUC of 0.79. In contrast, other models such as LR, SVM, and KNN exhibited poorer performance in terms of accuracy and AUC values, indicating the significant advantage of ensemble methods in handling complex clinical prediction tasks.
Conclusion
This study demonstrates the potential of machine learning models, particularly ensemble learning models based on soft voting mechanisms, in predicting in-hospital mortality risk among heart failure patients in the ICU. The overall performance of the ensemble learning model confirms its effectiveness as an adjunct clinical decision-making tool. Future research should further optimize the models and validate them in a broader patient population to enhance their practical utility and accuracy in real clinical settings.
Importance
Singapore is considering subsidizing left ventricular assist devices (LVADs) for end-stage heart failure (ESHF) and uses cost-effectiveness evidence to inform the determination. Yet, no economic evaluation has thus far been conducted.
Objective
To estimate the lifetime cost-effectiveness of LVAD compared with optimal medical management for transplant-ineligible patients.
Design, Setting, and Participants
This economic evaluation used a Markov model to simulate survival, stroke incidence, other adverse events, and heart failure hospitalizations for a cohort of adult patients in Singapore with transplant-ineligible ESHF, most of whom were inotrope dependent. Latest LVAD mortality data from a randomized clinical trial were age-adjusted, and an indirect comparison of prior trial results was performed to estimate survival for inotrope-dependent and inotrope-independent patients. Costs were estimated (in 2023 Singapore dollars [SGD]) using cohort billing data from 2017 to 2022 and National Heart Centre Singapore LVAD charges. Statistical analysis was performed from December 2023 to July 2024.
Exposure
HeartMate 3 LVAD (Abbott).
Main Outcomes and Measures
Health care costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) evaluated against a threshold of SGD 114 000 (US 301 999), producing an ICER of SGD 117 370 (US 79 446) per QALY gained for inotrope-dependent patients and SGD 174 798 (US $130 446) per QALY gained for inotrope-independent patients (with 59% and 19% probabilities, respectively, of attaining high value). The inotrope-dependent ICER was sensitive to model input changes and structural assumptions, whereas the inotrope-independent ICER consistently exceeded the high-value threshold in scenario analyses. In threshold analyses, a 44% reduction in the total implantation price or a 54% reduction in the all-cause mortality hazard were required for LVAD to be high value for inotrope-independent patients. Confidence that the inotrope-dependent ICER is high value increased to 75% and 85% with respective 20% and 33% reductions in total implantation price.
Conclusions and Relevance
In this economic evaluation comparing LVAD with optimal medical management, LVAD was potentially high value for most transplant-ineligible patients who are inotrope dependent. Confidence in this result was improved with plausible price reductions, yet only extreme changes rendered LVAD high value for inotrope-independent patients.
Introduction: international studies have shown that hospital readmissions of patients with cardiovascular diseases (CVD) are related to worse clinical outcomes and increased health costs. Objective: to estimate one-year survival in patients with multiple admissions for cardiovascular diseases and to compare it with that of those who had a single hospital admission. Method: a secondary analysis of hospital discharge databases of the Ministry of Public Health of patients over 14 years of age with CVD admissions in 2020 in Uruguay was performed. Two groups were generated: group 1 (G1), people with 1 hospital admission (HI), and group 2 (G2), with 2 or more hospital admissions (HIs). For the survival curves, the Kaplan-Meier method and log-rank test were used. Results: in 2020, there were 20,354 people with HIs due to CVD alive at discharge. There were 17,499 in G1 (mean age 67.9 ± 15.3 years, 55.1% men) and 2,855 in G2 (mean age 69.7 ± 13.6 years, 58.1% men), with 37,5% of readmissions ≤ 30 days. Survival at one year for G1 vs. G2 was 84.6% vs. 71.7% (95% confidence interval (95% CI): 84.1%; 85.1% vs. 70.1%; 73.4%), p < 0.05>. CVD was the cause of death in 42.2% and 61.6%, respectively, p < 0.05. The adjusted HR of mortality at one year for G2 was 1.86 (95% CI: 1.74; 2.00) compared to G1. Conclusions: in Uruguay, patients with HIs due to CVD had a worse life prognosis at one year, with an increased risk of death of 86%. CVD was responsible for almost 2/3 of mortality.
Digital maturity and readiness are well-known concepts; however in reviewing the research early breakthrough digital health innovations (DHI) can be challenging to capture and assess as part of the common maturity and assessment models utilized. Even though there are many digital maturity models available today (Schallmo, D.R.A., Tidd, J. (eds) Digitalization. Management for Professionals. Springer, Cham. https://doi.org/10.1007/978-3-030-69380-0_5), he challenge is mainly due to innovation projects’ immaturity and usual lack of fidelity, integration, and inconclusive service pathway design at that point, along with most organizations marked at being at “early or intermediate stages of digital maturity” (Ladu L, Koch C, Ashari PA, Technol Soc 77: 102564, 2024), and a recent publication stated that “frontier and emerging technology” was not fully aligned with many of the maturity models used (Zhao, Schalet, Alsalamah, Stud Health Technol Inform 305:257–260, 2023).
The Oxford Dictionary defines innovation as “the process through which new products, concepts, services, methods, or techniques are developed” (Oxford definitions—www.oxfordreference.com/display/10.1093/oi/authority.20110803100004376) or as Joseph Schumpeter argues ensuring the system is made ready for “supporting the process of creative destruction” (Hospers 2005 Vol18 page 35—https://link.springer.com/content/pdf/10.1007/s12130-005-1003-1.pdf). Through this innovation lens, it is therefore important to examine how, and if, we can assess new emerging innovations through standard digital maturity models (DMMs), and whether DMA digital maturity assessment (DMA) tools can fully accommodate new and upcoming DHIs that are not yet fully conceived, connected, or stable within mature hospital and healthcare systems.
This chapter discusses how organizations are assessing their digital maturity, taking into consideration a drive for more integrated care ambitions (UK Gov—https://www.gov.uk/government/publications/a-plan-for-digital-health-and-social-care/a-plan-for-digital-health-and-social-care) and the use of disruptive technologies and innovations to help solve the major challenges. Case studies are used within this chapter to illustrate how a heuristic innovation readiness framework is used to demonstrate that the innovation project is increasing in readiness level terms, and how innovations accumulate evidence through each stage with the ambition to be ultimately handed over for service and technical integration (linking to more mature and anchored systems within hospitals and other associated systems), what we would commonly regard as moving out the research and development (R&D) stage into business as usual (BAU).
Background: Although tricuspid regurgitation (TR) is no longer considered a negligible disease, its detailed status in real-world heart failure (HF) patients remains unknown.
Methods and Results: From the KUNIUMI registry, we evaluated data for 1,646 consecutive HF patients. The primary endpoint was all-cause mortality over a median follow-up period of 3.0 years (interquartile range 1.4–3.0 years). Of the 1,646 HF patients, 369 (22.4%) had moderate or greater TR; the mean (±SD) age of these patients was 82.0±8.5 years. Atrial functional TR was the most common etiology of TR in HF patients with moderate or greater TR (70.7%), and was more common in HF patients with severe than moderate TR (75.5% vs. 65.3%; P=0.032). The mortality rate was high in HF patients with severe and moderate TR (27.1% and 17.0%, respectively). During follow-up, 33.1% of HF patients with moderate TR progressed to severe TR, and showed unfavorable all-cause mortality compared with those with unchanged TR. Atrial functional TR was a more common etiology in HF patients with moderate TR and worsened TR than in those with unchanged TR (84.6% vs. 59.5%; P=0.004). Right atrial enlargement was independently correlated with worsened TR.
Conclusions: Moderate or greater TR was prevalent in 22.4% of the real-world super-aged HF population. Even HF patients with moderate TR had poor outcomes, with right atrial remodeling a key factor for worsened TR.
Background
Patients with heart failure (HF) are typically classified based on left ventricular ejection fraction (LVEF). However, this may not optimally reflect distinct groups or predict risk. Therefore, alternative classification methods are needed.
Objective
Our aim was to classify patients with HF based on sociodemographic and clinical data using latent class analysis, assess if latent classes pose varying risks of mortality and rehospitalization, and explore if these classes offer better risk stratification than LVEF or N-terminal prohormone of brain natriuretic peptide (NT-proBNP) alone.
Methods
Data from 1045 patients were analyzed using latent class analysis to identify classes and assess mortality and rehospitalization risks. Kaplan-Meier curves with log-rank tests were used to compare mortality across latent classes, LVEF-based groups, and NT-proBNP–based groups.
Results
Three latent classes were identified. Class 1 (48.8%) comprised middle-aged males with HF with reduced ejection fraction (HFrEF) and high NT-proBNP levels. Class 2 (26.1%) consisted of mainly older females with HF with preserved ejection fraction, high body mass index, hypertension, atrial fibrillation, and anemia. Class 3 (25.2%) included younger patients with HFrEF, high body mass index, and a high smoking rate. Class 1 and 2 had higher mortality risks ( P < .001) and longer rehospitalization durations ( P = .011) than class 3.
Conclusion
Latent class analysis categorized a heterogeneous group of patients with HF into homogeneous classes. These classes provide a close approximation of what could be observed in clinical practice and provide insight into patients at higher risk of mortality and rehospitalization.
Heart failure is one of the major health threats in Western societies, and its prevalence is steadily increasing. Many data show the important impact of sex (biological) and gender (sociocultural) differences on most aspects (diagnosis, etiology, treatments, and outcomes) of heart failure. For example, compared to men, women with heart failure are older, have more co-morbidities, and develop different phenotypes of heart failure. Postpartum cardiopathy is unique in women. The iatrogenic effects of cancer therapies are more frequent among women compared to men. Currently, the integration of sex and gender differences into the therapy of heart failure is rare. Consequently, women derive disadvantages from a nonspecifically adapted therapy for heart failure, get worse outcomes, and have more iatrogenic adverse effects than men. This situation is medically unfortunate and increases medical expenditures. A sex-guided approach to the correct evaluation of patients with heart failure should become the cornerstone for the correct management of these patients.
Heart failure with preserved ejection fraction (HFpEF) remains a major health concern with limited therapeutic options. Growing evidence supports the multiple benefits of ketones in heart disease, but their impact on HFpEF remains unknown. We investigated whether increasing ketones can help to manage HFpEF. Using the ZSF1 rat model of HFpEF, 16‐week‐old rats were randomly assigned to one of three subgroups: (i) control diet; (ii) ketogenic diet (KD); or (iii) control diet with added exogenous ketone salts (KS) in their drinking water for 10 weeks. We found that both KD and KS ameliorated the HFpEF phenotype by improving structural echocardiographic parameters, lowering glycaemia and lipid profiles, and reducing HFpEF‐related fibrosis and hypertrophy without impacting in vivo diastolic function. Nevertheless, ex vivo cardiomyocyte preparations showed improved calcium handling and myofilament relaxation, suggesting benefits at the cellular level. Interestingly, KD still proved effective, despite the potentially adverse increase in fat mass. There was decreased myofilament Ca²⁺ sensitivity and normalized active and passive tension in both groups, especially KS. These results suggest that providing ketone through the diet or supplements could be a valuable strategy to complement HFpEF treatment. Given the well‐known challenges of implementing dietary changes, exogenous KS offer a more practical and effective option to achieve these benefits. image
Key points
Ketogenic diet and ketone salts effectively reversed the cardiac structural impairments associated with the ZSF1 Obese heart failure with preserved ejection fraction (HFpEF) phenotype by ameliorating left ventricular mass.
Both treatments reduced fibrosis and hypertrophy, leading to improved or, in the case of ketone salts, even reversed cardiomyocyte contractile and relaxation performance.
Ketone salts also reversed HFpEF‐related cardiomyocyte stiffness and prevented a reduction in the development of maximum force.
Both treatments improved myofilament Ca²⁺ sensitivity.
Both treatments also improved the metabolic profile, reducing hyperglycaemia, blood triglycerides and levels of NT‐proBNP, a well‐known biomarker of worsening heart failure.
Background
Research on the care needs of patients with heart failure (HF) has predominantly relied on cross-sectional studies. Consequently, there is limited understanding of how care needs evolve over time within this population.
Objectives
The aims of this study were to explore the trajectories of care needs in patients with HF 1 year after discharge and analyze the potential factors that can predict these trajectories.
Methods
A total of 197 patients with HF were recruited and followed at 1, 3, 6, and 12 months postdischarge. Care needs were assessed using the care needs survey questionnaire, and potential factors were selected based on the Andersen Behavioral Model. A growth mixture model was used to identify the trajectories of care needs, whereas logistic regression analyses were used for statistical comparisons.
Results
Three trajectories in the care needs of patients with HF were identified: (1) a mild increase trajectory, (2) a decline trajectory, and (3) a persistently high trajectory. Need factors were the most significant determinants of care needs trajectories, with higher New York Heart Association functional classification, left ventricular ejection fraction less than 40%, and lower self-reported health serving as key predictors of persistently high trajectory. In contrast, only lower self-efficacy and the absence of a spouse as predisposing factors were associated with an increased risk of maintaining persistently high levels of care needs.
Conclusion
Care needs after discharge in patients with HF can be characterized by 3 trajectories. Need factors will help clinicians with early identification of patients with persistently high level of care needs.
Wnt signaling encompasses multiple and complex signaling cascades and is involved in many developmental processes such as tissue patterning, cell fate specification, and control of cell division. Consequently, accurate regulation of signaling activities is essential for proper embryonic development. Wnt signaling is mostly silent in the healthy adult organs but a reactivation of Wnt signaling is generally observed under pathological conditions. This has generated increasing interest in this pathway from a therapeutic point of view. In this review article, the involvement of Wnt signaling in cardiovascular development will be outlined, followed by its implication in myocardial infarct healing, cardiac hypertrophy, heart failure, arrhythmias, and atherosclerosis. The initial experiments not always offer consensus on the effects of activation or inactivation of the pathway, which may be attributed to (i) the type of cardiac disease, (ii) timing of the intervention, and (iii) type of cells that are targeted. Therefore, more research is needed to determine the exact implication of Wnt signaling in the conditions mentioned above to exploit it as a powerful therapeutic target. © 2015 American Physiological Society. Compr Physiol 5:1183‐1209, 2015.
To evaluate how recommendations of European guidelines regarding pharmacological and non-pharmacological treatments for heart failure (HF) are adopted in clinical practice.
The ESC-HF Long-Term Registry is a prospective, observational study conducted in 211 Cardiology Centres of 21 European and Mediterranean countries, members of the European Society of Cardiology (ESC). From May 2011 to April 2013, a total of 12 440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. Intravenous treatments for acute HF were heterogeneously administered, irrespective of guideline recommendations. In chronic HF, with reduced EF, renin-angiotensin system (RAS) blockers, beta-blockers, and mineralocorticoid antagonists (MRAs) were used in 92.2, 92.7, and 67.0% of patients, respectively. When reasons for non-adherence were considered, the real rate of undertreatment accounted for 3.2, 2.3, and 5.4% of the cases, respectively. About 30% of patients received the target dosage of these drugs, but a documented reason for not achieving the target dosage was reported in almost two-thirds of them. The more relevant reasons for non-implantation of a device, when clinically indicated, were related to doctor uncertainties on the indication, patient refusal, or logistical/cost issues.
This pan-European registry shows that, while in patients with acute HF, a large heterogeneity of treatments exists, drug treatment of chronic HF can be considered largely adherent to recommendations of current guidelines, when the reasons for non-adherence are taken into account. Observations regarding the real possibility to adhere fully to current guidelines in daily clinical practice should be seriously considered when clinical practice guidelines have to be written.
AIMS: The ESC-HF Pilot survey was aimed to describe clinical epidemiology and 1-year outcomes of outpatients and inpatients with heart failure (HF). The pilot phase was also specifically aimed at validating structure, performance, and quality of the data set for continuing the survey into a permanent Registry.Methods
The ESC-HF Pilot study is a prospective, multicentre, observational survey conducted in 136 Cardiology Centres in 12 European countries selected to represent the different health systems across Europe. All outpatients with HF and patients admitted for acute HF on 1 day per week for eight consecutive months were included. From October 2009 to May 2010, 5118 patients were included: 1892 (37%) admitted for acute HF and 3226 (63%) patients with chronic HF. The all-cause mortality rate at 1 year was 17.4% in acute HF and 7.2% in chronic stable HF. One-year hospitalization rates were 43.9% and 31.9%, respectively, in hospitalized acute and chronic HF patients. Major regional differences in 1-year mortality were observed that could be explained by differences in characteristics and treatment of the patients. CONCLUSION: The ESC-HF Pilot survey confirmed that acute HF is still associated with a very poor medium-term prognosis, while the widespread adoption of evidence-based treatments in patients with chronic HF seems to have improved their outcome profile. Differences across countries may be due to different local medical practice as well to differences in healthcare systems. This pilot study also offered the opportunity to refine the organizational structure for a long-term extended European network.
There are over 1 million hospitalizations for heart failure (HF) annually in the United States alone, and a similar number has been reported in Europe. Recent clinical trials investigating novel therapies in patients with hospitalized HF (HHF) have been negative, and the post-discharge event rate remains unacceptably high. The lack of success with HHF trials stem from problems with understanding the study drug, matching the drug to the appropriate HF subgroup, and study execution. Related to the concept of study execution is the importance of including appropriate study sites in HHF trials. Often overlooked issues include consideration of the geographic region and the number of patients enrolled at each study center. Marked differences in baseline patient co-morbidities, serum biomarkers, treatment utilization and outcomes have been demonstrated across geographic regions. Furthermore, patients from sites with low recruitment may have worse outcomes compared to sites with higher enrollment patterns. Consequently, sites with poor trial enrollment may influence key patient end points and likely do not justify the costs of site training and maintenance. Accordingly, there is an unmet need to develop strategies to identify the right study sites that have acceptable patient quantity and quality. Potential approaches include, but are not limited to, establishing a pre-trial registry, developing site performance metrics, identifying a local regionally involved leader and bolstering recruitment incentives. This manuscript summarizes the roundtable discussion hosted by the Food and Drug Administration between members of academia, the National Institutes of Health, industry partners, contract research organizations and academic research organizations on the importance of selecting optimal sites for successful trials in HHF.
The prognosis of patients hospitalized with acute heart failure (AHF) is poor and risk stratification may help clinicians guide care. The objectives of the Acute Heart Failure Database (AHEAD) registry are to assess patient characteristics, etiology, treatment and outcome of AHF.
The AHEAD main registry includes patients hospitalized for AHF in seven centers with a Catheterization Laboratory Service in the Czech Republic. The data were collected from September 2006 to October 2009. The inclusion criteria for the database adhere to the European guidelines for AHF (2005) and patients were systematically classified according to the basic syndromes, type and etiology of AHF.
Of 4,153 patients, 12.7% died during hospitalization. The median length of hospitalization was 7.1 days. Mean age of patients was 71.5 ± 12.4 years; men were younger (68.6 ± 12.4 years) compared to women (75.5 ± 11.5 years) (P < 0.001). De-novo heart failure was seen in 58.3% of the patients. According to the classification of heart failure syndromes, acute decompensated heart failure (ADHF) was reported in 55.3%, hypertensive AHF in 4.4%, pulmonary edema in 18.4%, cardiogenic shock in 14.7%, high output failure in 3.3%, and right heart failure in 3.8%. The mortality of cardiogenic shock was 62.7%, of right AHF 16.7%, of pulmonary edema 7.1%, of high output HF 6.1%, whereas the mortality of hypertensive AHF or ADHF was < 2.5%. According to multivariate analyses, low systolic blood pressure, low cholesterol level, hyponatremia, hyperkalemia, the use of inotropic agents and norepinephrine were predictive parameters for in-hospital mortality in patients without cardiogenic shock. Severe left ventricular dysfunction and renal insufficiency were predictive parameters for mortality in patients with cardiogenic shock. Invasive ventilation and age over 70 years were the most important predictive factors for mortality in both genders with or without cardiogenic shock.
The AHEAD Main registry provides up-to-date information on the etiology, treatment and hospital outcomes of patients hospitalized with AHF. The results highlight the highest risk patients.
We performed a survey on acute heart failure (AHF) in nine countries in four continents. We aimed to describe characteristics and management of AHF among various countries, to compare patients with de novo AHF versus patients with a pre-existing episode of AHF, and to describe subpopulations hospitalized in intensive care unit (ICU) versus cardiac care unit (CCU) versus ward.
Data from 4,953 patients with AHF were collected via questionnaire from 666 hospitals. Clinical presentation included decompensated congestive HF (38.6%), pulmonary oedema (36.7%) and cardiogenic shock (11.7%). Patients with de novo episode of AHF (36.2%) were younger, had less comorbidities and lower blood pressure despite greater left ventricular ejection fraction (LVEF) and were more often admitted to ICU. Overall, intravenous (IV) diuretics were given in 89.7%, vasodilators in 41.1%, and inotropic agents (dobutamine, dopamine, adrenaline, noradrenaline and levosimendan) in 39% of cases. Overall hospital death rate was 12%, the majority due to cardiogenic shock (43%). More patients with de novo AHF (14.2%) than patients with a pre-existing episode of AHF (10.8%) (p = 0.0007) died. There was graded mortality in ICU, CCU and ward patients with mortality in ICU patients being the highest (17.8%) (p < 0.0001).
Our data demonstrated the existence of different subgroups based on de novo or pre-existing episode(s) of AHF and the site of hospitalization. Recognition of these subgroups might improve management and outcome by defining specific therapeutic requirements.
β-Blockers for the treatment of heart failure are underprescribed in the United States despite the availability of extensive data and the current guidelines that support their use. The ongoing Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) study was designed to determine if initiation of beta blockade prior to hospital discharge is safe and improves the long-term use of β-blockers. IMPACT-HF is a multicenter, randomized, open-label trial of carvedilol initiated before hospital discharge or to usual care in 363 patients hospitalized for worsening heart failure. The primary end point of the study is the number of patients treated with any β-blocker at 60 days. Secondary endpoints include β-blocker dose achieved and a composite clinical endpoint. The data from the IMPACT-HF trial will provide evidence to evaluate whether in-hospital initiation of β-blocker therapy is effective in improving the long-term use of β-blockers in this population.
Age adjusted hospitalisation rates for heart failure have increased considerably throughout the western world in the 1980s and early 1990s, as documented by reports from New Zealand, the USA, Sweden, Spain, Scotland, and the Netherlands.1,2 Hospitalisations account for as much as 70% of the health care budget spent on heart failure.1 Angiotensin converting enzyme (ACE) inhibition became the cornerstone of heart failure treatment in the 1990s, following demonstration of reduction in mortality and readmissions in patients with heart failure or left ventricular dysfunction enrolled in clinical trials.3 We examined trends in hospitalisations for heart failure and ACE inhibitor prescription rates in the Netherlands from 1980 to 1999.
All hospital admissions, including in-hospital deaths, with a first listed discharge diagnosis of heart failure were studied, using the methods described in detail previously.2 Briefly, International classification of diseases , ninth revision (ICD-9) codes 428.x (heart failure), 402.x (hypertensive heart disease), and 429.1 (myocardial degeneration) were used to identify discharges for heart failure. Complete national data on discharges were obtained from Prismant and on Dutch population figures from Statistics Netherlands. From 1980 to 1999 the mean age of patients admitted for heart failure increased from 71.2 to 72.9 years in men and from 75.0 to 77.7 years in women. Age adjusted discharge rates were calculated by direct standardisation to the European standard population. Trends over time in discharge rates were analysed separately for men and women using Poisson regression. The model included calendar year, …
Background:
Heart failure (HF) is an important contributor to both the burden and cost of national healthcare expenditures, with more older Americans hospitalized for HF than for any other medical condition. With the aging of the population, the impact of HF is expected to increase substantially.
Methods and results:
We estimated future costs of HF by adapting a methodology developed by the American Heart Association to project the epidemiology and future costs of HF from 2012 to 2030 without double counting the costs attributed to comorbid conditions. The model assumes that HF prevalence will remain constant by age, sex, and race/ethnicity and that rising costs and technological innovation will continue at the same rate. By 2030, >8 million people in the United States (1 in every 33) will have HF. Between 2012 and 2030, real (201021 billion to 31 billion in 2012 to 160 billion in direct costs).
Conclusions:
The estimated prevalence and cost of care for HF will increase markedly because of aging of the population. Strategies to prevent HF and improve the efficiency of care are needed.
Context: Estimation of mortality risk in patients hospitalized with acute decompensated heart failure (ADHF) may help clinicians guide care. Objective: To develop a practical user-friendly bedside tool for risk stratification for patients hospitalized with ADHF. Design, Setting, and Patients: The Acute Decompensated Heart Failure National Registry (ADHERE) of patients hospitalized with a primary diagnosis of ADHF in 263 hospitals in the United States was queried with analysis of patient data to develop a risk stratification model. The first 33 046 hospitalizations (derivation cohort; October 2001-February 2003) were analyzed to develop the model and then the validity of the model was prospectively tested using data from 32 229 subsequent hospitalizations (validation cohort; March-July 2003). Patients had a mean age of 72.5 years and 52% were female. Main Outcome Measure: Variables predicting mortality in ADHF. Results: When the derivation and validation cohorts are combined, 37 772 (58%) of 65 275 patient-records had coronary artery disease. Of a combined cohort consisting of 52 164 patient-records, 23 910 (46%) had preserved left ventricular systolic function. In-hospital mortality was similar in the derivation (4.2%) and validation (4.0%) cohorts. Recursive partitioning of the derivation cohort for 39 variables indicated that the best single predictor for mortality was high admission levels of blood urea nitrogen (≥43 mg/dL [15.35 mmol/L]) followed by low admission systolic blood pressure (<115 mm Hg) and then by high levels of serum creatinine (≥2.75 mg/dL [243.1 μmol/L]). A simple risk tree identified patient groups with mortality ranging from 2.1% to 21.9%. The odds ratio for mortality between patients identified as high and low risk was 12.9 (95% confidence interval, 10.4-15.9) and similar results were seen when this risk stratification was applied prospectively to the validation cohort. Conclusions: These results suggest that ADHF patients at low, intermediate, and high risk for in-hospital mortality can be easily identified using vital sign and laboratory data obtained on hospital admission. The ADHERE risk tree provides clinicians with a validated, practical bedside tool for mortality risk stratification.
More than a million hospitalizations for heart failure (HHF) occur annually in the United States, with mortality and readmission rates up to 50% within 60 to 90 days after discharge. The annual costs for HF care exceed $40 billion, with the majority spent on HHF. Hospital reimbursement is now tied to 30-day readmission rates among patients with HF.1 Most HHF patients have worsening chronic HF and are receiving recommended therapies. Despite improved signs or symptoms by discharge, postdischarge event rates remain high. About half of the HHF patients have preserved left ventricular ejection fraction for which there is no evidence-based treatment.
Background:
Hospitalized heart failure (HHF) is a critical issue in Japan. To improve its management and outcomes, the clinical features, in-hospital management, and outcomes should be analyzed to improve the guidelines for HHF.
Methods and results:
The acute decompensated heart failure syndromes (ATTEND) registry is the largest study of HHF in Japan. The present report covers the clinical features and in-hospital management of HHF patients. The data from 4,842 enrolled patients have demonstrated that most Japanese HHF patients are elderly, with new onset, and a history of hypertension and orthopnea on admission. During hospitalization, furosemide and carperitide were commonly used and the length of stay was extremely long (mean 30 days), with 6.4% in-hospital mortality.
Conclusions:
The findings of the present study suggest the following: (1) the focus for hypertensive elderly and diabetic patients should be on primary prevention of HHF,(2) more intensive management with noninvasive positive pressure ventilation should be performed at the urgent stage, (3) it is necessary to clarify the clinical benefit of carperitide and angiotensin-receptor blockers, because they are commonly used in Japan, and (4) it is necessary to clarify the relationship between in-hospital mortality and length of stay from the viewpoint of both outcome and cost of patient care.
Objectives:
This study sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis.
Background:
Heart failure patients are frequently admitted for both heart failure and other causes.
Methods:
Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based on the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and sex-standardized hospitalization rates were determined by dividing the number of hospitalizations by the U.S. population in a given year and using direct standardization.
Results:
The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, whereas secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and sex-adjusted rates of primary heart failure hospitalizations decreased steadily from 2001 to 2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased from 1,370 to 1,476 per 100,000 people from 2001 to 2006, then decreased to 1,359 per 100,000 people in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections.
Conclusions:
Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and noncardiac conditions.
Hospitalization for heart failure (HF) is a clinical entity associated with high postdischarge morbidity and mortality, yet few therapies are available to improve outcomes in patients with this condition. In the past decade, large phase III studies of HF treatments have failed to demonstrate drug efficacy, safety, or both, despite encouraging results from preceding phase II trials. This Review is focused on this disconnect between the results of phase II and phase III trials of drugs for HF and discusses findings from five drug-development programs (for levosimendan, tezosentan, tolvaptan, rolofylline, and nesiritide) to shed light on common themes in clinical trials conducted in patients hospitalized for HF. In particular, the importance of selecting the 'right' patient population, drug, and clinical end points to optimize the trial design is discussed. Areas that require further investigation are highlighted and we suggest possible directions that will help to guide future clinical trials in these patients. Large, expensive phase III trials should not be initiated without adequate phase II evidence or on the basis of overly optimistic interpretation of phase II data. Additionally, drug development programs should be targeted not only to change short-term symptoms, but also to improve the postdischarge event rate.
Objectives:
The study investigated whether the number of participants enrolled per site in an acute heart failure trial is associated with participant characteristics and outcomes.
Background:
Whether and how site enrollment volume affects clinical trials is not known.
Methods:
A total of 4,133 participants enrolled among 359 sites were grouped on the basis of total enrollment into 1 to 10, 11 to 30, and >30 participants per site and were compared for outcomes (cardiovascular mortality or heart failure hospitalization).
Results:
Per-site enrollment ranged from 0 to 75 (median 6; 77 sites had no enrollment). Regional differences in enrollment were noted between North and South America, and Western and Eastern Europe (p < 0.001). Participants from sites with fewer enrollments were more likely to be older and male, have lower ejection fraction and blood pressure as well as worse comorbidity and laboratory profile, and were less likely to be on angiotensin-converting enzyme inhibitors or aldosterone antagonists. During a median follow-up of 9.9 months, 1,700 (41%) participants had an outcome event. Compared to event rate at sites with >30 participants (32%), those with 1 to 10 (51%, hazard ratio [HR]: 1.77, 95% confidence interval [CI]: 1.56 to 2.02) and 11 to 30 (42%, HR: 1.44, 95% CI: 1.28 to 1.62) participants per site groups had worse outcomes. This relationship was comparable across regions (p = 0.43). After adjustment for risk factors, participants enrolled at sites with fewer enrollees were at higher risk for adverse outcomes (HR: 1.26, 95% CI: 1.08 to 1.46 for 1 to 10; HR: 1.22, 95% CI: 1.07 to 1.38 for 11 to 30 vs. >30 participant sites). Higher proportion of participants from site with >30 participants completed the protocol (45.5% for <10, 61.7% for 11 to 30, and 68.4% for sites enrolling >30 participants; p < 0.001).
Conclusions:
Baseline characteristics, protocol completion, and outcomes differed significantly among higher versus lower enrolling sites. These data imply that the number of participant enrolled per site may influence trials beyond logistics.
Registries and surveys improve knowledge of the 'real world'. This paper aims to describe baseline clinical profiles, management strategies, and the in-hospital outcome of patients admitted to hospital for an acute heart failure (AHF) episode.
IN-HF Outcome is a nationwide, prospective, multicentre, observational study conducted in 61 Cardiology Centres in Italy. Up to December 2009, 5610 patients had been enrolled, 1855 (33%) with AHF and 3755 (67%) with chronic heart failure (CHF). Baseline and in-hospital outcome data of AHF patients are presented. Mean age was 72 ± 12 years, and 39.8% were female. Hospital admission was due to new-onset heart failure (HF) in 43% of cases. Co-morbid conditions were observed more frequently in the worsening HF group, while those with de novo HF showed a higher heart rate, blood pressure, and more preserved left ventricular ejection fraction (LVEF). Electrical devices were previously implanted in 13.3% of the entire group. Inotropes were administered in 19.4% of the patients. The median duration of hospital stay was 10 days (interquartile range 7-15). All-cause in-hospital death was 6.4%, similar in worsening and de novo HF. Older age, hypotension, cardiogenic shock, pulmonary oedema, symptoms of hypoperfusion, hyponatraemia, and elevated creatinine were independent predictors of all-cause death.
Our registry confirms that in-hospital mortality in AHF is still high, with a long length of stay. Pharmacological treatment seems to be practically unchanged in the last decades, and the adherence to HF guidelines concerning implantable cardioverter defibrillators/cardiac resynchronization therapy is still very low. Some AHF phenotypes are characterized by worst prognosis and need specific research projects.
Cardiac troponin testing is commonly performed in patients with heart failure (HF). Despite being strongly linked to spontaneous (Type I) acute myocardial infarction (MI)-a common cause of acute HF syndromes-it is well recognized that concentrations of circulating troponins above the 99th percentile of a normal population in the context of both acute and chronic HF are highly prevalent, and frequently unrelated to Type I MI. Other mechanism(s) leading to troponin elevation in HF syndromes remain elusive in many cases but prominently includes supply-demand inequity (Type II MI), which may be associated with coronary artery obstruction and endothelial dysfunction, or may occur in the absence of coronary obstruction due to increased oxygen demand related to increased wall tension, anaemia, or other factors provoking subendocardial injury. Non-coronary triggers, such as cellular necrosis, apoptosis, or autophagy in the context of wall stress may explain the troponin release in HF, as can toxic effects of circulating neurohormones, toxins, inflammation, and infiltrative processes, among others. Nonetheless, across a wide spectrum of HF syndromes, when troponin elevation occurs, independent of mechanism, it is strongly predictive of an adverse outcome. Clinicians should be aware of the high frequency of troponin elevation when measuring the marker in patients with HF, should keep in mind the possible causes of this phenomenon, and, independent of a diagnosis of 'acute MI', should recognize the considerable ramifications of troponin elevation in this setting.
Heart failure with preserved ejection fraction (EF) is a common syndrome, but trends in treatments and outcomes are lacking.
We analyzed data from 275 hospitals in Get With the Guidelines-Heart Failure from January 2005 to October 2010. Patients were stratified by EF as reduced EF (EF <40% [HF-reduced EF]), borderline EF (40%≤EF<50% [HF-borderline EF]), or preserved (EF ≥50% [HF-preserved EF]). Using multivariable models, we examined trends in therapies and outcomes. Among 110 621 patients, 50% (55 083) had HF-reduced EF, 14% (15 184) had HF-borderline EF, and 36% (40 354) had HF-preserved EF. From 2005 to 2010, the proportion of hospitalizations for HF-preserved EF increased from 33% to 39% (P<0.0001). In multivariable analyses, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at discharge decreased in all EF groups, and β-blocker use increased. Patients with HF-preserved EF less frequently achieved blood pressure control (adjusted odds ratio, 0.44 versus HF-reduced EF; P<0.001) and were more likely discharged to skilled nursing (adjusted odds ratio, 1.16 versus HF-reduced EF; P<0.001). In-hospital mortality for HF-preserved EF decreased from 3.32% in 2005 to 2.35% in 2010 (adjusted odds ratio, 0.89 per year; P=0.01) but was stable for patients with HF-reduced EF (3.03%-2.83%; adjusted odds ratio, 0.93 per year; P=0.10).
Hospitalization for HF-preserved EF is increasing relative to HF-reduced EF. Although in-hospital mortality for patients with HF-preserved EF declined over the study period, an important opportunity remains for identifying evidence-based therapies in patients with HF-preserved EF.
BACKGROUND: The Randomized Aldactone Evaluation Study (RALES) demonstrated that spironolactone significantly improves outcomes in patients with severe heart failure. Use of angiotensin-converting-enzyme (ACE) inhibitors is also indicated in these patients. However, life-threatening hyperkalemia can occur when these drugs are used together. METHODS: We conducted a population-based time-series analysis to examine trends in the rate of spironolactone prescriptions and the rate of hospitalization for hyperkalemia in ambulatory patients before and after the publication of RALES. We linked prescription-claims data and hospital-admission records for more than 1.3 million adults 66 years of age or older in Ontario, Canada, for the period from 1994 through 2001. RESULTS: Among patients treated with ACE inhibitors who had recently been hospitalized for heart failure, the spironolactone-prescription rate was 34 per 1000 patients in 1994, and it increased immediately after the publication of RALES, to 149 per 1000
Estimation of mortality risk in patients hospitalized with acute decompensated heart failure (ADHF) may help clinicians guide care.
To develop a practical user-friendly bedside tool for risk stratification for patients hospitalized with ADHF.
The Acute Decompensated Heart Failure National Registry (ADHERE) of patients hospitalized with a primary diagnosis of ADHF in 263 hospitals in the United States was queried with analysis of patient data to develop a risk stratification model. The first 33,046 hospitalizations (derivation cohort; October 2001-February 2003) were analyzed to develop the model and then the validity of the model was prospectively tested using data from 32,229 subsequent hospitalizations (validation cohort; March-July 2003). Patients had a mean age of 72.5 years and 52% were female.
Variables predicting mortality in ADHF.
When the derivation and validation cohorts are combined, 37,772 (58%) of 65,275 patient-records had coronary artery disease. Of a combined cohort consisting of 52,164 patient-records, 23,910 (46%) had preserved left ventricular systolic function. In-hospital mortality was similar in the derivation (4.2%) and validation (4.0%) cohorts. Recursive partitioning of the derivation cohort for 39 variables indicated that the best single predictor for mortality was high admission levels of blood urea nitrogen (> or =43 mg/dL [15.35 mmol/L]) followed by low admission systolic blood pressure (<115 mm Hg) and then by high levels of serum creatinine (> or =2.75 mg/dL [243.1 micromol/L]). A simple risk tree identified patient groups with mortality ranging from 2.1% to 21.9%. The odds ratio for mortality between patients identified as high and low risk was 12.9 (95% confidence interval, 10.4-15.9) and similar results were seen when this risk stratification was applied prospectively to the validation cohort.
These results suggest that ADHF patients at low, intermediate, and high risk for in-hospital mortality can be easily identified using vital sign and laboratory data obtained on hospital admission. The ADHERE risk tree provides clinicians with a validated, practical bedside tool for mortality risk stratification.
It is unclear if the presence of atrial fibrillation (AF) on admission is associated with worse in-hospital outcomes in patients hospitalized with heart failure (HF). This study evaluated the clinical characteristics, management, length of stay, and mortality of HF patients with and without AF.
We studied 99 810 patients from 255 sites admitted with HF enrolled in Get With The Guidelines-Heart Failure between January 1, 2005, and December 31, 2010. Patients with AF on admission were compared with patients in sinus rhythm. A total of 31 355 (31.4%) HF patients presented with AF, of which 6701 (21.3%) were newly diagnosed. Patients in AF were older (77±12 versus 70±15, P<0.001) and were more likely to have history of stroke and valvular heart disease. AF patients had higher B-type natriuretic peptide levels and ejection fraction (42±17% versus 39±17%, P<0.001). AF patients were more likely to be hospitalized >4 days (48.8% versus 41.5%, P<0.001), discharged to a facility other than home (28.5% versus 19.7%, P<0.001), and had higher hospital mortality rate (4.0% versus 2.6%, P<0.001). AF, particularly newly diagnosed, was independently associated with adverse outcomes (adjusted odds ratios and 95% confidence intervals for mortality 1.17, 1.05-1.29, P=0.0029, and 1.29, 1.10-1.52, P=0.0023 for AF and newly diagnosed AF, respectively).
In patients hospitalized with HF, AF is present in one-third and is independently associated with adverse hospital outcomes and longer length of stay. Whether prompt restoration of sinus rhythm would improve outcomes in patients hospitalized with HF and new-onset or paroxysmal AF is unclear and requires further study.
Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF) patients, yet the population is poorly characterized and associated with conflicting outcomes data. We aimed to evaluate the clinical characteristics and outcomes of HF patients with systolic dysfunction and COPD in a large acute HF registry.
OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) was a performance-improvement registry of patients hospitalized with HF (n =48 612), which included a pre-specified subgroup of patients (n =5,701) with 60- to 90-day follow-up. We performed a retrospective analysis of the clinical characteristics and outcomes (length of stay, and in-hospital and 60-day mortality) of patients with systolic dysfunction according to baseline COPD status. COPD was present in 25% of the patients. These patients had more co-morbidities compared with patients without COPD. They were less likely to receive a beta-blocker or angiotensin-converting enzyme inhibitor during hospitalization and at discharge (P < 0.001). COPD was associated with an increased median length of stay [5 days (interquartile range 3-8) vs. 4 days (interquartile range 3-7), P < 0.0001] and increased in-hospital all-cause and non-cardiovascular (CV) mortality, with rates of 4.5% vs. 3.7% (P =0.01) and 1.0% vs. 0.6% (P =0.01), respectively, for the two endpoints, but similar 60-day mortality (6.2% vs. 6.0%, P =0.28). After risk adjustment, the in-hospital non-CV mortality remained increased (odds ratio 1.65, 95% confidence interval 1.12-2.41; P =0.01).
The presence of COPD in HF patients with systolic dysfunction is associated with an increased burden of co-morbidities, lower use of evidence-based HF medications, longer hospitalizations, and increased in-hospital non-CV mortality, but similar post-discharge mortality.
There are no sex-specific survival comparisons between patients with heart failure (HF) with reduced and those with preserved ejection fraction. Large registries noting women have better survival than men combined HF patients with reduced and preserved EF. Other registries that compared patients with reduced and preserved EF did not analyze their data by sex. We sought to evaluate sex/EF differences in mortality and risk factors for survival in hospitalized patients with HF.
We included hospitals fully participating in Get With The Guidelines-Heart Failure that admitted HF patients with reduced (EF <40%) or preserved (EF ≥50%) EF. The primary end point was in-hospital mortality. Multivariate generalized estimating equation logistic models were used to compute odds ratios accounting for hospital clustering.
The study cohort consisted of 51,428 patients with EF <40% (36% women, 64% men) and 37,699 patients with EF ≥50% (65% women, 35% men). Women compared with men with reduced and preserved EF were older and more likely to have hypertension, depression, or valvular heart disease and less likely to have coronary artery disease or peripheral vascular disease. There were no sex differences in in-hospital mortality (EF <40%, 2.69% women vs 2.89% men, P = .20; EF ≥50%, 2.61% women vs 2.62% men, P = .96), and risk factors such as age, systolic blood pressure, heart rate, and history of renal failure/dialysis were highly predictive of death for each sex/EF subgroup.
In a large, multicenter registry, we found that despite differences in baseline characteristics, women and men with reduced and preserved EF have similar in-hospital mortality and risk factors predicting death.
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2010 alone, the various Statistical Updates were cited 1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year's edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing various disorders of heart rhythm. Also, the 2012 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Update.
Heart failure (HF) is a leading cause of hospitalization. Although a number of multicenter international HF hospital registries have been published, there are limited data for the Asia Pacific region.
ADHERE (ie, Acute Decompensated Heart Failure Registry) International-Asia Pacific is an electronic web-based observational database of 10,171 patients hospitalized with a principal diagnosis of HF from 8 Asia-Pacific countries between January 2006 and December 2008.
The median age (67 years) varied by more than 2 decades across the region. Fifty-seven percent of patients were male. Ninety percent of patients were Asian and 8.4% were white. Dyspnea was the presenting symptom in 95%, with 80% having documented rales. During the index hospitalization, left ventricular function was assessed in 50%, and intravenous therapies included diuretics (85%), vasodilators (14%), and positive inotropes (15%). In-hospital mortality was 4.8%. Discharge medications included angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (63%), β-blockers (41%), and aldosterone antagonists (31%).
Compared with other multicenter registries, patients hospitalized with acute HF in the Asia Pacific region tend to present with more severe clinical symptoms and signs and are younger, especially in countries at an earlier stage in their epidemiological transition. Echocardiography and disease-modifying medications are used less often, highlighting potential opportunities to improve outcomes.
Heart failure (HF) is the most common cause of hospitalization in patients older than 65 years in the United States.¹ In the early 1990s, data from clinical trials and registries demonstrated that in patients hospitalized with HF, mortality and rehospitalization rates could be as high as 15% and 30%, respectively, at 60 to 90 days after discharge.²,3 During this period, major efforts were directed toward reducing the length of stay in patients hospitalized with HF.⁴ Performance measures were developed and later adopted by the Centers for Medicare & Medicaid Services (CMS) with the intent to improve postdischarge outcomes.⁵ Although these measures were implemented across the country, the rehospitalization rate for patients with HF did not appear to decrease.⁴,6 Recently, because of changes in CMS reimbursement patterns, the focus has shifted toward 30-day postdischarge readmission rates as a measure of care.
It is not known whether recent declines in ischemic heart disease and its risk factors have been accompanied by declines in heart failure (HF) hospitalization and mortality.
To examine changes in HF hospitalization rate and 1-year mortality rate in the United States, nationally and by state or territory.
From acute care hospitals in the United States and Puerto Rico, 55,097,390 fee-for-service Medicare beneficiaries hospitalized between 1998 and 2008 with a principal discharge diagnosis code for HF.
Changes in patient demographics and comorbidities, HF hospitalization rates, and 1-year mortality rates.
The HF hospitalization rate adjusted for age, sex, and race declined from 2845 per 100,000 person-years in 1998 to 2007 per 100,000 person-years in 2008 (P < .001), a relative decline of 29.5%. Age-adjusted HF hospitalization rates declined over the study period for all race-sex categories. Black men had the lowest rate of decline (4142 to 3201 per 100,000 person-years) among all race-sex categories, which persisted after adjusting for age (incidence rate ratio, 0.81; 95% CI, 0.79-0.84). Heart failure hospitalization rates declined significantly faster than the national mean in 16 states and significantly slower in 3 states. Risk-adjusted 1-year mortality decreased from 31.7% in 1999 to 29.6% in 2008 (P < .001), a relative decline of 6.6%. One-year mortality rates declined significantly in 4 states but increased in 5 states.
The overall HF hospitalization rate declined substantially from 1998 to 2008 but at a lower rate for black men. The overall 1-year mortality rate declined slightly over the past decade but remains high. Changes in HF hospitalization and 1-year mortality rates were uneven across states.
The aim of this study was to develop a clinical model predictive of in-hospital mortality in a broad hospitalized heart failure (HF) patient population.
Heart failure patients experience high rates of hospital stays and poor outcomes. Although predictors of mortality have been identified in HF clinical trials, hospitalized patients might differ greatly from trial populations, and such predictors might underestimate mortality in a real-world population.
The OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) is a registry/performance improvement program for patients hospitalized with HF in 259 U.S. hospitals. Forty-five potential predictor variables were used in a stepwise logistic regression model for in-hospital mortality. Continuous variables that did not meet linearity assumptions were transformed. All significant variables (p < 0.05) were entered into multivariate analysis. Generalized estimating equations were used to account for the correlation of data within the same hospital in the adjusted models.
Of 48,612 patients enrolled, mean age was 73.1 years, 52% were women, 74% were Caucasian, and 46% had ischemic etiology. Mean left ventricular ejection fraction was 0.39 +/- 0.18. In-hospital mortality occurred in 1,834 (3.8%). Multivariable predictors of mortality included age, heart rate, systolic blood pressure (SBP), sodium, creatinine, HF as primary cause of hospitalization, and presence/absence of left ventricular systolic dysfunction. A scoring system was developed to predict mortality.
Risk of in-hospital mortality for patients hospitalized with HF remains high and is increased in patients who are older and have low SBP or sodium levels and elevated heart rate or creatinine at admission. Application of this risk-prediction algorithm might help identify patients at high risk for in-hospital mortality who might benefit from aggressive monitoring and intervention.
Heart failure (HF) is a major public health problem, with a prevalence of more than 5 million cases and an incidence of 660 000 new cases per year in the United States alone.1Quiz Ref IDAmong patients older than 65 years, HF has become the most common discharge diagnosis and the primary cause of readmission within 60 days of discharge, resulting in estimated costs of $34.8 billion per year.1 Nearly half of all patients with HF have a preserved ejection fraction (HFPEF).2- 5 Patients with HFPEF have a high all-cause mortality after hospitalization for HF: 2.9%, in-hospital mortality4; 9.5%, 60- to 90-day mortality4; 22% to 29%, 1-year mortality2,3; and 65%, 5-year mortality.2,3 These data underscore the urgent need to find ways to improve outcomes for these patients.
Commentary on: ZannadFMcMurrayJJKrumH; EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med2011;364:11–21.
A major conundrum in the management of acute heart failure syndromes is the observation that patients are generally treated successfully during the in-hospital phase, but have a markedly high post-discharge event rate [1, 2]. The 30-day readmission rate has remained fairly constant or increased over the last decade at approximately 25% [3, 4]. Over one-third of patients hospitalized for acute heart failure syndromes are dead 1 year after discharge [3]. Despite fairly successful implementation of heart failure performance metrics in recent years, there has been no significant improvement in these outcomes [5]. It has become clear that our current state-of-the-art care of patients with heart failure exacerbation is not sufficient.
Black and Hispanic populations are at increased risk for developing heart failure (HF) at a younger age and experience differential morbidity and possibly differential mortality compared with whites. Yet, there have been insufficient data characterizing the clinical presentation, quality of care, and outcomes of patients hospitalized with HF as a function of race/ethnicity.
We analyzed 78,801 patients from 257 hospitals voluntarily participating in the American Heart Association's Get With The Guidelines-HF Program from January 2005 thru December 2008. There were 56,266 (71.4%) white, 17,775 (22.6%) black, and 4,760 (6.0%) Hispanic patients. In patients hospitalized with HF, we sought to assess clinical characteristics, adherence to core and other guideline-based HF care measures, and in-hospital mortality as a function of race and ethnicity.
Relative to white patients, Hispanic and black patients were significantly younger (median age 78.0, 63.0, 64.0 years, respectively), had lower left ventricular ejection fractions, and had more diabetes mellitus and hypertension. With few exceptions, the provision of guideline-based care was comparable for black, Hispanic, and white patients. Black and Hispanic patients had lower in-hospital mortality than white patients: black/white odds ratio 0.69, 95% CI 0.62-0.78, P < .001 and Hispanic/white odds ratio 0.81, 95% CI 0.67-0.98, P = .03.
Hispanic and black patients hospitalized with HF have more cardiovascular risk factors than white patients; however; they have similar or better in-hospital mortality rates. Within the context of a national HF quality improvement program, HF care was equitable and improved in all racial/ethnic groups over time.
Cardiac resynchronization therapy (CRT) has been demonstrated to improve mortality and morbidity in patients with chronic, stable heart failure who have reduced left ventricular ejection fraction and prolonged QRS duration. Patients with acute heart failure syndromes (AHFS) have been excluded from major CRT trials. The potential benefits and risks of implementation of these devices in the AHFS setting are largely unknown. In this review, we discuss the role that early implementation of CRT may have in improving postdischarge outcomes. In addition, we also discuss the potential adverse consequences of inserting these devices in patients who are in the tenuous clinical state of AHFS.
Implantable cardioverter-defibrillators have proven efficacy in reducing mortality in patients with reduced left ventricular ejection fraction in both the primary and the secondary prevention settings. All randomized trials demonstrating this benefit have been conducted in outpatients with stable heart failure symptoms. Whether implantable cardioverter-defibrillators confer a benefit when implemented in patients with chronically reduced left ventricular ejection fraction in the acute heart failure setting is unknown. The purpose of this document is to review the existing literature related to this subject.
Patients with heart failure (HF) fall into two categories—those who are stable and ambulatory with a relatively low event rate, and patients requiring hospitalization who are characterized by high post-discharge mortality and rates of rehospitalization. HF trials in 2010 contributed to the advancement of outpatient management, whereas the development of novel therapies with a survival benefit remains an unmet need in acute HF syndromes.
Patients with heart failure (HF) are hospitalized over a million times annually in the United States. Hospitalization marks a fundamental change in the natural history of HF, leading to frequent subsequent rehospitalizations and a significantly higher mortality compared with nonhospitalized patients. Three-fourths of all HF hospitalizations are due to exacerbation of symptoms in patients with known HF. One-half of hospitalized HF patients experience readmission within 6 months. Preventing HF hospitalization and rehospitalization is important to improve patient outcomes and curb health care costs. To implement cost-effective strategies to contain the HF hospitalization epidemic, optimal schemes to identify high-risk individuals are needed. In this review, we describe the risk factors that have been associated with hospitalization risk in HF and the various multimarker risk prediction schemes developed to predict HF rehospitalization. We comment on areas that represent gaps in our knowledge or difficulties in interpretation of the current literature, representing opportunities for future research. We also discuss issues with using HF readmission rate as a quality indicator.
Heart failure (HF) is the most frequent cause of hospitalization for patients >65 years of age.1,–,5 More than 1 million patients are admitted to the hospital with HF each year in the United States, and this number is likely to increase because of aging of the general population, improved survival after acute cardiovascular conditions, and prevention of sudden cardiac death. Hospitalization for HF is one of the most powerful independent risk factors for death among patients with HF. Mortality during the initial hospitalization ranges from 6% to 7% in Europe to 3% to 4% in the United States, depending on the length of hospital stay.1,2 Poor outcomes have universally been shown after discharge, with 60- to 90-day mortality rates of 5% to 15% and hospital readmission rates of 30%.1,6,7 Depending on the duration of the first hospitalization and on the number of previous hospitalizations, the risk of dying after a hospitalization for HF is increased from 4-fold to 16-fold compared with before the hospitalization.8
Article see p 1806
Whereas the prognosis of patients with chronic HF has improved in recent years, there has been no change in the high risk of death or rehospitalization after an HF hospitalization.6,9–11 This has multiple causes. First, the hospitalization for HF may be the expression of end-stage HF. In these patients, all therapies have already been tried and have become ineffective or were not tolerated. There are no chances to improve their symptoms and prognosis except with the use of assist devices or heart transplantation. These patients, however, are only a small proportion, <5%, of all the patients hospitalized for HF. An improvement in outcomes is possible in the others.1,12 In addition …