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Background The prevalence of heart failure (HF) is increasing in developed countries. Considering the significant socioeconomic burden of HF, nationwide actions against HF are indispensable. To that end, relevant information on regional variations among HF patients are required. Purpose We aimed to explore the geographic variations in the characteristics and outcomes of hospitalized HF patients using a nationwide inpatient database. Methods and results Using the Diagnosis Procedure Combination database which is a nationwide inpatient database in Japan, we carried out a comprehensive analysis of 447,818 hospitalized patients with HF (median age 81 years, 238,192 men) who were admitted between January 2010 and March 2018 in Japan. We divided the study population into seven geographical regions based on the location of the admitted hospital. Background characteristics were almost similar among all seven regions. The implementation rates of intubation, hemodialysis, inotropic agent, and advanced circulatory supports including intra-aortic balloon pumping and extracorporeal membrane oxygenation varied among the seven regions. There was a significant difference in the length of hospital stay and the in-hospital mortality among the seven regions. The multivariable logistic regression analysis including baseline clinical charasteristics and medication administered within two days after hospital admission fitted with a generalized estimation equation for in-hospital mortality showed that there was still a significant difference in the in-hospital mortality among the seven regions (Table). Conclusion The analysis of a nationwide inpatient database showed that geographical variations existed regarding the outcomes of patients hospitalized for HF. This suggests the necessity of further efforts to establish a standardized medical care system in this era of HF pandemic. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141)