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Aims: According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes. Methods and results: Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (n = 185 821) or urinary albumin‐to‐creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m2, present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m2 were categorized into four stages: 45–59 (n = 72 606), 30–44 (n = 74 812), 15–29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m2. Five‐year all‐cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all‐cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62–1.65), 2.00 (1.98–2.02), 2.49 (2.45–2.52), 2.28 (2.21–2.35), and 1.22 (1.20–1.24), respectively. Respective age‐adjusted HRs (95% CIs) were 1.13 (1.12–1.14), 1.36 (1.34–1.37), 1.87 (1.84–1.89), 2.24 (2.18–2.31) and 1.19 (1.17–1.21), and multivariable‐adjusted HRs (95% CIs) were 1.11 (1.10–1.12), 1.24 (1.22–1.25), 1.46 (1.43–1.48), 1.42 (1.38–1.47), and 1.13 (1.11–1.16). Similar patterns were observed for associations with hospitalizations. Conclusion: Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO‐defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria. [ABSTRACT FROM AUTHOR]

Early in the COVID-19 pandemic, cardiology clinics rapidly implemented telemedicine to maintain access to care. Little is known about subsequent trends in telemedicine use and visit volumes across cardiology subspecialties. We conducted a retrospective cohort study including all patients with ambulatory visits at a multispecialty cardiovascular center in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). Telemedicine use increased from 3.5% of visits (1200/33,976) during the pre-COVID period to 63.0% (21,251/33,706) during the COVID period. Visit volumes were below pre-COVID levels from March to May 2020 but exceeded pre-COVID levels after June 2020, including when local COVID-19 cases peaked. Telemedicine use was above 75% of visits in all cardiology subspecialties in April 2020 and stabilized at rates ranging from over 95% in electrophysiology to under 25% in heart transplant and vascular medicine. From June 2020 to February 2021, subspecialties delivering a greater percentage of visits through telemedicine experienced larger increases in new patient visits (r = 0.81, p = 0.029). Telemedicine can be used to deliver a significant proportion of outpatient cardiovascular care though utilization varies across subspecialties. Higher rates of telemedicine adoption may increase access to care in cardiology clinics. [ABSTRACT FROM AUTHOR]

An editorial focuses on disparities in access to heart transplants, particularly examining the differences in organ offer acceptance rates based on race and gender. It highlights potential biases in the transplant process and discusses factors contributing to disparities in post-transplant outcomes, including socioeconomic status and immune function.

Aims: Sex differences in long‐term outcomes following hospitalization for heart failure (HF) across ejection fraction (EF) subtypes are not well described. In this study, we evaluated the risk of mortality and rehospitalization among males and females across the spectrum of EF over 5 years of follow‐up following an index HF hospitalization event. Methods and results: Patients hospitalized with HF between 1 January 2006 and 31 December 2014 from the American Heart Association's Get With The Guidelines‐Heart Failure registry with available 5‐year follow‐up using Medicare Part A claims data were included. The association between sex and risk of mortality and readmission over a 5‐year follow‐up period for each HF subtype (HF with reduced EF [HFrEF, EF ≤40%], HF with mildly reduced EF [HFmrEF, EF 41–49%], and HF with preserved EF [HFpEF, EF >50%]) was assessed using adjusted Cox models. The effect modification by the HF subtype for the association between sex and outcomes was assessed by including multiplicative interaction terms in the models. A total of 155 670 patients (median age: 81 years, 53.4% female) were included. Over 5‐year follow‐up, males and females had comparably poor survival post‐discharge; however, females (vs. males) had greater years of survival lost to HF compared with the median age‐ and sex‐matched US population (HFpEF: 17.0 vs. 14.6 years; HFrEF: 17.3 vs. 15.1 years; HFmrEF: 17.7 vs. 14.6 years for age group 65‐69 years). In adjusted analysis, females (vs. males) had a lower risk of 5‐year mortality (adjusted hazard ratio [aHR] 0.89, 95% confidence interval [CI] 0.87–0.90, p < 0.0001), and the risk difference was most pronounced among patients with HFrEF (aHR 0.87, 95% CI 0.85–0.89; pinteraction[sex*HF subtype] = 0.04). Females (vs. males) had a higher adjusted risk of HF readmission over 5‐year follow‐up (aHR 1.06, 95% CI 1.04–1.08, p < 0.0001), with the risk difference most pronounced among patients with HFpEF (aHR 1.11, 95% CI 1.07–1.14; pinteraction[sex*HF subtype] = 0.001). Conclusions: While females (vs. males) had lower adjusted mortality, females experienced a significantly greater loss in survival time than the median age‐ and sex‐matched US population and had a greater risk of rehospitalization over 5 years following HF hospitalization. [ABSTRACT FROM AUTHOR]

A patient's likelihood to recommend a hospital is used to assess the quality of their experience. This study investigated whether room type influences patients' likelihood to recommend Stanford Health Care using Hospital Consumer Assessment of Healthcare Providers and Systems survey data from November 2018 to February 2021 (n = 10,703). The percentage of patients who gave the top response was calculated as a top box score, and the effects of room type, service line, and the COVID-19 pandemic were represented as odds ratios (ORs). Patients in private rooms were more likely to recommend than patients in semi-private rooms (aOR: 1.32; 95% CI: 1.16–1.51; 86% vs 79%, p <.001), and service lines with only private rooms had the greatest increases in odds of a top response. The new hospital had significantly higher top box scores than the original hospital (87% vs 84%, p <.001), indicating that room type and hospital environment impact patients' likelihood to recommend. [ABSTRACT FROM AUTHOR]

Aims: The long‐term outcome in patients with heart failure (HF) after hospitalization may vary substantially depending on their age and left ventricular ejection fraction (LVEF). We aimed to assess the relative rates of cardiovascular death (CVD) and non‐CVD based on the age and how the rates differ under the updated LVEF classification system. Methods and results: Consecutively registered hospitalized patients with HF (N = 3558; 39.7% women with a mean age of 73.9 ± 13.3 years) were followed for a median of 2 (interquartile range, 0.8–3.1) years. The CVDs and non‐CVDs were evaluated based on age [young (<65 years), older (65–84 years), and very old (≥85 years)] and LVEF classification [HF with preserved EF (HFpEF; LVEF ≥50%) and non‐HFpEF (LVEF <50%)]. The adverse clinical events were adjudicated independently by a central committee. Overall, 1505 (42.3%) had HFpEF [young: n = 182 (12.1%), older: n = 894 (59.4%), very old: n = 429 (28.5%)], and 2053 (57.7%) had non‐HFpEF [young: n = 575 (28.0%), older: n = 1159 (56.5%), very old: n = 319 (15.5%)]. During the follow‐up, the crude incidence of all‐cause death was higher in non‐HFpEF than in HFpEF across all age groups (non‐HFpEF vs. HFpEF, young: 10.4% vs. 5.5%, log‐rank P = 0.10; older: 26.6% vs. 20.9%, log‐rank P = 0.002; very old: 36.7% vs. 31.7%, log‐rank P = 0.043). CVDs accounted for more than half of all deaths in non‐HFpEF (young 65.0%, older 64.2%, and very old 55.6%), whereas the proportion of CVDs remained less than half in HFpEF (young 50.0%, older 41.2%, very old 38.2%). HF readmission was associated with subsequent all‐cause death in non‐HFpEF [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.41–2.09, P < 0.001], but not in HFpEF (HR: 1.12, 95% CI: 0.87–1.43, P = 0.39). Conclusions: The probability of a non‐CVD increases in both LVEF categories with advancing age, but that it is greater in the HFpEF category. The findings indicate that mitigating CV‐related outcomes alone may be insufficient for treating HF in older population, particularly in the HFpEF category. [ABSTRACT FROM AUTHOR]

Background: Reference change value (RCV) is used to assess the significance of the difference between two measurements after accounting for pre‐analytic, analytic, and within‐subject variability. The objective of the current study was to define the RCV for global longitudinal strain (GLS) using different semi‐automated software in standard clinical practice. Methods: Using a test‐retest study design, we quantified the median coefficient of variation (CV) for GLS using AutoStrain and Automated Cardiac Motion Quantification (aCMQ) by Philips. Triplane left‐ventricular ejection fraction (LVEF) was measured for comparison. Multivariable regression analysis was performed to determine factors influencing test‐retest CV including image quality and the presence of segmental wall motion abnormalities (WMA). RCV was reported using a standard formula assuming two standard deviations for repeated measurements; results were also translated into Bayesian probability. Total measurement variation was described in terms of its three different components: pre‐analytic (acquisition), analytic (measuring variation), and within‐subject (biological) variation. Result: Of the 44 individuals who were screened, 41 had adequate quality for strain quantification. The mean age of the cohort was 56.4 ± 16.8 years, 41% female, LVEF was 55.8 ± 9.8% and the median and interquartile range for LV GLS was −17.2 [−19.3 to −14.8]%. Autostrain was more time efficient (80% less analysis time) and had a lower total median CV than aCMQ (CV = 7.4% vs. 17.6%, p <.001). The total CV was higher in patients with WMA (6.4% vs. 13.2%, p =.035). In non‐segmental disease, the CV translates to a RCV of 15% (corresponding to a probability of real change of 80%). Assuming a within‐subject variability of 4.0%, the component analysis identified that inter‐reader variability accounts for 3.7% of the CV, while acquisition variability accounts for 4.0%. Conclusion: Using test‐retest analysis and CVs, we find that an RCV of 15% for GLS represents an optimistic estimate in routine clinical practice. Based on our results, a higher RCV of 17%–21% is needed in order to provide a high probability of clinically meaningful change in GLS in all comers. The methodology presented here for determining measurement reproducibility and RCVs is easily translatable into clinical practice for any imaging parameter. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing.Materials and Methods: We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors.Results: Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]).Discussion: Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse.Conclusion: Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines.Trial Registration: NCT02709772. [ABSTRACT FROM AUTHOR]

Cardiovascular disease is the leading cause of pregnancy mortality. Socioeconomic and racial disparities in pregnancy are well established. Despite this, little is known about the impact of social determinants of health in pregnant patients with heart disease. This study aims to determine whether pregnant patients with heart disease living in lower income neighborhoods and managed at cardio-obstetrics programs have higher rates of cardiac events or preterm deliveries compared with those living in higher income neighborhoods. This is a retrospective cohort study of 206 patients between 2010 and 2020 at a quaternary care hospital in Northern California. The exposure was household income level based on neighborhood defined by the US Census data. Patients in lower income neighborhoods (N = 103) were 45% Hispanic, 34% White, and 14% Asian versus upper income neighborhoods (N = 103), which were 48% White, 31% Asian, and 12% Hispanic (p < 0.001). There was no significant difference in the rates of intrapartum cardiac events (10% vs. 4%; p = 0.16), postpartum cardiac events (14% vs. 17%; p = 0.7), and preterm delivery (24% vs. 17%; p = 0.23). The rates of antepartum hospitalization were higher for lower income neighborhoods (42% vs 22%; p = 0.004). While there is no significant difference in cardiac events and preterm delivery rates between patients from low versus high income neighborhoods, patients from lower income neighborhoods have higher antepartum hospitalization rates. Earlier identification of clinical deterioration provided by a cardio-obstetrics team may contribute to increased hospitalizations, which might mitigate socioeconomic disparities in outcomes for these pregnant patients with heart disease. [ABSTRACT FROM AUTHOR]

Background: In patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOAC), bleeding risk scores provide only modest discrimination for major or intracranial bleeding. However, warfarin experience may impact HAS‐BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly) score performance in patients evaluated for DOACs, as HAS‐BLED was derived and validated in warfarin cohorts. Methods: We performed a retrospective cohort study of patients prescribed DOAC for AF in the Veterans Health Administration between 2010 and 2017. We determined modified HAS‐BLED score discrimination and calibration for bleeding, for patients treated with DOAC, stratified by prior warfarin exposure. We also determined the association between DOAC–warfarin‐naïve status to bleeding (nonintracranial and intracranial) with DOAC–warfarin‐experienced patients as reference. Results: The DOAC analysis cohort included 100, 492 patients with AF (age [mean ± SD]: 72.9 ± 9.6 years; 1.7% female; 90.1% White), of which 26, 760 patients (26.6%) and 73, 732 patients (73.4%) were warfarin experienced or naïve, respectively. HAS‐BLED discrimination for bleeds was modest for patients treated with DOAC, regardless of prior warfarin experience (concordance statistics: 0.53–0.59). For DOAC–warfarin‐naïve patients, as compared to DOAC–warfarin‐experienced patients, adjusted risk of intracranial bleeding was lower, while risk of nonintracranial bleeding was higher (intracranial bleeding propensity adjusted with inverse probability of treatment weights [IPTWs]: hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.78–0.95, p =.0040) (nonintracranial bleeding propensity adjusted with IPTW: HR: 1.15, 95% CI: 1.11–1.19, p <.0001). Conclusion: Patients' modified HAS‐BLED score at the time of DOAC initiation, regardless of prior warfarin use, provided only modest discrimination for intracranial and nonintracranial bleeds. These data argue against maintaining DOAC eligible patients on warfarin therapy regardless of modified HAS‐BLED score. [ABSTRACT FROM AUTHOR]

Background: There remains uncertainty regarding optimal primary atherosclerotic cardiovascular disease (ASCVD) prevention practices for older adults. Objective: To assess statin treatment patterns and incident ASCVD among older patients for primary prevention across the spectrum of ASCVD risk. Design: Retrospective cohort study of participants without ASCVD aged 65–79 years. Patients were stratified by age (65–69, 70–75, > 75 years) and 10-year ASCVD risk category (low/borderline, intermediate, high) based on the Pooled Cohort Equations. Multivariable logistic regressions were used to identify predictors of moderate- or high-intensity statin prescriptions. Cox proportional models were used to estimate hazard ratios (HRs) for incident ASCVD. Participants: Patients aged 65–79 years without ASCVD from a Northern California health system. Main Measures: Statin prescriptions and incident ASCVD events. Key Results: There were 54,066 patients, with 10,288 (19%) aged > 75 years and 57% women. Compared with younger groups, adults > 75 years were less likely to be prescribed moderate- or high-intensity statin prescriptions across ASCVD risk groups (all p < 0.001); this persisted after multivariable adjustment including for ASCVD risk (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74–0.86). Adults > 75 years were more likely to experience incident ASCVD (HR 1.42, 95% CI 1.23–1.63). Women (OR 0.85, 95% CI 0.81–0.89) and underweight older adults (OR 0.45, 95% CI 0.33–0.61) were also less likely to receive moderate- or high-intensity statins. Conclusions: Among older adults aged 65–79 years without prior ASCVD, those > 75 years of age were less likely to receive moderate- or high-intensity statins regardless of ASCVD risk compared with their younger counterparts, while experiencing more incident ASCVD. Efforts are warranted to study the reasons for age-based differences in statin use in older adults, particularly those at highest ASCVD risk. [ABSTRACT FROM AUTHOR]

Background: Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustained over 9 years, and evaluates its value and impact on EBP.Methods: In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level.Results: The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Most members were practising clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%) and others (n = 38, 2.8%). Participation was assessed to be "active" for 70.6% versus "passive" for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership.Conclusions: Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives. [ABSTRACT FROM AUTHOR]

Objectives To assess the applicability of Electronic Frailty Index (eFI) and Hospital Frailty Risk Score (HFRS) algorithms to Japanese administrative claims data and to evaluate their association with long-term outcomes. Study Design and Setting A cohort study using a regional government administrative healthcare and long-term care (LTC) claims database in Japan 2014–18. Participants Plan enrollees aged ≥50 years. Methods We applied the two algorithms to the cohort and assessed the scores' distributions alongside enrollees' 4-year mortality and initiation of government-supported LTC. Using Cox regression and Fine–Gray models, we evaluated the association between frailty scores and outcomes as well as the models' discriminatory ability. Results Among 827,744 enrollees, 42.8% were categorised by eFI as fit, 31.2% mild, 17.5% moderate and 8.5% severe. For HFRS, 73.0% were low, 24.3% intermediate and 2.7% high risk; 35 of 36 predictors for eFI, and 92 of 109 codes originally used for HFRS were available in the Japanese system. Relative to the lowest frailty group, the highest frailty group had hazard ratios [95% confidence interval (CI)] of 2.09 (1.98–2.21) for mortality and 2.45 (2.28–2.63) for LTC for eFI; those for HFRS were 3.79 (3.56–4.03) and 3.31 (2.87–3.82), respectively. The area under the receiver operating characteristics curves for the unadjusted model at 48 months was 0.68 for death and 0.68 for LTC for eFI, and 0.73 and 0.70, respectively, for HFRS. Conclusions The frailty algorithms were applicable to the Japanese system and could contribute to the identifications of enrollees at risk of long-term mortality or LTC use. [ABSTRACT FROM AUTHOR]

Following the adoption of an acuity-adaptable unit model in an academic medical center, a $13M increase in cost of intermediate intensive care unit (IICU) accommodations was observed. The authors followed A3 methodology to determine the root cause of this increase and developed a 3-prong intervention centered on physician engagement, given that physicians have the ability to order a patient's level of care. This intervention consisted of: (1) identifying physician champions to promote appropriate IICU use, (2) visual changes to essential electronic medical record tools, and (3) data-driven feedback to physician champions. In the year following intervention deployment, average IICU length of stay decreased from 1.08 to 0.62 days and average IICU use decreased from 21.4% to 12.3%, corresponding to ~$5.7M cost savings with no significant change in balancing measures observed. Together, these results demonstrate that a multicomponent intervention aimed at engaging physicians reduced inappropriate IICU use with no increase in adverse events. [ABSTRACT FROM AUTHOR]

Background/Objectives: Older adults (>75 years of age) represent two‐thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi‐society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. Design Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. Setting: A large multi‐specialty health system in Northern California. Participants: A total of 24,651 adults older than 75 years with ASCVD. Measurements Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. Results: The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. Conclusions: Despite increasing prescription rates between 2007 and 2018, guideline‐recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD. [ABSTRACT FROM AUTHOR]

In this document, we propose a universal definition of heart failure (HF) as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. We also propose revised stages of HF as: At risk for HF (Stage A), Pre‐HF (Stage B), Symptomatic HF (Stage C) and Advanced HF (Stage D). Finally, we propose a new and revised classification of HF according to left ventricular ejection fraction (LVEF). This includes HF with reduced ejection fraction (HFrEF): symptomatic HF with LVEF ≤40%; HF with mildly reduced ejection fraction (HFmrEF): symptomatic HF with LVEF 41–49%; HF with preserved ejection fraction (HFpEF): symptomatic HF with LVEF ≥50%; and HF with improved ejection fraction (HFimpEF): symptomatic HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF > 40%. [ABSTRACT FROM AUTHOR]