Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes: Observations From the Global Registry of Acute Coronary Events (GRACE) Telemedical Interventional Monitoring in Heart Failure (TIM-HF), a randomized, controlled intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with heart failure: study design. Web-based Internet telemedicine management of patients with heart failure. Influence of Nonfatal Hospitalization for Heart Failure on Subsequent Mortality in Patients With Chronic Heart Failure Managing heart failure care using an internet-based telemedicine system. Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality Heart Rate and Cardiac Rhythm Relationships With Bisoprolol Benefit in Chronic Heart Failure in CIBIS II Trial Heart failure--related mortality and hospitalization in the year following admission to a long-term care facility: the geriatric outcomes and longitudinal decline in heart failure (GOLD-HF) study. Design of the Reduction of Events with Darbepoetin alfa in Heart Failure (RED-HF): a Phase III, anaemia correction, morbidity-mortality trial. Rationale and design of PRIMA II: A multicenter, randomized clinical trial to study the impact of in-hospital guidance for acute decompensated heart failure treatment by a predefined NT-PRoBNP target on the reduction of readmIssion and Mortality rAtes. Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up. Risk stratification after hospitalization for decompensated heart failure. Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Resource utilization and costs in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme. Clinical trials update from the European Society of Cardiology Heart Failure meeting 2011: TEHAF, WHICH, CARVIVA, and atrial fibrillation in GISSI-HF and EMPHASIS-HF. Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study. Tailored Telemonitoring in patients with heart failure: results from a multicentre randomized controlled trial (the TEHAF-study) Prevalence and impact of worsening renal function in patients hospitalized with decompensated heart failure: results of the prospective outcomes study in heart failure (POSH). [Randomized controlled clinical trial of a home care unit intervention to reduce readmission and death rates in patients discharged from hospital following admission for heart failure]. Evaluation of a telemedicine system for heart failure patients: feasibility, acceptance rate, satisfaction and changes in patient behavior: results from the CARME (CAtalan Remote Management Evaluation) study Metoprolol CR/XL in Female Patients With Heart Failure: Analysis of the Experience in Metoprolol Extended-Release Randomized Intervention Trial in Heart Failure (MERIT-HF) NT-ProBNP reduction percentage during hospital stay predicts long-term mortality and readmission in heart failure patients Investigating a TELEmedicine solution to improve MEDication adherence in chronic Heart Failure (TELEMED-HF): study protocol for a randomized controlled trial
Background —Few data are available on the impact of heart failure ( HF ) across all types of acute coronary syndromes ( ACS ) . Methods and Results —The Global Registry of Acute Coronary Events ( GRACE ) is a prospect i ve study of patients hospitalized with ACS . Data from 16 166 patients were analyzed : 13 707 patients without prior HF or cardiogenic shock at presentation were identified . Of these , 1778 ( 13 % ) had an admission diagnosis of HF ( Killip class II or III ) . HF on admission was associated with a marked increase in mortality rates during hospitalization ( 12.0 % versus 2.9 % [ with versus without HF ] , P < 0.0001 ) and at 6 months after discharge ( 8.5 % versus 2.8 % , P < 0.0001 ) . Of note , HF increased mortality rates in patients with unstable angina ( defined as ACS with normal biochemical markers of necrosis ; mortality rates : 6.7 % with versus 1.6 % without HF at admission , P < 0.0001 ) . By logistic regression analysis , admission HF was an independent predictor of hospital death ( odds ratio , 2.2 ; P < 0.0001 ) . Admission HF was associated with longer hospital stay and higher readmission rates .  Patients with HF had lower rates of catheterization and percutaneous cardiac intervention , and fewer received & bgr;-blockers and statins . Hospital development of HF ( versus HF on presentation ) was associated with an even higher in-hospital mortality rate ( 17.8 % versus 12.0 % , P < 0.0001 ) . In patients with HF , in-hospital revascularization was associated with lower 6-month death rates ( 14.0 % versus 23.7 % , P < 0.0001 ; adjusted hazard ratio , 0.5 ; 95 % CI , 0.37 to 0.68 , P < 0.0001 ) . Conclusions —In this observational registry , heart failure was associated with reduced hospital and 6-month survival across all ACS subsets , including patients with normal markers of necrosis . More aggressive treatment of these patients may be warranted to improve prognosis AIMS Remote patient management ( telemonitoring ) may help to detect early signs of cardiac decompensation , allowing optimization of and adherence to treatments in chronic heart failure ( CHF ) . Two meta-analyses have suggested that telemedicine in CHF can reduce mortality by 30 - 35 % . The aim of the TIM-HF study was to investigate the impact of telemedical management on mortality in ambulatory CHF patients . Methods CHF patients [ New York Heart Association ( NYHA ) II/III , left ventricular ejection fraction (LVEF)≤35 % ] with a history of cardiac decompensation with hospitalization in the past or therapy with intravenous diuretics in the prior 24 months ( no decompensation required if LVEF≤25 % ) were r and omized 1:1 to an intervention group of daily remote device monitoring ( electrocardiogram , blood pressure , body weight ) coupled with medical telephone support or to usual care led by the patients ' local physician . In the intervention group , 24/7 physician-led medical support was provided by two central telemedical centres . A clinical event committee blinded to treatment allocation assessed cause of death and reason for hospitalization . The primary endpoint was total mortality . The first secondary endpoint was a composite of cardiovascular mortality or hospitalization due to heart failure . Other secondary endpoints included cardiovascular mortality , all-cause and cause-specific hospitalizations ( all time to first event ) as well as days lost due to heart failure hospitalization or cardiovascular death ( in % of follow-up time ) , and changes in quality of life and NYHA class . Overall , 710 CHF patients were recruited . The mean follow-up was 21.5±7.2 months , with a minimum of 12 months . Perspective The study will provide important prospect i ve outcome data on the impact of telemedical management in patients with CHF An Internet-based store- and -retrieval telemedicine system to communicate between patients and their healthcare provider was tested . The system requires no specialized equipment , is Web-based , and allows frequent surveillance of the health status of the patients with heart failure ( HF ) . Thirty six patients were recruited to evaluate a Web-based telemedicine system for reducing care encounters . Eighteen patients were r and omized to the telemedicine arm ( group T ) , and 18 were given usual clinical care ( group C ) in our HF center . Patients in group T reported three times weekly via a secure Internet site for telemedicine intervention . We studied patients with HF with New York Heart Association ( NYHA ) class 2 to 4 with hospitalization within past 6 months . Mean age was 56.1 + /- 12.6 years ( 66.7 % male ; 66.7 % Caucasian , 27.8 % African American , and 5.6 % Hispanic ) .  Mean ejection fraction ( EF ) was 23.9 % + /- 17.6 % in group T and 26.6 % + /- 16.4 % in group C. Over an 8-month period , unscheduled ( group T-3 ; group C-5 ) , and scheduled clinic visits ( group T-11 , group C-7 ) were similar ( p = NS ) ; one group T patient was transplanted , one group C patient died . Total hospital days were lower with group T ( 44 days ) compared to group C ( 133 days ) , p < 0.05 . An Internet-based telemedicine system was able to closely monitor patients with HF . Surveillance through Internet-based telemedicine result ed in less hospitalization compared to control patients . This system may be helpful in reducing the cost of HF patient care Background — Patients with chronic heart failure ( HF ) are at increased risk of both fatal and nonfatal major adverse cardiovascular events . We used data from the C and esartan in Heart failure : Assessment of Reduction in Mortality and morbidity ( CHARM ) trials to assess the influence of nonfatal hospitalizations for HF on subsequent mortality rates in a broad spectrum of HF patients . Methods and Results — In the present study , 7599 patients with New York Heart Association class II to IV HF and reduced or preserved left ventricular ejection fraction were r and omized to placebo or c and esartan . We assessed the risk of death after discharge from a first hospitalization for HF using time-up date d Cox proportional-hazards models on 7572 patients for whom discharge data were available . Of 7572 patients , 1455 ( 19 % ) had at least 1 HF hospitalization , and 586 of 1819 deaths occurred after discharge from an HF hospitalization . The mortality rate was increased after HF hospitalizations , even after adjustment for baseline predictors of death ( hazard ratio , 3.15 ; 95 % confidence interval , 2.83 to 3.50 ) . Longer duration of HF hospitalization enhanced the risk of dying , as did repeat HF hospitalizations . Moreover , risk of death was highest within a month of discharge and then declined progressively over time , particularly for death result ing from HF progression and for sudden cardiac death . We observed a similar pattern of risk associated with all-cause hospitalization , although the magnitude was less than that with HF hospitalization . Conclusions — In patients with chronic HF , the risk of death is greatest in the early period after discharge after a hospitalization for HF and is directly related to the duration and frequency of HF hospitalizations . These findings suggest a role for increased surveillance in the early postdischarge period of greatest vulnerability after an HF admission BACKGROUND Managing patients with heart failure ( HF ) is labor intensive , and follow-up is often inadequate to detect day-to-day changes that ultimately lead to decompensation . We tested the effect of an Internet-based telemedicine ( T ) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF . METHODS AND RESULTS HF patients in NYHA Class II-IV were r and omized to usual care ( UC , n = 24 ) or T ( T plus UC , n = 24 ) and followed for 1 year .  Office visits , emergency department visits , hospitalizations , telephone calls , and number of Internet communications were measured over the 1-year period . Left ventricular ejection fraction ( EF ) was assessed by echocardiography in both groups . For T , mean age was 53.2 + /- 2.0 years ( 72 % male , 61 % Caucasian , 39 % African American ) . For UC , mean age was 54.1 + /- 2.6 years ( 76 % male , 72 % Caucasian , 14 % African American , and 14 % Hispanic ) .  HF etiologies and EF were similar in both groups . During the 12-month period , UC had 74 total phone calls to the practice , whereas T had 88 telephone calls plus 1887 telemedicine data messages ( 6.5 messages/patient/month ) . ER visits were lower in the T group ( T 5 , UC 12 ; P < .05 ) . Hospital admissions ( T 24 , C 40 ; P = .025 ) and total hospital days ( T 84 , UC 226 days ; P < .005 ) were lower in T. Unscheduled clinic visits ( T 13 , UC 13 ; P = NS ) and scheduled clinic visits ( T 78 , UC 94 ; P = NS ) were similar in both groups . CONCLUSIONS Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations , hospital days , and emergency department visits AIMS Hospitalizations for heart failure ( HF ) are common and are associated with significant morbidity , mortality and cost . However , precipitating factors leading to HF hospitalization and their importance with respect to subsequent outcomes are not well understood . METHODS AND RESULTS The symptoms and signs present at admission and investigator-identified factors thought to have contributed to the first adjudicated HF hospitalization in the C and esartan in Heart Failure : Assessment of Reduction in Mortality and Morbidity ( CHARM ) programme were prospect ively collected and stratified by ejection fraction ( EF ) . Potential precipitants were collected using a specifically design ed case report form and categorized according to the presence of cardiovascular ( CV ) , non-CV and unknown factors . Associations between these factors and subsequent rehospitalization and mortality rates were examined . Of 1668 patients who experienced HF hospitalization , 1152 had reduced EF ( ≤40 % , HFrEF ) and 516 had preserved EF ( HFpEF ) . Overall , 54 % had CV , 32 % had non-CV and 14 % had unknown factors thought to have precipitated HF , with similar proportions in the HFrEF and HFpEF groups . The most common precipitants were arrhythmia ( 15 % ) , other non-CV factors ( 11 % ) and respiratory infection ( 10 % ) . Subsequent CV readmission rates were highest in those whose initial HF hospitalization was precipitated by CV factors . However , mortality rates were similar among patients with any of the three categories of precipitating factors . Results were similar in HFrEF and HFpEF . CONCLUSIONS Among chronic HF patients hospitalized for decompensation , the investigator-reported precipitating factor was not associated with the subsequent mortality rate , but was associated with type of readmission : readmissions for CV reasons were more likely when the index precipitant was CV Background —&bgr;-Blockade – induced benefit in heart failure ( HF ) could be related to baseline heart rate and treatment-induced heart rate reduction , but no such relationships have been demonstrated . Methods and Results —In CIBIS II , we studied the relationships between baseline heart rate ( BHR ) , heart rate changes at 2 months ( HRC ) ,  nature of cardiac rhythm ( sinus rhythm or atrial fibrillation )  , and outcomes ( mortality and hospitalization for HF ) . Multivariate analysis of CIBIS II showed that in addition to & bgr;-blocker treatment , BHR and HRC were both significantly related to survival and hospitalization for worsening HF , the lowest BHR and the greatest HRC being associated with best survival and reduction of hospital admissions . No interaction between the 3 variables was observed , meaning that on one h and , HRC-related improvement in survival was similar at all levels of BHR , and on the other h and , bisoprolol-induced benefit over placebo for survival was observed to a similar extent at any level of both BHR and HRC . Bisoprolol  reduced mortality in patients with sinus rhythm ( relative risk 0.58 , P < 0.001 ) but not in patients with atrial fibrillation ( relative risk 1.16 , P = NS ) . A similar result was observed for cardiovascular mortality and hospitalization for HF worsening . Conclusions —BHR and HRC are significantly related to prognosis in heart failure . & bgr;-Blockade with bisoprolol further improves survival at any level of BHR and HRC and to a similar extent . The benefit of bisoprolol is question able , however , in patients with atrial fibrillation BACKGROUND Heart failure ( HF ) is common in long-term care facilities ( LTCs ) . This study compared mortality and hospitalization rates and examined predictors of these outcomes among new LTC residents with and without HF . METHODS AND RESULTS This prospect i ve cohort study followed 546 newly admitted residents from 42 LTCs for up to 1 year . Health information was collected from participant and caregiver interviews , physicians ' records , diagnostic procedures , and hospitalization records . Multivariate logistic regression modeling determined predictors of hospitalization among residents , and Cox proportional hazards regression determined predictors for time to mortality . HF prevalence was 21.4 % . The sample was predominantly ( > 70 % ) female , and individuals with HF were significantly older with higher prevalence of reduced left ventricular ejection fraction . Overall annual mortality and hospitalization rates were 24 % and 27 % , respectively . Among residents with HF , 42 % died and 31 % were hospitalized within 1 year . Among residents with HF , use of major tranquilizers was the strongest predictor of sooner mortality ; use of anticoagulants and major tranquilizers also increased mortality risk , whereas higher baseline function was associated with longer time to mortality . History of peripheral vascular disease was the strongest predictor of hospitalizations among residents with HF , and use of antiplatelet agents and history of any smoking exposure increased this risk . CONCLUSIONS Among LTC residents , HF is associated with high mortality and hospitalization rates . Many factors contribute to mortality and hospitalizations among residents with HF , and comprehensive HF management programs are needed to improve outcomes BACKGROUND Patients with heart failure ( HF ) and anaemia have greater functional impairment , worse symptoms , increased rates of hospital admission , and a higher risk of death , compared with non-anaemic HF patients . Whether correcting anaemia can improve outcomes is unknown . OBJECTIVE The Reduction of Events with Darbepoetin alfa in Heart Failure trial ( RED-HF ; Clinical Trials.gov NCT 003 58215 ) was design ed to evaluate the effect of the long-acting erythropoietin-stimulating agent darbepoetin alfa on mortality and morbidity ( and quality of life ) in patients with HF and anaemia . METHODS Approximately 2600 patients with New York Heart Association class II-IV , an ejection fraction < or = 40 % , and a haemoglobin ( Hb ) consistently < or = 12.0 g/dL but > or = 9.0 g/dL will be enrolled . Patients are r and omized 1:1 to double-blind subcutaneous administration of darbepoetin alfa or placebo . Investigators are also blinded to Hb measurements and darbepoetin alfa is dosed to achieve an Hb concentration of 13.0 g/dL ( but not exceeding 14.5 g/dL ) with sham adjustments of the dose of placebo . The primary endpoint is the time to death from any cause or first hospital admission for worsening HF , whichever occurs first . The study will complete when approximately 1150 subjects experience a primary endpoint BACKGROUND Hospital admissions for acute decompensated heart failure ( ADHF ) are frequent and are accompanied by high percentages of mortality and readmissions . Brain natriuretic peptide ( BNP ) and the inactive N-terminal fragment of its precursor proBNP ( NT-proBNP ) are currently the best predictors of prognosis in heart failure ( HF ) patients . In the setting of chronic HF , studies that performed guidance of therapy by NT-proBNP have had only limited success . For patients with ADHF , retrospective studies have shown that a reduction in NT-proBNP of ≤30 % during admission is a significant predictor of HF readmissions and mortality . These data suggest a role for NT-proBNP guidance in the setting of ADHF admissions . STUDY DESIGN The PRIMA II is an investigator-initiated , multicenter , r and omized , controlled , prospect i ve 2-arm trial that investigates the impact of inhospital guidance for ADHF treatment by a predefined NT-proBNP target ( > 30 % reduction during admission ) on the reduction of readmission and mortality rates within 180 days . Consenting ADHF patients with NT-proBNP levels of > 1,700 ng/L are eligible . After achieving clinical stability , a total of 340 patients are r and omized to either NT-proBNP-guided or conventional treatment ( 1:1 ) . The primary end point is dual , that is , a composite of all-cause mortality and readmission for HF in 180 days and the number of days alive out of hospital in 180 days . Secondary end points are readmissions and /or mortality in 180 days , cost effectiveness of hospitalization days in 180 days , readmissions and mortality in 90 days , and quality of life . CONCLUSION The PRIMA II trial aims at providing scientific evidence for the use of NT-proBNP-guided therapy compared with conventional treatment in patients admitted for ADHF OBJECTIVES The purpose of this study was to assess the rate of death and hospitalization for heart failure ( HF ) 1 and 3 years after a r and omized trial of telephone intervention aim ed to improve education and compliance in stable patients with HF ended . BACKGROUND The long-term effects of HF programs are not well known . METHODS In all , 1,518 patients with HF were r and omized into the DIAL ( R and omized Trial of Phone Intervention in Chronic Heart Failure ) . After completion of the trial , patients were followed up to 3 years to assess major outcomes . Compliance with diet , weight control , and treatment was evaluated . The effect of the intervention on mortality and HF hospitalizations was assessed using relative risk ( RR ) , relative risk reduction , and Cox proportional hazards model for adjusting by potential confounders . RESULTS The rate of death or hospitalization for HF was lower in the intervention group ( 37.2 % vs. 42.6 % , RR : 0.81 , 95 % confidence interval [ CI ] : 0.69 to 0.96 ; p = 0.013 ) 1 and 3 years ( 55.7 % vs. 57.5 % , RR : 0.88 , 95 % CI : 0.77 to 1.00 ; p = 0.05 ) after the intervention ended . This benefit was mainly caused by a reduction in admission for HF ( 28.5 % vs. 35.1 % after 3 years , RR : 0.72 , 95 % CI : 0.60 to 0.87 ; p = 0.0004 ) . Patients who showed improvement in 1 or more of 3 key compliance indicators ( diet , weight control , and medication ) had lower risks of events . CONCLUSIONS The benefit observed during the intervention period persisted and was sustained 1 and 3 years after the intervention ended . This effect may be explained by the impact of the educational intervention on patients ' behavior and habits BACKGROUND Decompensated heart failure ( HF ) is among the most common indications for hospitalization in the United States , but little is known about features on admission that predict adverse events . We used data from the Outcomes of a Prospect i ve Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure ( OPTIME-CHF ) study to develop a model that would predict outcomes in patients with decompensated HF . METHODS AND RESULTS OPTIME-CHF r and omized 949 patients hospitalized with decompensated HF for 48 to 72 hours of infusion of either milrinone or placebo .  We used multivariable modeling to evaluate variables on admission that would be predictive of 60-day mortality or the composite of death or rehospitalization at 60 days . Variables at presentation that predicted death at 60 days were increased age , lower systolic blood pressure , New York Heart Association class IV symptoms , elevated blood urea nitrogen ( BUN ) , and decreased sodium . Predictors of the composite of death or rehospitalization within 60 days were the number of HF hospitalizations in the preceding 12 months , elevated BUN , lower systolic blood pressure , decreased hemoglobin , and a history of percutaneous coronary intervention ( PCI ) . The discriminatory power of the model was substantial for the mortality model ( c-index .77 ) but less for the composite endpoint ( c-index .69 ) . CONCLUSIONS Risk stratification of patients with decompensated HF may be accomplished using easily assessed clinical variables . Further research into the validity of this model in independent sample s will potentially aid in the development of risk stratification strategies BACKGROUND Patients with heart failure ( HF ) are at high risk for mortality and rehospitalization in the early period after hospital discharge . We developed clinical models predictive of short-term clinical outcomes in a broad patient population discharged after hospitalization for HF . METHODS The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure ( OPTIMIZE-HF ) registry is a comprehensive hospital-based registry and performance-improvement program for patients hospitalized with HF . Follow-up data were scheduled to be prospect ively collected at 60 to 90 days postdischarge in a prespecified 10 % sample . For the 4,402 patients included in this analysis , 19 prespecified potential predictor variables were used in a stepwise Cox proportional hazards model for all-cause mortality . Logistic regression including 45 potential variables was used to model mortality or rehospitalization . RESULTS The 60- to 90-day postdischarge mortality rate was 8.6 % ( n = 481 ) , and 29.6 % ( n = 1,715 ) were rehospitalized . Factors predicting early postdischarge mortality include age , serum creatinine , reactive airway disease , liver disease , lower systolic blood pressure , lower serum sodium , lower admission weight , and depression . Use of statins and beta-blockers at discharge was associated with significantly decreased mortality . The C-index of the model was 0.74 . The most important predictors for the combined end point of death or rehospitalization were admission serum creatinine , systolic blood pressure , admission hemoglobin , discharge use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker , and pulmonary disease . From this analysis , 8 factors identified to carry significant risk were selected for use in a point scoring system to predict the risk of mortality within 60 days after discharge , with a C-index of 0.72 . CONCLUSIONS A substantial risk of mortality and mortality or rehospitalization is present in the first 60 to 90 days after discharge from a hospitalization for HF . Several factors were identified that signal high-risk patients . Application of these findings with a simple algorithm can distinguish patients who are low risk from those at high risk who may benefit from closer monitoring and aggressive evidence -based treatment AIMS More treatments are needed to improve clinical outcomes in chronic heart failure ( HF ) . It is , however , important that treatments for a condition as common as HF are affordable . We have carried out a prospect i ve economic analysis of the C and esartan in Heart failure : Assessment of Reduction in Mortality and morbidity ( CHARM ) programme . METHODS AND RESULTS Patients with NYHA class II-IV HF and LVEF < or = 0.40 were r and omized to CHARM-Alternative if intolerant of an ACE-inhibitor or to CHARM-Added if taking an ACE-inhibitor . Patients with a LVEF > 0.40 were r and omized in CHARM-Preserved . Each trial compared the effect of c and esartan to placebo on the primary outcome of cardiovascular death or HF hospitalization . Detailed information was prospect ively collected on hospital admissions , procedures /operations and drugs . A cost-consequence analysis was performed for France , Germany and the UK for CHARM-Overall and a cost-effectiveness analysis for the low LVEF trials . The cost of c and esartan was substantially offset by a reduction in hospital admissions , especially for HF . In the cost-consequence analysis , c and esartan was cost-saving in most scenarios for CHARM-Alternative and Added but the marginal annual net cost per patient was upto 372 euros per year in CHARM-Preserved , in which c and esartan did not reduce the primary outcome significantly . In the cost-effectiveness analysis of patients with a LVEF < or = 0.40 , c and esartan was cost-saving in some scenarios and in the others the maximum cost per life year gained was 3881 euros . CONCLUSION C and esartan improves functional class , reduces the risk of hospital admission , and increases survival in patients with a HF and a LVEF < or = 0.40 at an acceptable cost This article provides information and a commentary on key trials relevant to the pathophysiology , prevention , and treatment of heart failure ( HF ) presented at the European Society of Cardiology Heart Failure meeting held in Gothenburg , Sweden in May 2011 . Unpublished reports should be considered as preliminary , since analyses may change in the final publication . In the TEHAF study , use of the Health Buddy ( ® ) monitoring system failed to reduce the number of HF admissions compared with usual care but a subgroup of patients with more recently diagnosed HF may have benefited . In the WHICH study , some reductions in the rate of hospital stay were observed in patients who underwent a  nurse-led home-based intervention programme following a hospital admission for an acute HF exacerbation , compared with patients who were followed in a specialized outpatient clinic . Results from CARVIVA-HF suggest that ivabradine alone or in combination with carvedilol  is safe and effective for improving exercise capacity and quality of life in HF patients on optimized angiotensin-converting enzyme inhibitor therapy . In the GISSI-HF study there was no difference in atrial fibrillation ( AF ) occurrence between the n-3 polyunsaturated fatty acids and placebo groups . In EMPHASIS-HF the incidence of new onset AF or flutter was reduced in patients with mild HF r and omized to eplerenone compared with placebo OBJECTIVES The purpose of this study was to assess whether management of heart failure ( HF ) guided by an individualized N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) target would lead to improved outcome compared with HF management guided by clinical assessment alone . BACKGROUND Natriuretic peptides may be attractive biomarkers to guide management of heart failure ( HF ) and help select patients in need of more aggressive therapy . The PRIMA ( Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality ? ) study is , to our knowledge , the first large , prospect i ve r and omized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome . METHODS A total of 345 patients hospitalized for decompensated , symptomatic HF with elevated NT-proBNP levels at admission were included . After discharge , patients were r and omized to either  clinical ly-guided outpatient management ( n = 171 ) , or management guided by an individually set NT-proBNP  ( n = 174 ) defined by the lowest level at discharge or 2 weeks thereafter . The primary end point was defined as number of days alive outside the hospital after index admission . RESULTS HF management guided by this individualized NT-proBNP target increased the use of HF medication ( p = 0.006 ) , and 64 % of HF-related events were preceded by an increase in NT-proBNP . Nevertheless , HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point ( 685 vs. 664 days , p = 0.49 ) , nor did it significantly improve any of the secondary end points . In the NT-proBNP-guided group mortality was lower , as 46 patients died ( 26.5 % ) versus 57 ( 33.3 % ) in the clinical ly-guided group , but this was not statistically significant ( p = 0.206 ) . CONCLUSIONS Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy , but failed to provide significant clinical improvement in terms of mortality and morbidity . ( Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [ PRIMA ] ; NCT00149422 ) Background Recent increasing prevalence of heart failure ( HF ) patients leads to an increasing burden to the health care system . Consequently , there is a need for innovative strategies to reduce HF hospitalizations . Methods We performed a multicentre r and omized controlled trial to test the hypothesis that telemonitoring in patients with HF , by means of the Health Buddy ® system ( HB ) , will reduce HF hospitalizations and number of contacts with caregivers as compared to care as usual ( CAU ) during 1 year follow-up , from October 1 , 2007 , through December 31 , 2008 . Results Among 382 patients —197 in the HB and 185 in the CAU-group—226 ( 59 % ) were male , mean age was 71.5 ( SD 11.2 ) , 45.5 % being ≥75 years of age ; 57 % of the patients were in NYHA HF class 2 , 40 % in class 3 and 3 % in class 4 . Both study groups were similar for demographic and clinical characteristics . Mean time to first heart failure related hospitalization was 161 days for the intervention group and 139 days for the usual-care group ; hospitalizations occurred in 18 ( 9.1 % ) compared to 25 patients ( 13.5 % ) respectively ( Kaplan – Meier p=0.151 , hazard ratio 0.65 , CI 0.35–1.17 ) . Combined endpoint of heart failure admission and all cause mortality was similar for both groups ( Kaplan – Meier p=0.641 hazard ratio 0.89 , CI 0.69–1.83 ) . Cox regression analysis disclosed an important interaction between group assignment and heart failure duration , p=0.007 , OR=0.983 , CI 0.970–0.995 indicating a significant decrease in heart failure hospitalizations in the intervention group if heart failure duration was < 18 months , p=0.026 , hazard ratio 0.26 , CI 0.07–0.94 . Contacts with the heart-failure-nurse were mean 1.36 ( range 0–11 ) in the intervention group vs. 1.74 ( 0–8 ) in the usual-care group ( Mann-Whitney p<0.001 ) . Mortality was 18 ( 9.1 % ) in the intervention-group and 12 ( 6.5 % ) in the usual-care-group ( Mann – Whitney p=0.34 , Cox-regression analysis p=0.82 ) . Conclusion Telemonitoring tends to reduce heart failure admissions and decreases contacts with specialized nurses . If heart failure duration is < 18 months heart failure admissions and readmissions are significantly reduced AIMS To determine the prevalence and risk factors for worsening renal function ( WRF ) among patients hospitalized for decompensated heart failure ( HF ) and the association with subsequent re-hospitalization and mortality . METHODS AND RESULTS We prospect ively enrolled 299 patients across eight European countries ( mean age 68 , 74 % men ) . HF was defined using the European Society of Cardiology criteria , but only patients with a history of ejection fraction < or = 40 % on echocardiography were recruited .  WRF was defined as an increase in serum creatinine > 26 micromol/L ( approximately 0.3 mg/dL ) from admission . Follow-up was 95 % complete to 6 months . Nearly one-third of patients [ 72 of 248 patients , 29 % ( 95 % CI 26 - 32 % ) ] developed WRF during hospitalization , excluding patients who had a major in-hospital complication likely to compromise renal function . The risk of WRF in this group was independently associated with serum creatinine levels on admission [ odds ratio ( OR ) 3.02 ( 95 % CI 1.58 - 5.76 ) ] , pulmonary oedema [ OR 3.35 ( 1.79 - 6.27 ) ] , and a history of atrial fibrillation [ OR 0.35 ( 0.18 - 0.67 ) ] . Although the mortality of WRF patients was not increased significantly , the length of stay was 2 days longer [ median 11 days ( 90 % range ( 4 - 41 ) vs. 9 days ( 4 - 34 ) , P=0.006 ] . The re-hospitalization rate was similar in both groups . CONCLUSION WRF is common in patients admitted to European hospitals with decompensated HF . Such patients have longer duration admissions , but a similar mortality and re-hospitalization rate to those without WRF ( if patients experiencing a major in-hospital complication are excluded ) INTRODUCTION AND OBJECTIVES To determine the effectiveness of a primarily educational intervention in heart failure ( HF ) patients implemented in a home care unit . METHODS This r and omized controlled clinical trial involved 279 HF patients who were discharged from a tertiary-care hospital between February 2001 and June 2002 . Patients with dementia , terminal non-cardiac disease , or chronic obstructive pulmonary disease were excluded . Data collected included the cause of cardiac decompensation . A primarily educational intervention was implemented in the patient 's home for up to 15 days after hospital discharge . Treatment was adjusted during the first week if necessary . The primary outcome measure was the 1-year cumulative incidence of readmission or death . Secondary measures were the incidence of readmission , mortality , and emergency department admission .  Telephone interviews were carried out 3 , 6 and 12 months after discharge , and clinical records were up date d when necessary . Emergency department admission in the first 6 months was monitored . RESULTS At 1-year follow-up , 62 of the 137 patients ( 45.3 % ) in the intervention group had been readmitted or died , compared with 75 of the 142 ( 52.8 % ) in the control group , ( relative risk=0.86 , P=.232 ) . Among patients who suffered decompensation because failure to adhere to treatment , 16 of the 45 ( 35.6 % ) in the intervention group were readmitted or died , compared with 34 of the 56 ( 60.7 % ) control group patients ( relative risk=0.59 , P=.016 ) . CONCLUSIONS This intervention is feasible but , when applied indiscriminately to every discharged heart failure patient , the best that can be expected is only a modest reduction in readmission and death rates , which , in this study in particular , did not achieve statistical significance Background : Telemedicine can be useful for managing heart failure ( HF ) , but patient acceptance of telemedicine and its impact on patient behavior are unclear . Aims : To assess a telemedicine program in a HF Unit . Methods and results : This sub- analysis of the CARME study assessed the use of an interactive telemedicine platform . This prospect i ve intervention study had a before/after design with HF patients r and omized 1:1 into two groups : A ) Motiva system ( educational videos , motivational messages , and question naires ) ; and B ) Motiva system + telemonitoring of blood pressure  , heart rate and weight .  Of 211 patients screened , 44 were excluded , 62 did not consent to participate and 8 withdrew consent prior to installation of the system . The final study population included 97 patients . During 1 year of follow-up , 22 patients voluntarily discontinued use of the system , 5 died ( three after early discontinuation ) and 5 withdrew consent before the last evaluation . A total of 15,017 question naires were sent to patients , with a median response rate of 88 % . Satisfaction with the system and tools was high ( median score 8.4/10 ) , especially with the self-monitoring chart , scale and sphygmomanometer . Positive changes were observed in patient behavior , especially for blood pressure and weight control ( p < 0.001 ) . After the study , 65 % of the patients wished to continue with telemonitoring , particularly those in Group B ( p = 0.004 ) . Conclusion : Less than half of our patients participated in the telemedicine study . However , those who completed the study had confidence in the system , a high degree of satisfaction with the tools and positive behavioral changes Background —Underrepresentation of women in heart failure clinical trials has limited conclusions regarding the effect of various management strategies on survival in women with heart failure and decreased left ventricular ejection fraction ( LVEF ) . Methods and Results —MERIT-HF ( Metoprolol Extended-Release R and omized Intervention Trial in Heart Failure ) was a r and omized , placebo-controlled study , the purpose of which was to evaluate the effect of metoprolol controlled-release/extended-release ( CR/XL ) in 3991 patients with New York Heart Association class II to IV heart failure and LVEF ≤0.40 . We performed a post hoc analysis to evaluate the effect of metoprolol CR/XL on outcome in women ( n=898 ) , including the outcome in 183 women with severe heart failure ( New York Heart Association class III/IV and LVEF < 0.25 ) . Treatment with metoprolol CR/XL in women result ed in a 21 % reduction in the primary combined end point of all-cause mortality/all-cause hospitalizations ( 164 versus 137 patients ; P = 0.044 ) . The number of cardiovascular hospitalizations was reduced by 29 % ( 164 versus 120;P = 0.013 ) , and hospitalization for worsening heart failure was reduced by 42 % ( 95 versus 56;P = 0.021 ) . Similar results were noted in the subgroup of women with severe heart failure , with a 57 % reduction in cardiovascular hospitalizations ( 63 versus 30;P = 0.005 ) and a 72 % reduction in hospitalization due to worsening heart failure ( 46 versus 14;P = 0.0004 ) . A pooling of mortality results from MERIT-HF , the Cardiac Insufficiency Bisoprolol Study ( CIBIS II ) , and the Carvedilol Prospect i ve R and omized Cumulative Survival Study ( COPERNICUS ) showed very similar survival benefits in women and men . Conclusions —The beneficial effects of metoprolol CR/XL extend to women with heart failure , including women with clinical ly stable severe heart failure We prospect ively evaluated whether the N-terminal brain natriuretic peptide ( NT-ProBNP ) reduction percentage , during hospitalization for acutely decompensated heart failure ( HF ) , has a prognostic significance in 6-month follow-up . In 120 patients consecutively admitted for acute HF to an internal medicine unit , plasma NT-ProBNP was measured on admission and at discharge . During a 6-month follow-up 52 ( 43.3 % ) patients had events : 9 ( 7.5 % ) died from cardiovascular causes , and 43 ( 35.8 % ) were readmitted for HF . In patients without events , the mean reduction percentage of NT-ProBNP was greater than in patients with events ( 39.5 ± 7.4 versus 26.3 ± 5.9 % ; P = 0.04 ) . In receiver operating characteristic curve analysis , the mean area under the curve for NT-ProBNP reduction percentage was 0.63 ( 95 % CI , 0.51–0.75 ; P = 0.04 ) for the composite end point ( death or readmission ) , and 0.81 ( 95 % CI , 0.65–0.97 , P = 0.01 ) for cardiovascular mortality . NT-ProBNP reduction percentage less than 30 % was the best cut-off for the identification of patients at risk of events . We suggest that in clinical practice the evaluation of change of NT-ProBNP levels during admission is probably more helpful than predischarge NT-ProBNP absolute value Background Frequent rehospitalisations and poorer survival chances in heart failure ( HF ) patients may partly be explained by poor medication adherence . There are multiple medication-related reasons for suboptimal adherence , but psychological reasons may also be important . A novel TELEmonitoring device may improve MEDication adherence in HF patients ( TELEMED-HF ) . TELEMED-HF is a r and omized , controlled clinical intervention trial design ed to examine ( 1 ) the efficacy and cost-efficiency of an electronic medication adherence support system in improving and monitoring HF patients ' medication adherence ; ( 2 ) the effect of medication adherence on hospitalizations and health care consumption ; as well as on ( 3 ) clinical characteristics , and Quality of Life ( QoL ) ; and ( 4 ) clinical , sociodemographic , and psychological determinants of medication adherence . Methods / Design Consecutive patients with chronic , systolic HF presenting to the outpatient clinic of the TweeSteden Hospital , The Netherl and s , will be approached for study participation and r and omly assigned ( 1:1 ) following blocked r and omization procedures to the intervention ( n = 200 ) or usual care arm ( n = 200 ) . Patients in the intervention arm use the medication support device for six months in addition to usual care . Post-intervention , patients return to usual care only and all patients participate in four follow-up occasions over 12 months . Primary endpoints comprise objective and subjective medication adherence , healthcare consumption , number of hospitalizations , and cost-effectiveness . Secondary endpoints include disease severity , physical functioning , and QoL. Discussion The TELEMED-HF study will provide us a comprehensive underst and ing of medication adherence in HF patients , and will show whether telemonitoring is effective and cost-efficient in improving adherence and preventing hospitalization in HF patients .Trial registration numberNCT01347528
Overall , telemedicine was shown to be beneficial , with home-based teletransmission effectively reducing all-cause mortality and HF-related hospital admission , length of stay and mortality in patients with HF
Telemedicine interventions may be associated with reductions in hospital admission rate and mortality in patients with heart failure ( HF ) .