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Objectives: This study sought to better understand the discrepant results of 2 trials of serelaxin on acute heart failure (AHF) and short-term mortality after AHF by analyzing causes of death of patients in the RELAX-AHF-2 (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF-2) trial., Background: Patients with AHF continue to suffer significant short-term mortality, but limited systematic analyses of causes of death in this patient population are available., Methods: Adjudicated cause of death of patients in RELAX-AHF-2, a randomized, double-blind, placebo-controlled trial of serelaxin in patients with AHF across the spectrum of ejection fraction (EF), was analyzed., Results: By 180 days of follow-up, 11.5% of patients in RELAX-AHF-2 died, primarily due to heart failure (HF) (38% of all deaths). Unlike RELAX-AHF, there was no apparent effect of treatment with serelaxin on any category of cause of death. Older patients (≥75 years) had higher rates of mortality (14.2% vs. 8.8%) and noncardiovascular (CV) death (27% vs. 19%) compared to younger patients. Patients with preserved EF (≥50%) had lower rates of HF-related mortality (30% vs. 40%) but higher non-CV mortality (36% vs. 20%) compared to patients with reduced EF., Conclusions: Despite previous data suggesting benefit of serelaxin in AHF, treatment with serelaxin was not found to improve overall mortality or have an effect on any category of cause of death in RELAX-AHF-2. Careful adjudication of events in the serelaxin trials showed that older patients and those with preserved EF had fewer deaths from HF or sudden death and more deaths from other CV causes and from noncardiac causes. (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF [RELAX-AHF-2]; NCT01870778)., Competing Interests: Author Disclosures The RELAX-AHF-2 trial was funded by Novartis. Dr. Loungani receives research support from Pfizer and Boston Scientific. Dr. Teerlink has received research grants and/or consulting fees from Abbott, AbbVie, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Cytokinetics, EBR Systems, Medtronic, Merck, and Novartis. Dr. Metra has received consulting honoraria as a member of trials’ committees or advisory boards from Abbott Vascular, Amgen, Bayer, Edwards Therapeutics, and Vifor Pharma. Dr. Allen has received research grants from National Heart, Lung, and Blood Institute (NHLBI), PCORI, and American Heart Association; and has acted as a consultant to Abbott, ACI Clinical, Amgen, Boston Scientific, Cytokinetics, and Novartis. Dr. Butler serves as a consultant for Abbott, Adrenomed, Amgen, Array, AstraZeneca, Bayer, Boehringer Ingelheim, CVRx, InnoLife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Novartis, Novo Nordisk, Relypsa, V-Wave Limited, and Vifor. Dr. Carson has received honoraria as a CEC member from Novartis. Drs. Chen, Gimpelewicz, and Holbro are all employees and shareholders of Novartis Pharma AG. Drs. Cotter and Davison received research grants and personal fees from Novartis during the trials’ conduct; and grants from Abbott Laboratories, Amgen, Celyad, Cirius Therapeutics, Roche Diagnostics, Sanofi, and Windtree Therapeutics. Dr. Filippatos has participated in committees of trials and registries sponsored by Novartis, Servier, Medtronic, Vifor, BI, and Bayer. Dr. Greenberg has received research support from the AHA, NIH, and Rocket Pharma; and serves as a consultant for ACI, Actelion, Akcea, Amgen, EBR Systems, Ionis, Janssen, Merck, MyoKardia, Novartis, Sanofi, Viking, Zensun, and Zoll. Dr. Januzzi is a Trustee of the American College of Cardiology; has received grant support from Novartis Pharmaceuticals and Abbott Diagnostics, and consulting income from Abbott, Janssen, Novartis, MyoKardia, and Roche Diagnostics; and participates in clinical endpoint committees/data safety monitoring boards for Abbott, AbbVie, Amgen, CVRx, Janssen, and Takeda. Dr. Lanfear has received research grants from NHLBI, Amgen, Bayer, and Janssen; and has acted as a consultant for Amgen, Janssen, Ortho Diagnostics, and Novartis. Dr. Pang has served as a consultant for Baxter, Bristol Myers Squibb, and Merck; and has received research or other support from Bristol Myers Squibb, Roche, Novartis, PCORI, AHA, NHLBI, AHRQ, OrthoDiagnostics, and Abbott. Dr. Piña is an Advisory Board member of Relypsa and Vifor. Dr. Ponikowski receives consulting fees and speaker honoraria from Vifor Pharma, Amgen, Servier, Novartis, Berlin Chemie, Bayer, Pfizer, Cibiem, Impulse Dynamics, Renal Guard Solutions, Boehringer Ingelheim, and AstraZeneca, and research grants from Vifor Pharma. Dr. Miller serves as a consultant for Abbott, Boehringer, CVRx, Pfizer, Novartis, and Respicardia; and receives research support from Merck. Dr. Voors has received consultancy fees and/or grant support from Amgen, AstraZeneca, Bayer AG, Boehringer Ingelheim, Cytokinetics, MyoKardia, Novo Nordisk, Novartis, Roche Diagnostics, Servier, and Vifor Pharma. Dr. Felker has received research grants from NHLBI, American Heart Association, Amgen, Bayer Merck, Cytokinetics, and Roche Diagnostics; and has acted as a consultant to Novartis, Amgen, Bristol Myers Squibb, Cytokinetics, Medtronic, Cardionomic, V-Wave, MyoKardia, InnoLife, EBR Systems, Arena, Abbott, Roche Diagnostics, Alnylam, LivaNova, Rocket Pharma, Reprieve, and SC Pharma. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Acute heart failure (HF) is a major public health problem with substantial associated economic costs. Because most patients who present to hospitals are admitted irrespective of their level of risk, novel approaches to manage acute HF are needed, such as the use of same-day access clinics for outpatient diuresis and observation units from the emergency department. Current published data lacks a comprehensive overview of the present state of acute HF management in various clinical settings. This review summarizes the strengths and limitations of acute HF care in the outpatient and emergency department settings. Finally, a variety of innovative technologies that have the potential to improve acute HF management are discussed., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Telehealth offers an innovative approach to improve heart failure care that expands beyond traditional management strategies. Yet the use of telehealth in heart failure is infrequent because of several obstacles. Fundamentally, the evidence is inconsistent across studies of telehealth interventions in heart failure, which limits the ability of cardiologists to make general conclusions. Where encouraging evidence exists, there are logistical challenges to broad-scale implementation as a result of insufficient understanding of how to transform telemedicine strategies into clinical practice effectively. Ultimately, when implementation is reasonable, the application of these efforts remains hampered by regulatory, reimbursement, and other policy issues. The primary aim of this paper is to describe these challenges and to outline a path forward to apply telehealth approaches to heart failure in conjunction with payment reform and pragmatic research study design., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: This study assessed the comparative frequency of precipitating clinical factors leading to hospitalization among heart failure (HF) patients with reduced, borderline, and preserved ejection fraction (EF) BACKGROUND: There are few data assessing the comparative frequency of clinical factors leading to HF among hospitalized among patients with reduced, borderline, and preserved EF., Methods: We analyzed the factors potentially contributing to HF hospitalization among 99,825 HF admissions from 305 hospitals in the Get With The Guidelines-HF (GWTG-HF) database between January 2005 and September 2013 and assessed their association with length of stay and in-hospital mortality., Results: Mean patient age was 72.6 ± 14.2 years, 49% were female, and mean EF was 39.3 ± 17.2%. Common factors included pneumonia/respiratory process (28.2%), arrhythmia (21.7%), medication noncompliance (15.8%), worsening renal failure (14.7%), and uncontrolled hypertension (14.5%). In patients with borderline EF (EF 40% to 49%), pneumonia was associated with longer hospital stay, whereas dietary and medication noncompliance were associated with reduced length of stay. In patients with preserved EF (EF ≥50% or qualitative assessment of normal or mild dysfunction), pneumonia, weight gain, and worsening renal function were independently associated with longer lengths of stay. Worsening renal function and pneumonia were independently associated with higher in-hospital mortality in all HF groups, and acute pulmonary edema was associated with higher mortality in reduced EF. Dietary noncompliance (14.7%) was associated with reduced mortality for all groups but reached statistical significance in the subgroups of reduced (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.46 to 0.91) and preserved systolic function (OR: 0.52; 95% CI: 0.33 to 0.83). Patients presenting with ischemia had a higher mortality rate (OR: 1.31; 95% CI: 1.02 to 1.69; and 1.72; 95% CI: 1.27 to 2.33, respectively, in the 2 groups)., Conclusions: Potential precipitating factors among patients hospitalized with HF vary by EF group and are independently associated with clinical outcomes., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The authors sought to describe characteristics, treatments, and in-hospital outcomes of hospitalized heart failure (HF) patients stratified by etiology., Background: Whether characteristics and outcomes of HF patients differ by cardiomyopathy etiology is unknown., Methods: The authors analyzed data on 156,013 hospitalized HF patients from 319 U.S. hospitals participating in Get With The Guidelines-HF between 2005 and 2013. Characteristics, treatments, and in-hospital outcomes were assessed by HF etiology. Standard regression techniques adjusted for site and patient-level characteristics were used to examine association between HF etiology and in-hospital outcomes., Results: Median age was 75 years, 69.2% were white, and 49.5% were women. Overall, 92,361 patients (59.2%) had ischemic cardiomyopathy and 63,652 patients (40.8%) had nonischemic cardiomyopathy (NICM). Hypertensive (n = 28,141; 48.5%) and idiopathic (n = 17,808; 30.7%) cardiomyopathies accounted for the vast majority of NICM patients. Post-partum (n = 209; 0.4%), viral (n = 447; 0.8%), chemotherapy (n = 721; 1.2%), substance abuse (n = 2,653; 4.6%), familial (n = 556; 1.0%), and other (n = 7,523; 13.0%) etiologies were far less frequent. There were significant differences in baseline characteristics between those with ischemic cardiomyopathy compared with NICM with respect to age (76 years vs. 72 years), sex (44.4% vs. 56.9% women), and ejection fraction (38% vs. 45%). Risk-adjusted quality of care provided to eligible patients varied minimally by etiology. Similarly, in-hospital mortality did not differ among ischemic compared with NICM patients. However, among NICM patients, only hypertensive cardiomyopathy had a lower mortality rate compared with idiopathic NICM (adjusted odds ratio: 0.83; 95% confidence interval: 0.71 to 0.97)., Conclusions: Characteristics of hospitalized HF patients vary by etiology. Both risk-adjusted quality of care and in-hospital outcomes did not differ by etiology., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Because little was previously known about Asian-American patients with heart failure (HF), we compared clinical profiles, quality of care, and outcomes between Asian-American and non-Hispanic white HF patients using data from the American Heart Association Get With The Guidelines-Heart Failure (GWTG-HF) program., Methods: We analyzed 153,023 HF patients (149,249 whites, 97.5%; 3774 Asian-Americans, 2.5%) from 356 U.S. centers participating in the GWTG-HF program (2005-2012). Baseline characteristics, quality of care metrics, in-hospital mortality, discharge to home, and length of stay were examined., Results: Relative to white patients, Asian-American HF patients were younger, more likely to be male, uninsured or covered by Medicaid, and recruited in the western region. They had higher prevalence of diabetes, hypertension, and renal insufficiency, but similar ejection fraction. Overall, Asian-American HF patients had comparable quality of care except that they were less likely to receive aldosterone antagonists at discharge (relative risk , 0.88; 95% confidence interval , 0.78-0.99), and anticoagulation for atrial fibrillation (RR, 0.91; 95% CI, 0.85-0.97) even after risk adjustment. Compared with white patients, Asian-American patients had comparable risk adjusted in-hospital mortality (RR, 1.11; 95% CI, 0.91-1.35), length of stay>4 days (RR, 1.01; 95% CI, 0.95-1.08), and were more likely to be discharged to home (RR, 1.08; 95% CI, 1.06-1.11)., Conclusions: Despite some differences in clinical profiles, Asian-American patients hospitalized with HF receive very similar quality of care and have comparable health outcomes to their white counterparts., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Little is known about global patterns of critical care unit (CCU) care and the relationship with outcomes in patients with acute decompensated heart failure (ADHF). Whether a ward or a CCU admission is associated with better outcomes is unclear., Methods: Patients in the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial were initially hospitalized in a ward or CCU (coronary or intensive care unit). Sites were geographically classified: Asia-Pacific (AP), Central Europe (CE), Latin America (LA), North America (NA), and Western-Europe (WE). The primary outcome of 30-day all-cause mortality or all-cause hospital readmission was adjusted using a two-stage multivariable logistic regression model with a generalized estimated equation that took sites within each country as a nested random factor., Results: Overall, 1944 (38.2%) patients were admitted to a CCU and 3150 (61.8%) to a ward, and this varied by region: 50.6% AP, 63.3% CE, 60.7% WE, 22.1% LA, and 28.6% NA. The 30-day death or readmission rate was 15.2% in ward patients and 17.0% in CCU patients (risk-adjusted Odds Ratio [OR] 1.44: 95% CI, 1.14-1.82). Compared with CCU patients in NA (24.1% 30-day event rate), the primary outcomes were: AP (10.4%, Odds Ratio [OR] 0.63; 95% confidence Interval [CI], 0.35 to 1.15), CE (10.4%, OR 0.56: 95% CI, 0.31 to 1.02), LA (22.4%, OR 0.60: 95% CI, 0.11 to 3.32), and WE (11.2%, OR 0.63, 95% CI, 0.25 to 1.56). No regional differences in 30-day mortality were observed; however, 30-day readmission rates were highest in NA sites., Conclusions: Management of patients with ADHF varies significantly, and after adjustment, CCU care was associated with higher risk of early mortality, not explained by international differences. These findings may help to improve the early decisions regarding risk stratification of patients hospitalized with ADHF., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The study sought to derive and validate risk-prediction tools from a large nationwide registry linked with Medicare claims data., Background: Few clinical models have been developed utilizing data elements readily available in electronic health records (EHRs) to facilitate "real-time" risk estimation., Methods: Heart failure (HF) patients ≥ 65 years of age hospitalized in the GWTG-HF (Get With The Guidelines-Heart Failure) program were linked with Medicare claims from January 2005 to December 2009. Multivariable models were developed for 30-day mortality after admission, 30-day rehospitalization after discharge, and 30-day mortality/rehospitalization after discharge. Candidate variables were selected based on availability in EHRs and prognostic value. The models were validated in a 30% random sample and separately in patients with reduced and preserved ejection fraction (EF)., Results: Among 33,349 patients at 160 hospitals, 3,002 (9.1%) died within 30 days of admission, 7,020 (22.8%) were rehospitalized within 30 days of discharge, and 8,374 (27.2%) died or were rehospitalized within 30 days of discharge. Compared with patients classified as low risk, high-risk patients had significantly higher odds of death (odds ratio [OR]: 8.82, 95% confidence interval [CI]: 7.58 to 10.26), rehospitalization (OR: 1.99, 95% CI: 1.86 to 2.13), and death/rehospitalization (OR: 2.65, 95% CI: 2.44 to 2.89). The 30-day mortality model demonstrated good discrimination (c-index 0.75) while the rehospitalization and death/rehospitalization models demonstrated more modest discrimination (c-indices of 0.59 and 0.62), with similar performance in the validation cohort and for patients with preserved and reduced EF., Conclusions: These predictive models allow for risk stratification of 30-day outcomes for patients hospitalized with HF and may provide a validated, point-of-care tool for clinical decision making., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)