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Importance: Despite advances in treatment and care quality for patients hospitalized with heart failure (HF), minimal improvement in mortality has been observed after HF hospitalization since 2010., Objective: To evaluate trends in mortality rates across specific intervals after hospitalization., Design, Setting, and Participants: This cohort study evaluated a random sample of Medicare fee-for-service beneficiaries with incident HF hospitalization from January 1, 2008, to December 31, 2018. Data were analyzed from February 2023 to May 2024., Main Outcomes and Measures: Unadjusted mortality rates were calculated by dividing the number of all-cause deaths by the number of patients with incident HF hospitalization for the following periods: in-hospital, 30 days (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Annual unadjusted and risk-adjusted mortality ratios were calculated (using logistic regression to account for differences in patient characteristics), defined as observed mortality divided by expected mortality based on 2008 rates., Results: A total of 1 256 041 patients (mean [SD] age, 83.0 [7.6] years; 56.0% female; 86.0% White) were hospitalized with incident HF. There was a substantial decrease in the mortality ratio for the in-hospital period (unadjusted ratio, 0.77; 95% CI, 0.67-0.77; risk-adjusted ratio, 0.74; 95% CI, 0.71-0.76). For subsequent periods, mortality ratios increased through 2013 and then decreased through 2018, resulting in no reductions in unadjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.94; 95% CI, 0.82-1.06; short-term mortality ratio, 1.02; 95% CI, 0.87-1.17; intermediate-term mortality ratio, 0.99; 95% CI, 0.79-1.19; and long-term mortality ratio, 0.96; 95% CI, 0.76-1.16) and small reductions in risk-adjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.88; 95% CI, 0.86-0.90; short-term mortality ratio, 0.94; 95% CI, 0.94-0.95; intermediate-term mortality ratio, 0.94; 95% CI, 0.92-0.95; and long-term mortality ratio, 0.95; 95% CI, 0.93-0.96)., Conclusions and Relevance: In this study of Medicare fee-for-service beneficiaries, there was a substantial decrease in in-hospital mortality for patients hospitalized with incident HF from 2008 to 2018, but little to no reduction in mortality for subsequent periods up to 3 years after hospitalization. These results suggest opportunities to improve longitudinal outpatient care for patients with HF after hospital discharge.

Background Although aldosterone antagonists improve outcomes in select individuals with heart failure and reduced ejection fraction, studies in the United States have raised concerns about underuse and overuse. Variations in the prescription of aldosterone antagonist in China are unknown. Methods and Results In the multicenter, hospital-based, retrospective China PEACE (China Patient-Centered Evaluative Assessment of Cardiac Events) study, we identified a nationally representative cohort of admissions for heart failure in a nationally representative sample of Chinese hospitals in 2015. Patients were classified into 1 of 3 groups according to their eligibility for spironolactone-"ideal" (left ventricular ejection fraction <40% and without contraindications), "contraindicated" (a documented contraindication, irrespective of left ventricular ejection fraction), and "uncertain-benefit" (all others). We measured hospital variation of spironolactone prescriptions at discharge in the "ideal" and "contraindicated" group and calculated the median odds ratio (MOR), a measure of institution-level variation for 2 individuals with similar characteristics discharged at 2 randomly selected hospitals. Hospital characteristics associated with spironolactone use were identified using multivariable linear regression model. Among 1222 ideal patients from 97 hospitals, the median rate of spironolactone prescription was 78.6% (interquartile range [IQR], 42.8%-89.6% [range, 0%-100%], MOR, 3.4 [95% CI, 2.7-4.0]) at discharge. Among 900 contraindicated patients from 83 hospitals, the median rate of spironolactone prescription was 30.0% (IQR, 9.1%-50.0% [range, 0%-100%], MOR, 3.1 [95% CI, 2.4-3.9]) at discharge. Hospitals with independent departments of cardiology and located in Eastern China were associated with a 38.0% (95% CI, 18.7-57.3; P <0.001) and a 14.6% (95% CI, 2.3%-26.9%; P =0.020) higher rate of spironolactone use for ideal patients. Conclusions In this national study of hospitals in China, the use of spironolactone among ideal patients and the inappropriate use of spironolactone among patients with contraindications was substantial, with rates that varied markedly by institution. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.

Background: Using DAs for preference-sensitive decisions is an evidence-based way to improve patient-centered decisions. Reimbursement mandates have increased the need for DAs in ICD care, although none have been formally evaluated. The objectives were to develop and pilot implantable cardioverter-defibrillator (ICD) decision aids (DAs) for patients considering primary prevention ICDs., Methods: Development Phase: An expert panel, including patients and physicians, iteratively developed four DAs: a one-page Option Grid TM conversation aid, a four-page in-depth paper tool, a 17-minute video, and an interactive website. Trial Phase: At three sites, patients with heart failure who were eligible for primary prevention ICDs were randomly assigned 2:1 to intervention (received DAs) or control (usual care). We conducted a mixed-methods evaluation exploring acceptability and feasibility., Results: Twenty-one eligible patients enrolled (15 intervention). Most intervention participants found the DAs to be unbiased (67%), helpful (89%), and would recommend them to others (100%). The pilot was feasible at all sites; however, using clinic staff to identify eligible patients was more efficient than chart review. Although the main goals were to measure acceptability and feasibility, intervention participants trended towards increased concordance between longevity values and ICD decisions (71% concordant vs. 29%, p = .06). Participants preferred the in-depth paper tool and video DAs. Access to a nurse during the decision-making window encouraged questions and improved participant-perceived confidence., Conclusions: Participants felt the DAs provided helpful, balanced information that they would recommend to other patients. Further exploration of this larger context of DA use and strategies to promote independent use related to electrophysiology (EP) visits are needed., (© 2021 Wiley Periodicals LLC.)

In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a β-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Importance: Little is known about the utilization rates and outcomes of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) placement among patients with advanced heart failure (HF)., Objective: To examine utilization rates, patient characteristics, and outcomes of ICD and CRT-D placements among patients with advanced HF., Design, Setting, and Participants: This cohort study was a post hoc analysis of 81 492 Medicare fee-for-service beneficiaries enrolled in the National Cardiovascular Data Registry ICD Registry between January 2010 and December 2014. Inclusion criteria were patients who had received an HF diagnosis, had a left ventricular ejection fraction of 35% or lower, and showed evidence of advanced HF, which was defined as New York Heart Association (NYHA) class IV symptoms, inotrope use within the last 60 days, left ventricular assist device in situ, or orthotopic heart transplant listing. The comparator group included patients with NYHA class II and no HF hospitalization within the last 12 months, no left ventricular assist device, no orthotopic heart transplant listing, and no current or recent inotrope use. All eligible patients underwent first-time ICD or CRT-D placement for primary prevention of sudden cardiac death. Data were analyzed from January 2010 to December 2014., Main Outcomes and Measures: All-cause mortality and periprocedural complications., Results: Of 81 492 Medicare patients, 3343 had advanced HF (4.1%) and 19 424 were in the comparator group (23.8%). Among the advanced HF population, the mean (SD) age of patients was 74 (9) years, and patients were predominantly white individuals (81.5%) and men (71.1%). The all-cause mortality rate at 30 days was 3.1% (95% CI, 2.6%-3.8%) in the advanced HF group vs 0.5% (0.4%-0.6%) in the comparator group (P < .001). In the advanced HF population, the aggregate in-hospital periprocedural complication rate was 3.74% (95% CI, 3.12%-4.44%) vs 1.10% (95% CI, 0.95%-1.25%) in the comparator group (P < .001). Most adverse events in this group were in-hospital fatality (1.82%; 95% CI, 1.40%-2.34%) and resuscitated cardiac arrest (1.05%; 95% CI, 0.73%-1.45%). Patients with NYHA class IV (hazard ratio, 1.40; 95% CI, 1.02-1.93; P = .04), ischemic heart disease (hazard ratio, 1.24; 95% CI, 1.04-1.48; P = .02), or diabetes (hazard ratio, 1.17; 95% CI, 1.04-1.33; P = .01) had a higher risk of death., Conclusions and Relevance: Among patients undergoing ICD or CRT-D placement for primary prevention of sudden cardiac death, only a small proportion had advanced HF. These patients experienced clinically important periprocedural complication rates associated with in-hospital death and cardiac arrest relative to patients with nonadvanced HF.

Whereas multiple national, international, and trial registries for heart failure have been created, international standards for clinical assessment and outcome measurement do not currently exist. The working group's objective was to facilitate international comparison in heart failure care, using standardized parameters and meaningful patient-centered outcomes for research and quality of care assessments. The International Consortium for Health Outcomes Measurement recruited an international working group of clinical heart failure experts, researchers, and patient representatives to define a standard set of outcomes and risk-adjustment variables. This was designed to document, compare, and ultimately improve patient care outcomes in the heart failure population, with a focus on global feasibility and relevance. The working group employed a Delphi process, patient focus groups, online patient surveys, and multiple systematic publications searches. The process occurred over 10 months, employing 7 international teleconferences. A 17-item set has been established, addressing selected functional, psychosocial, burden of care, and survival outcome domains. These measures were designed to include all patients with heart failure, whether entered at first presentation or subsequent decompensation, excluding cardiogenic shock. Sources include clinician report, administrative data, and validated patient-reported outcome measurement tools: the Kansas City Cardiomyopathy Questionnaire; the Patient Health Questionnaire-2; and the Patient-Reported Outcomes Measurement Information System. Recommended data included those to support risk adjustment and benchmarking across providers and regions. The International Consortium for Health Outcomes Measurement developed a dataset designed to capture, compare, and improve care for heart failure, with feasibility and relevance for patients and clinicians worldwide., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

In this update, we focus on selected topics of high clinical relevance for health care providers who treat patients with heart failure (HF), on the basis of clinical trials published after 2017. Our objective was to review the evidence, and provide recommendations and practical tips regarding the management of candidates for the following HF therapies: (1) transcatheter mitral valve repair in HF with reduced ejection fraction; (2) a novel treatment for transthyretin amyloidosis or transthyretin cardiac amyloidosis; (3) angiotensin receptor-neprilysin inhibition in patients with HF and preserved ejection fraction (HFpEF); and (4) sodium glucose cotransport inhibitors for the prevention and treatment of HF in patients with and without type 2 diabetes. We emphasize the roles of optimal guideline-directed medical therapy and of multidisciplinary teams when considering transcatheter mitral valve repair, to ensure excellent evaluation and care of those patients. In the presence of suggestive clinical indices, health care providers should consider the possibility of cardiac amyloidosis and proceed with proper investigation. Tafamidis is the first agent shown in a prospective study to alter outcomes in patients with transthyretin cardiac amyloidosis. Patient subgroups with HFpEF might benefit from use of sacubitril/valsartan, however, further data are needed to clarify the effect of this therapy in patients with HFpEF. Sodium glucose cotransport inhibitors reduce the risk of incident HF, HF-related hospitalizations, and cardiovascular death in patients with type 2 diabetes and cardiovascular disease. A large clinical trial recently showed that dapagliflozin provides significant outcome benefits in well treated patients with HF with reduced ejection fraction (left ventricular ejection fraction ≤ 40%), with or without type 2 diabetes., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Importance: Given the emerging heart failure (HF) epidemic in China, monitoring and improving the quality of care for heart failure is a top priority., Objectives: To assess the quality of HF care provided to inpatients by examining the adherence to quality measures for HF care at the hospital level and to identify factors associated with the quality of care., Design, Setting, and Participants: In this multicenter, hospital-based, retrospective cross-sectional study in China, medical records of patients hospitalized for HF from January 1, 2015, to December 31, 2015, were analyzed from January 1, 2018, to May 20, 2019. In the first stage, simple random sampling stratified by economic-geographical regions in China was used to generate a list of participating hospitals. In the second stage, 15 538 hospitalizations from the 189 selected hospitals were systematically sampled, and 10 004 HF hospitalizations were included in the final sample., Main Outcomes and Measures: Adherence to the following 4 core performance measures at the hospital level: (1) left ventricular ejection fraction assessment during hospitalization; (2) evidence-based β-blocker (bisoprolol, carvedilol, or metoprolol succinate) for eligible patients at discharge; (3) angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for eligible patients at discharge; and (4) scheduled follow-up appointment at discharge. At the hospital level, a composite performance score (ranging from 0-1) was also calculated by averaging these measures., Results: In total, 10 004 hospital admissions for HF at 189 hospitals were included in this study. The median (interquartile range [IQR]) patient age at admission was 73 (65-80) years, and 5117 (51.1%) of the patients were men. Among all hospitals, the median rate of adherence to measure 1 was 66.7% (IQR, 45.5%-80.7%; range, 0%-100%). The rate for adherence to measure 2 was 14.8% (IQR, 0%-37.5%; range, 0%-81.8%), and the rate for measure 3 was 57.1% (IQR, 36.4%-75.0%; range, 0%-100%). For measure 4, the median rate of adherence was 11.5% (IQR, 3.3%-32.8%; range, 0%-96.7%). The median (IQR) composite performance score across all hospitals was 40.0% (26.9%-51.9%), with a range from 2.2% to 85.4%. The median odds ratios of adherence were 2.2 (95% CI, 2.0-2.4) for measure 1, 2.1 (95% CI, 1.8-2.4) for measure 2, 2.4 (95% CI, 2.0-2.9 for measure 3, and 4.8 (95% CI, 3.9-5.8) for measure 4 among hospitals., Conclusions and Relevance: The findings of this study suggest that quality of care for patients with HF in China may be substandard, and there is wide heterogeneity in the quality of care for HF among hospitals. The findings also suggest the need for a national strategy to improve and standardize the quality of HF care in China.

Objectives: This study sought to develop models for predicting mortality and heart failure (HF) hospitalization for outpatients with HF with preserved ejection fraction (HFpEF) in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial., Background: Although risk assessment models are available for patients with HF with reduced ejection fraction, few have assessed the risks of death and hospitalization in patients with HFpEF., Methods: The following 5 methods: logistic regression with a forward selection of variables; logistic regression with a lasso regularization for variable selection; random forest (RF); gradient descent boosting; and support vector machine, were used to train models for assessing risks of mortality and HF hospitalization through 3 years of follow-up and were validated using 5-fold cross-validation. Model discrimination and calibration were estimated using receiver-operating characteristic curves and Brier scores, respectively. The top prediction variables were assessed by using the best performing models, using the incremental improvement of each variable in 5-fold cross-validation., Results: The RF was the best performing model with a mean C-statistic of 0.72 (95% confidence interval [CI]: 0.69 to 0.75) for predicting mortality (Brier score: 0.17), and 0.76 (95% CI: 0.71 to 0.81) for HF hospitalization (Brier score: 0.19). Blood urea nitrogen levels, body mass index, and Kansas City Cardiomyopathy Questionnaire (KCCQ) subscale scores were strongly associated with mortality, whereas hemoglobin level, blood urea nitrogen, time since previous HF hospitalization, and KCCQ scores were the most significant predictors of HF hospitalization., Conclusions: These models predict the risks of mortality and HF hospitalization in patients with HFpEF and emphasize the importance of health status data in determining prognosis. (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist [TOPCAT]; NCT00094302)., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Over the past 2 decades, guidelines for digoxin use have changed significantly. However, little is known about the national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over this time period., Methods: To describe digoxin prescription trends, we conducted a population-level, cohort study using data from IQVIA, Inc.'s National Prescription Audit (2007-2014) for patients aged ≥65 years. Further, in a national cohort of Medicare fee-for-service beneficiaries aged ≥65 years in the United States, we assessed temporal trends of hospitalizations associated with digoxin toxicity and the outcomes of these hospitalizations between 1999 and 2013., Results: From 2007 through 2014, the number of digoxin prescriptions dispensed decreased by 46.4%; from 8,099,856 to 4,343,735. From 1999 through 2013, the rate of hospitalizations with a principal or secondary diagnosis of digoxin toxicity decreased from 15 to 2 per 100,000 person-years among Medicare fee-for-service beneficiaries. In-hospital and 30-day mortality rates associated with hospitalization for digoxin toxicity decreased significantly among Medicare fee-for-service beneficiaries; from 6.0% (95% confidence interval [CI], 5.2-6.8) to 3.7% (95% CI, 2.2-5.7) and from 14.0% (95% CI, 13.0-15.2) to 10.1% (95% CI, 7.6-13.0), respectively. Rates of 30-day readmission for digoxin toxicity decreased from 23.5% (95% CI, 22.1-24.9) in 1999 to 21.7% (95% CI, 18.0-25.4) in 2013 (P < .05)., Conclusion: While digoxin prescriptions have decreased, it is still widely prescribed. However, the rate of hospitalizations for digoxin toxicity and adverse outcomes associated with these hospitalizations have decreased. These findings reflect the changing clinical practice of digoxin use, aligned with the changes in clinical guidelines., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background Heart failure (HF) is an emerging epidemic in China and accounts for significant healthcare resource utilization in the inpatient setting. To create evidence-based, life-saving, and cost-saving hospitalization systems, the first step is to characterize the contemporary national landscape of inpatient HF care. Methods and Results In the China PEACE 5r-HF study (China Patient-centered evaluative Assessment of Cardiac Events Retrospective Study of Heart Failure), we used 2-stage random sampling to create a nationally representative cohort of 10 004 admissions for HF from 189 hospitals in 2015 in China. Data on patient characteristics, management, and outcomes were obtained through centralized medical record abstraction. The median age of the cohort was 73 years (interquartile range, 65-80), and 48.9% were women. More than half (56.2%) of the patients were hospitalized in rural areas. Prevalence of ejection fraction ≥50%, 40% to 50%, and <40% was 60.3%, 17.7%, and 22.0%, respectively. We identified substantial gaps in care, including underutilization of diagnostic tests such as echocardiograms (63.6%), chest imaging (75.2%), and biomarker testing (56.4%), low prescription rates of guideline-recommended medications during hospitalization and at discharge, suboptimal rates of follow-up appointments (24.3%), and widespread utilization of traditional Chinese medicine (74.8%). The combined rate of in-hospital mortality and treatment withdrawal in our study was 3.5%, and median length-of-stay was 9 days (interquartile range, 7-13). Conclusions Patients admitted with acute HF in China have distinctive epidemiology and receive substandard care, but have low inpatient mortality despite long length of stay. These findings provide opportunities for streamlining efficiencies while improving quality of inpatient HF care in China. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.

Aims: To assess the association of body mass index (BMI) with heart failure (HF) outcomes after cardiac resynchronization therapy with defibrillator (CRT-D) implantation., Methods and Results: Medicare beneficiaries with HF aged ≥ 65 years (n = 18 922) undergoing first-time CRT-D from the National Cardiovascular Data Registry (NCDR) Implantable Cardioverter-Defibrillator Registry between 2010 and 2013, were followed for 3 years post-implantation. Survival curves and covariate adjusted hazard ratio (aHR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by BMI status. Of 18 922 HF patients receiving CRT-D, 5265 (27.8%) were normal weight, 6896 (37%) were overweight, 6318 (33.4%) were obese, and 353 (1.8%) were underweight. Compared to those of normal weight (BMI 18.5-24.9 kg/m 2 ), underweight patients had a higher 3-year post-device implantation risk of death [aHR: 1.34 (95% confidence interval 1.09-1.65); P < 0.001] and of readmission [sub-aHR: 1.25 (1.09-1.42); P < 0.001]. The corresponding 3-year aHRs for death were 0.83 (0.77-0.89) for overweight, 0.74 (0.67-0.82) for obesity class I (BMI 30-34.9 kg/m 2 ), 0.78 (0.68-0.90) for obesity class II (BMI 35-39.9 kg/m 2 ), and 0.75 (0.60-0.93) for obesity class III (BMI ≥ 40 kg/m 2 , P for all categories < 0.001). Individuals with class III obesity had a higher risk of readmission [sub-aHR: 1.17 (1.06-1.30)]. There were no differences in rates of device-related complications within 90 days across BMI categories., Conclusion: Most elderly patients with HF receiving CRT-D were overweight or obese. While being underweight was associated with greater risks of death and hospitalization, overweight and obese patients were at lower risk of death after CRT-D., (© 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiology.)

Background Traditional Chinese medicine (TCM) is used in the treatment of many conditions, including heart failure (HF), although it is not well characterized. Methods and Results We conducted a retrospective analysis of TCM use in a random sample of hospitalizations for HF within a random sample of Western medicine hospitals in China in 2015 using data from the China PEACE 5r-HF (China Patient-Centered Evaluative Assessment of Cardiac Events 5 Retrospective Heart Failure Study). We describe the frequency of TCM use and its association with patient characteristics, in-hospital use of evidence-based therapies, and hospital characteristics using hierarchical logistic regression models. Finally, we assessed risk-adjusted in-hospital bleeding and mortality. Among 10 004 patients hospitalized with HF (median age, 73 years; 48.9% women) from 189 hospitals, 74.7% received TCM (83.3% administered intravenously). The most commonly used agent was Salvia miltiorrhiza (51.2%). Patients with coronary artery disease (odds ratio [OR], 1.73; 95% CI, 1.53-1.95) or stroke (OR, 1.32; 95% CI, 1.15-1.51) were more likely to receive TCM; there was no correlation with evidence-based therapy use. Nearly all hospitals (99.4%) used TCM, with substantial variation across hospitals (median OR, 3.29; 95% CI, 2.82-3.76). In-patient bleeding (OR, 1.39; 95% CI, 1.03-1.88) and mortality (OR, 1.36; 95% CI, 1.04-1.79) were higher with Salvia miltiorrhiza, although not with other TCMs. Conclusions In a nationally representative sample of patients hospitalized with acute HF in China, three fourths received TCM. Nearly all hospitals used TCM, although use varied substantially by hospital. Although TCM was not used in lieu of evidence-based therapies for HF, we found a signal for harm with the most commonly used TCM. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.

Aims: To compare the management of patients with diabetes and heart failure with reduced ejection fraction (HFrEF) in the United States and Asia to understand variations in treatment patterns across different healthcare systems., Materials and Methods: Our cohort included patients with diabetes and HFrEF (ejection fraction <40%) from a US-based registry of adults with diabetes (2013-2016, electronic health records) and a multi-national Asian registry of adults with heart failure (2010-2016, prospective registry). Asian countries were categorized as high income (HI) or low income (LI), according to the United Nations classification. Rates of use of guideline-directed medical therapies (determined through review of active medication lists) were compared across regions., Results: Patients with diabetes and HFrEF in the United States (n = 28 877) were older, had higher body mass indices, and were more likely to have coronary disease than those in Asia (n = 2235). Compared with US patients, the use of guideline-directed medical therapy for HFrEF was lower in patients in LI Asian countries (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers: patients in the United States, 77% vs. patients in HI Asian countries, 76% vs patients in LI Asian countries, 69%; β-blockers: patients in the United States, 91% vs. patients in HI Asian countries, 87% vs. patients in LI Asian countries, 69%; P < 0.001 for both). Insulin was used more commonly in the United States (44% vs. 24% vs. 25%, respectively; P < 0.001), whereas sulphonylureas were more often prescribed in Asian countries (42% vs. 52% vs. 54%; respectively, P < 0.001). Thiazolidinediones were prescribed in 6% of US patients compared with <1% of patients in Asia. The use of newer diabetes medications was <5% in all., Conclusion: In both the United States and Asia, opportunities for improvement in the use of evidence-based therapies exist for patients with both diabetes and HFrEF. Effective tools to guide medication choices for these complex, high-risk patients could have substantial impact on quality and outcomes., (© 2018 John Wiley & Sons Ltd.)

Background: Landmark studies have demonstrated the safety and efficacy of implantable cardioverter-defibrillators (ICDs) in selected stable ambulatory patients with heart failure (HF) with a reduced ejection fraction receiving optimal medical therapy. It is not known whether a recent hospitalization for HF before ICD placement is associated with subsequent outcomes., Methods: A post hoc analysis was performed of Medicare beneficiaries enrolled in the National Cardiovascular Data Registry's ICD Registry with a known diagnosis of HF and an ejection fraction ≤35% underdoing a new ICD placement for primary prevention. Patients were grouped based on the timing of ICD placement from the last hospitalization for HF. The association between timing of ICD placement and outcomes was assessed by using multivariable logistic regression models., Results: The final analytic cohort included 81 180 patients undergoing initial ICD placement for primary prevention who were currently hospitalized for HF (n=11 563, 14%), hospitalized for HF within 3 months (n=6252, 8%), or hospitalized for HF >3 months previously or had no previous hospitalizations for HF (n=63 365, 78%). Patients currently or recently hospitalized for HF had a higher unadjusted composite periprocedural complication rate (2.60% versus 1.71% versus 1.25%, P<0.001). After adjusting for potential confounders, patients currently hospitalized for HF were at higher risk for death (odds ratio, 2.25; 95% CI, 2.02-2.52; P <0.001) and all-cause readmission (odds ratio, 1.89; 95% CI, 1.79-1.99; P <0.001) at 90 days., Conclusion: Older patients currently or recently hospitalized for HF undergoing initial ICD placement for primary prevention experienced a higher rate of periprocedural complications and were at increased risk of death in comparison with those receiving an ICD without recent HF hospitalization. Additional prospective, real-world, pragmatic, comparative effectiveness studies should be conducted to define the optimal timing of ICD placement.

Background: Optimal glucose-lowering strategies in patients with both heart failure (HF) and type 2 diabetes mellitus (T2D) are not well defined, particularly as novel medication classes emerge.We sought to evaluate current patterns of glucose-lowering medication use in adults with T2D with and without HF., Methods: The DCR is a US-based outpatient registry of adults with diabetes; currently includes 3074 providers in 203 practices. We used hierarchical, modified Poisson regression models to examine the relationship between concomitant HF with use of each glucose-lowering medication class, adjusting for other factors that could impact selection of one medication class over another: age, chronic kidney disease (CKD), coronary artery disease (CAD), number of glucose-lowering medications, and insurance., Results: Among 456,106 adults with T2D, 125,161 (27%) had a diagnosis of HF (30% HFrEF, 15%HFmrEF, 55% HFpEF). Patients with T2D and HF were more likely to be older and male, and to have CAD, atrial fibrillation, and CKD. In the multivariable models, HF was associated with a greater use of insulin (RR 1.39, 95% CI 1.36-1.42) and lower use of thiazolidinediones (RR 0.79, 95% CI 0.74-0.83), SGLT2 inhibitors (RR 0.83, 95% CI 0.79-0.89), and metformin (RR 0.84, 95% CI 0.82-0.86). Among the subgroup of patients with HF, thiazolidinediones, GLP-1 receptor agonists, and SGLT2 inhibitors were used even less often in patients with lower ejection fraction, indicating that both the diagnosis of clinical HF and ejection fraction may influence the choice of glucose-lowering medications., Conclusion: In a large US-based outpatient registry, we found that a quarter of adults with T2D had a diagnosis of HF, which was predominantly HFpEF. Although certain T2D medication use in patients with HF appeared consistent with evidence (less use of thiazolidinediones), others appeared contrary to evidence (less use of metformin and SGLT2 inhibitors)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Heart failure (HF) is a leading cause of hospitalisation in China, which is experiencing a rapid increase in cardiovascular disease prevalence. Yet, little is known about current burden of disease, quality of care and treatment outcomes of HF in China. The objective of this paper is to describe the study methodology, data collection and abstraction, and progress to date of the China Patient-centered Evaluative Assessment of Cardiac Events 5 Retrospective Heart Failure Study (China PEACE 5r-HF)., Methods and Analysis: The China PEACE 5r-HF Study will examine a nationally representative sample of more than 10 000 patient records hospitalised for HF in 2015 in China. The study is a retrospective cohort study. Patients have been selected using a two-stage sampling design stratified by economic-geographical regions. We will collect patient characteristics, diagnostic testing, treatments and in-hospital outcomes, including death and complications, and charges of hospitalisation. Data quality will be monitored by a central coordinating centre and will address case ascertainment, data abstraction and data management. As of October 2017, we have sampled 15 538 medical records from 189 hospitals, and have received 15 057 (96.9%) of these for data collection, and completed data abstraction and quality control on 7971., Ethics and Dissemination: The Central Ethics Committee at the Chinese National Center for Cardiovascular Diseases approved the study. All collaborating hospitals accepted central ethics committee approval with the exception of 15 hospitals, which obtained local approval by internal ethics committees. Findings will be disseminated in future peer-reviewed papers and will serve as a foundation for improving the care for HF in China., Trial Registration Number: NCT02877914., Competing Interests: Competing interests: HMK works under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures, is chair of a cardiac scientific advisory board for United Health, and is the recipient of research grants from Medtronic, Inc and Johnson & Johnson through Yale University., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In US clinical practice, many patients who undergo placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death receive dual-chamber devices. The superiority of dual-chamber over single-chamber devices in reducing the risk of inappropriate ICD shocks in clinical practice has not been established. The objective of this study was to compare risk of adverse outcomes, including inappropriate shocks, between single- and dual-chamber ICDs for primary prevention., Methods and Results: We identified patients receiving a single- or dual-chamber ICD for primary prevention who did not have an indication for pacing from 15 hospitals within 7 integrated health delivery systems in the Longitudinal Study of Implantable Cardioverter-Defibrillators from 2006 to 2009. The primary outcome was time to first inappropriate shock. ICD shocks were adjudicated for appropriateness. Other outcomes included all-cause hospitalization, heart failure hospitalization, and death. Patient, clinician, and hospital-level factors were accounted for using propensity score weighting methods. Among 1042 patients without pacing indications, 54.0% (n=563) received a single-chamber device and 46.0% (n=479) received a dual-chamber device. In a propensity-weighted analysis, device type was not significantly associated with inappropriate shock (hazard ratio, 0.91; 95% confidence interval, 0.59-1.38 [ P =0.65]), all-cause hospitalization (hazard ratio, 1.03; 95% confidence interval, 0.87-1.21 [ P =0.76]), heart failure hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.72-1.21 [ P =0.59]), or death (hazard ratio, 1.19; 95% confidence interval, 0.93-1.53 [ P =0.17])., Conclusions: Among patients who received an ICD for primary prevention without indications for pacing, dual-chamber devices were not associated with lower risk of inappropriate shock or differences in hospitalization or death compared with single-chamber devices. This study does not justify the use of dual-chamber devices to minimize inappropriate shocks., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research., (Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Millions of Americans live in the US territories, but health outcomes and payments among Medicare beneficiaries in these territories are not well characterized., Methods: Among Fee-for-Service Medicare beneficiaries aged 65 years and older hospitalized between 1999 and 2012 for acute myocardial infarction (AMI), heart failure (HF), and pneumonia, we compared hospitalization rates, patient outcomes, and inpatient payments in the territories and states., Results: Over 14 years, there were 4,350,813 unique beneficiaries in the territories and 402,902,615 in the states. Hospitalization rates for AMI, HF, and pneumonia declined overall and did not differ significantly. However, 30-day mortality rates were higher in the territories for all 3 conditions: in the most recent time period (2008-2012), the adjusted odds of 30-day mortality were 1.34 [95% confidence interval (CI), 1.21-1.48], 1.24 (95% CI, 1.12-1.37), and 1.85 (95% CI, 1.71-2.00) for AMI, HF, and pneumonia, respectively; adjusted odds of 1-year mortality were also higher. In the most recent study period, inflation-adjusted Medicare in-patient payments, in 2012 dollars, were lower in the territories than the states, at $9234 less (61% lower than states), $4479 less (50% lower), and $4403 less (39% lower) for AMI, HF, and pneumonia hospitalizations, respectively (P<0.001 for all)., Conclusions and Relevance: Among Medicare Fee-for-Service beneficiaries, in 2008-2012 mortality rates were higher, or not significantly different, and hospital reimbursements were lower for patients hospitalized with AMI, HF, and pneumonia in the territories. Improvement of health care and policies in the territories is critical to ensure health equity for all Americans.

Background: Atrial fibrillation (AF) and heart failure with reduced ejection fraction frequently coexist. The AATAC (Ablation versus Amiodarone for Treatment of persistent Atrial fibrillation in patients with Congestive heart failure and an implantable device) trial suggests that catheter ablation may benefit these patients. However, applicability to contemporary ambulatory cardiology practice is unknown., Methods and Results: Using the outpatient National Cardiovascular Data Registry ® Practice Innovation and Clinical Excellence Registry, we identified participants meeting AATAC enrollment criteria between 2013 and 2014. Treatment with medications and procedures was assessed at registry inclusion. From 164 166 patients with AF and heart failure, 8483 (7%) patients potentially met AATAC inclusion criteria. Eligible subjects, compared to AATAC trial participants, were older (mean age, 71.2±11.4 years) and had greater comorbidity (coronary artery disease 79.2%, hypertension 82.4%, and diabetes mellitus 31.8%). AF was predominantly paroxysmal (65.5%), rather than persistent/permanent (16.7%) or new onset (17.8%), whereas all patients in the AATAC trial had persistent AF. Commonly used atrioventricular-nodal blocking agents were carvedilol (71.2%), digoxin (31.9%), and metoprolol (27.1%). Rhythm control with anti-arrhythmic drugs was reported in 29.0% of AATAC eligible patients (predominantly amiodarone [24.6%]) and 9.3% had undergone catheter ablation. Patients who underwent ablation were more likely to be younger and have less comorbidities than those who did not., Conclusions: Among the contemporary ambulatory AF/heart failure with reduced ejection fraction population, treatment is predominantly rate control with few catheter ablations. Application of AATAC findings has the potential to markedly increase the use of catheter ablation in this population, although significant differences in clinical profiles might influence ablation outcomes in practice., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Among patients with implantable defibrillators (ICD), use of remote patient monitoring (RPM) is associated with lower risk of death and rehospitalization. Standard ICD RPM can be supplemented with weight and blood pressure data. It is not known whether standard RPM plus routine weight and blood pressure transmission (RPM+) is associated with better outcomes., Methods and Results: RPM+ patients (n=4106) were compared with patients who only transmitted standard ICD RPM data (n=14 183). Logistic regression models identified patient, physician, and hospital characteristics associated with RPM+ utilization. Mortality and rehospitalization were examined using landmark analyses at 180 days after ICD implant in Medicare fee-for-service patients. In these analyses, we examined the independent association between RPM+ utilization and times to events up to 3 years after device implantation with Cox regression models. We further examined whether the association between RPM+ and outcomes varied by frequency or type of transmissions. Determinants of RPM+ utilization included impaired ejection fraction, cardiac resynchronization therapy, and institutional practice. The risk of mortality of RPM+ patients was similar to standard ICD RPM patients (hazard ratio, 1.06; 95% confidence interval, 0.94-1.19; P =0.34). RPM+ patients also had similar risks of all-cause hospitalization (subdistribution hazard ratio, 1.03; 95% confidence interval, 0.94-1.14; P =0.52), cardiovascular hospitalization (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; P =0.15), or heart failure hospitalizations (subdistribution hazard ratio, 0.90; 95% confidence interval, 0.78-1.05; P =0.18). RPM+ transmission frequency was not associated with outcomes., Conclusions: In patients using standard ICD RPM, the added transmission of weight and blood pressure data was not associated with improved outcomes., (© 2017 American Heart Association, Inc.)

Importance: Cardiac resynchronization therapy (CRT) reduces the risk for mortality and heart failure-related events in select patients. Little is known about the use of CRT in combination with an implantable cardioverter defibrillator (ICD) in patients who are eligible for this therapy in clinical practice., Objective: To (1) identify patient, clinician, and hospital characteristics associated with CRT defibrillator (CRT-D) use and (2) determine the extent of hospital-level variation in the use of CRT-D among guideline-eligible patients undergoing ICD placement., Design, Setting, and Participants: Multicenter retrospective cohort from 1428 hospitals participating in the National Cardiovascular Data Registry ICD Registry between April 1, 2010, and June 30, 2014. Adult patients meeting class I or IIa guideline recommendations for CRT at the time of device implantation were included in this study., Main Outcomes and Measures: Implantation of an ICD with or without CRT., Results: A total of 63 506 eligible patients (88.6%) received CRT-D at the time of device implantation. The mean (SD) ages of those in the ICD and CRT-D groups were 67.9 (12.2) years and 68.4 (11.5) years, respectively. In hierarchical multivariable models, black race was independently associated with lower use of CRT-D (odds ratio [OR], 0.77; 95% CI, 0.71-0.83) as was nonprivate insurance (OR, 0.90; 95% CI, 0.85-0.95 for Medicare and OR, 0.73; 95% CI, 0.65-0.82 for Medicaid). Clinician factors associated with greater CRT-D use included clinician implantation volume (OR, 1.01 per 10 additional devices implanted; 95% CI, 1.01-1.01) and electrophysiology training (OR, 3.13 as compared with surgery-boarded clinicians; 95% CI, 2.50-3.85). At the hospital level, the overall median risk-standardized rate of CRT-D use was 79.9% (range, 26.7%-100%; median OR, 2.08; 95% CI, 1.99-2.18)., Conclusions and Relevance: In a national cohort of patients eligible for CRT-D at the time of device implantation, nearly 90% received a CRT-D device. However, use of CRT-D differed by race and implanting operator characteristics. After accounting for these factors, the use of CRT-D continued to vary widely by hospital. Addressing disparities and variation in CRT-D use among guideline-eligible patients may improve patient outcomes.

Background: Large-scale data on outcomes with cardiac resynchronization therapy with defibrillator in patients with diabetes mellitus are limited. We compared outcomes after cardiac resynchronization therapy with defibrillator implantation among patients with heart failure who have diabetes mellitus versus those without diabetes mellitus., Methods and Results: Survival curves and covariate adjusted hazard ratio (HR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by diabetes mellitus status among 18 428 patients at least 65 years old receiving cardiac resynchronization therapy with defibrillator from the National Cardiovascular Data Registry, implantable cardioverter-defibrillator registry between 2006 and 2009, with up to 3 years of follow-up. Accounting for differences between groups, compared with those without diabetes mellitus (n=11 345), patients with diabetes mellitus (n=7083) had a higher risk of death both at 1 year (HR, 1.16 [95% confidence interval (CI), 1.05-1.29]; P=0.0037) and 3 years (HR, 1.21 [1.14-1.29]; P<0.001) after device implantation and higher risks of all-cause readmission (sub-HR, 1.16 [1.11-1.21] at 1 year; P<0.0001; sub-HR, 1.15 [1.11-1.19] at 3 years; P<0.0001) and heart failure-related readmission (sub-HR, 1.18 [1.09-1.28] at 1 year; P<0.0001; and sub-HR, 1.22 [1.15-1.30] at 3 years; P<0.0001). Device-related complications within 90 days did not differ between those with and without diabetes mellitus (odds ratio: 0.90 [0.77-1.06]; P=0.37). Interactions of age, sex, ischemic cardiomyopathy, renal failure, or QRS duration were not significant., Conclusions: In older patients with heart failure receiving cardiac resynchronization therapy with defibrillator, diabetes mellitus was independently associated with greater risks of death and rehospitalization, but similar risks of procedural complications., (© 2016 American Heart Association, Inc.)

Background: Atrial fibrillation is common in patients with heart failure, but outcomes of patients with both conditions who receive cardiac resynchronization therapy with defibrillator (CRT-D) compared with an implantable cardioverter-defibrillator (ICD) alone are unclear., Methods and Results: Using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims, we identified 8951 patients with atrial fibrillation who were eligible for CRT-D and underwent first-time device implantation for primary prevention between April 2006 and December 2009. We used Cox proportional hazards models and inverse probability-weighted estimates to compare outcomes with CRT-D versus ICD alone. Cumulative incidence of mortality (744 [33%] for ICD; 1893 [32%] for CRT-D) and readmission (1788 [76%] for ICD; 4611 [76%] for CRT-D) within 3 years and complications within 90 days were similar between groups. After inverse weighting for the probability of receiving CRT-D, risks of mortality (hazard ratio, 0.83; 95% confidence interval, 0.75-0.92), all-cause readmission (hazard ratio, 0.86; 95% confidence interval, 0.80-0.92), and heart failure readmission (hazard ratio, 0.68; 95% confidence interval, 0.62-0.76) were lower with CRT-D compared with ICD alone. There was no significant difference in the 90-day complication rate (hazard ratio, 0.88; 95% confidence interval, 0.60-1.29). We observed hospital-level variation in the use of CRT-D among patients with atrial fibrillation., Conclusions: Among eligible patients with heart failure and atrial fibrillation, CRT-D was associated with lower risks of mortality, all-cause readmission, and heart failure readmission, as well as with a similar risk of complications compared with ICD alone., (© 2016 American Heart Association, Inc.)

Importance: Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care., Objective: To assess and compare mortality and readmission rates among men in VA and non-VA hospitals., Design, Setting, and Participants: Cross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA)., Exposures: Hospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital., Main Outcomes and Measures: For each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed., Results: We studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ≥65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P = .02; -0.2 percentage-point difference) and HF (11.4% vs 11.9%, P = .008; -0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P = .045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P < .001). In within-MSA comparisons, VA hospitals had lower mortality rates for AMI (percentage-point difference, -0.22; 95% CI, -0.40 to -0.04) and HF (-0.63; 95% CI, -0.95 to -0.31), and mortality rates for pneumonia were not significantly different (-0.03; 95% CI, -0.46 to 0.40); however, VA hospitals had higher readmission rates for AMI (0.62; 95% CI, 0.48 to 0.75), HF (0.97; 95% CI, 0.59 to 1.34), or pneumonia (0.66; 95% CI, 0.41 to 0.91)., Conclusions and Relevance: Among older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas, although absolute differences between these outcomes at VA and non-VA hospitals were small.

Background: Geriatric conditions may influence outcomes among patients receiving implantable cardioverter-defibrillators (ICDs). We sought to determine the prevalence of frailty and dementia among older adults receiving primary prevention ICDs and to determine the impact of multimorbidity on mortality within 1 year of ICD implantation., Methods and Results: The cohort included 83 792 Medicare patients from the National Cardiovascular Data Registry ICD Registry who underwent first primary prevention ICD implantation between 2006 and 2009. These data were merged with Medicare analytic files to determine the prevalence of frailty, dementia, and other conditions before ICD implantation, as well as 1-year mortality. A validated claim-based algorithm was used to identify frail patients. Mutually exclusive patterns of chronic conditions were examined. The association of each pattern with 1-year mortality was assessed using logistic regression models adjusted for selected patient characteristics. Approximately 1 in 10 Medicare patients with heart failure receiving a primary prevention ICD had frailty (10%) or dementia (1%). One-year mortality was 22% for patients with frailty, 27% for patients with dementia, and 12% in the overall cohort. Several multimorbidity patterns were associated with high 1-year mortality rates: dementia with frailty (29%), frailty with chronic obstructive pulmonary disease (25%), and frailty with diabetes mellitus (23%). These patterns were present in 8% of the cohort., Conclusions: More than 10% of Medicare beneficiaries with heart failure receiving primary prevention ICDs have frailty or dementia. These patients had significantly higher 1-year mortality than those with other common chronic conditions. Frailty and dementia should be considered in clinical decision-making and guideline development., (© 2015 American Heart Association, Inc.)

Background: Despite concerns about mineralocorticoid receptor antagonist therapies (MRAs) underuse and misuse in patients with heart failure, temporal and institutional variations of MRA prescription have not been reported., Methods and Results: We studied a national sample of veterans hospitalized for heart failure between 2003 and 2009 and left ventricular ejection fraction <40%. We identified ideal and non-ideal candidates for MRA therapy based on American College of Cardiology/American Heart Association guidelines. We measured temporal trends and hospital variation of MRA prescriptions within 90 days after discharge. We determined the median odds ratio (MOR), a measure of the relative odds of an MRA prescription for 2 individuals with similar characteristics discharged at 2 randomly selected hospitals. From 37 126 patients (n=131 hospitals), 9355 were ideal-MRA candidates, and 4056 were non-ideal candidates. Among ideal candidates, 36% received an MRA, but there was a decline in use (41% in 2003 to 31% in 2009, P<0.001). Of non-ideal candidates, 27% received an MRA with a decline in use (34% in 2003 to 22% in 2009, P<0.001). Hospital MRA prescription ranged from 0% to 71% for ideal candidates and 0% to 100% for non-ideal candidates. The median odds ratios of MRA prescription for ideal and non-ideal candidates were 1.44 and 1.36, respectively; a median odds ratio >1.2 indicates significant practice-level variation., Conclusions: There was decreasing MRA use between 2003 and 2009 with wide institutional variation in MRA prescription, which suggests opportunities for improvement to stimulate MRA use in ideal candidates while further reducing use in those with contraindications., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Guidelines for heart failure (HF) recommend prescription of guideline-directed medical therapy before hospital discharge; some of these therapies are included in publicly reported performance measures. The burden of new medications for individual patients has not been described., Methods and Results: We used Get With The Guidelines-HF registry data from 2008 to 2013 to characterize prescribing, indications, and contraindications for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, and anticoagulants. The difference between a patient's medication regimen at hospital admission and that recommended by HF quality measures at discharge was calculated. Among 158 922 patients from 271 hospitals with a primary discharge diagnosis of HF, initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was indicated in 18.1% of all patients (55.5% of those eligible at discharge were not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at admission), β-blockers in 20.3% (50.5% of eligible), aldosterone antagonists in 24.1% (87.4% of eligible), hydralazine/isosorbide dinitrate in 8.6% (93.1% of eligible), and anticoagulants in 18.0% (58.0% of eligible). Cumulatively, 0.4% of patients were eligible for 5 new medication groups, 4.1% for 4 new medication groups, 9.4% for 3 new medication groups, 10.1% for 2 new medication groups, and 22.7% for 1 new medication group; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures. Compared with newly indicated medications (mean, 1.45 ± 1.23), actual new prescriptions were lower (mean, 1.16 ± 1.00)., Conclusions: A quarter of patients hospitalized with HF need to start >1 medication to meet HF quality measures. Systems for addressing medication initiation and managing polypharmacy are central to HF transitional care., (© 2015 American Heart Association, Inc.)

Background: Implantable cardioverter-defibrillator (ICD) therapy is associated with improved outcomes in patients with heart failure (HF), but whether this association holds among older patients with multiple comorbid illnesses and worse HF burden remains unclear., Methods and Results: Using the National Cardiovascular Data Registry's ICD Registry and the Get With The Guidelines-Heart Failure (GWTG-HF) registry linked with Medicare claims, we examined outcomes associated with primary-prevention ICD versus no ICD among HF patients aged ≥65 years in clinical practice. We included patients with an ejection fraction ≤35% who received (ICD Registry) and who did not receive (GWTG-HF) an ICD. Compared with patients with an ICD, patients in the non-ICD group were older and more likely to be female and white. In matched cohorts, the 3-year adjusted mortality rate was lower in the ICD group versus the non-ICD group (46.7% versus 55.8%; adjusted hazard ratio [HR] 0.76; 95% CI 0.69 to 0.83). There was no associated difference in all-cause readmission (HR 0.99; 95% CI 0.92 to 1.08) but a lower risk of HF readmission (HR 0.88; 95% CI 0.80 to 0.97). When compared with no ICD, ICDs were also associated with better survival in patients with ≤3 comorbidities (HR 0.77; 95% CI 0.69 to 0.87) and >3 comorbidities (HR 0.77; 95% CI 0.64 to 0.93) and in patients with no hospitalization for HF (HR 0.75; 95% CI 0.65 to 0.86) and at least 1 prior HF hospitalization (HR 0.69; 95% CI 0.58 to 0.82). In subgroup analyses, there were no interactions between ICD and mortality risk for comorbidity burden (P=0.95) and for prior HF hospitalization (P=0.46)., Conclusion: Among older HF patients, ICDs for primary prevention were associated with lower risk of mortality even among those with high comorbid illness burden and prior HF hospitalization., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Clinical trials have demonstrated the benefit of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death in selected high-risk individuals. Because of small numbers of women enrolled in these trials, outcomes for women after hospital discharge have not been well described. We compared procedure-related complications and outcomes after hospital discharge between men and women undergoing single- or dual-chamber ICD implantation for primary prevention., Methods: In patients 65 years or older with Medicare fee-for-service coverage, we identified 38,912 initial implants (25% women) who received single- or dual-chamber ICDs for primary prevention between January 2006 and December 2009 in the NCDR and evaluated gender differences in outcomes., Results: Women had greater comorbidity and more advanced heart failure (HF) at the time of ICD implantation than did men. Device-related complications, death at 6 months, all-cause readmissions, and HF readmissions at 6 months were significantly more common in women (7.2% vs 4.8%, 6.5% vs 5.6%, 37.2% vs 31.7%, and 14.0% vs 10.0% respectively; P < .001 for all). Women continued to have higher odds of procedural complications (odds ratio [OR] 1.39, 95% CI 1.26-1.53, P < .001), 6-month all-cause readmission (OR 1.22, 95% CI 1.16-1.28, P < .001), and 6-month HF readmission (OR 1.32, 95% CI 1.23-1.42, P < .001), with a trend toward higher 6-month mortality (OR 1.08, 95% CI 0.98-1.20, P = .123), compared with men, after adjusting for differences in baseline characteristics and device type (single vs dual chamber)., Conclusions: Among older patients receiving ICDs for primary prevention in clinical practice, women experience worse outcomes than do men. Reasons for gender differences in outcomes are poorly understood and require further investigation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: We sought to determine survival for patients with heart failure after an implantation of an implantable cardioverter defibrillator (ICD) for primary prevention in the United States and to develop a simple model that would predict mortality risk., Background: Clinical trials have found that patients with heart failure with a 1-year mortality risk near 20% may not benefit from an ICD., Methods: We identified patients from the ICD Registry of the National Cardiovascular Disease Registries who underwent ICD implantation for primary prevention from 2007 to 2009. Two risk scores for mortality were developed in 2 cohorts: one limited to those with a B-type natriuretic peptide (BNP) value and a second for all patients. The scores were obtained from derivation datasets and tested in a validation sets using logistic regression models and classification and regression trees., Results: In a primary prevention population with BNP available (18,725) the 6 variables most predictive of 1-year mortality were age ≥75, BNP ≥700 pg/mL, chronic lung disease, dialysis, blood urea nitrogen ≥30 mg/dL, and systolic blood pressure <120 mmHg. Patients with zero risk factors had a 3.3% one-year mortality compared to a 66.7% one-year mortality for those with all 6 risk factors. Those with ≥3 risk factors (24.0% of the population) had a 25.8% one-year mortality. A second score using a larger cohort that did not consider BNP identified similar risk factors., Conclusions: A simple validated risk score can identify patients at high and low risk for death within a year after ICD placement. A large fraction of those currently implanted with an ICD in the United States have a high 1-year mortality and may not benefit from ICD therapy., (Published by Elsevier Inc.)

Background: Medicare hospital core process measures have improved over time, but little is known about how the distribution of performance across hospitals has changed, particularly among the lowest performing hospitals., Methods: We studied all US hospitals reporting performance measure data on process measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN) to the Centers for Medicare & Medicaid Services from 2006 to 2011. We assessed changes in performance across hospital ranks, variability in the distribution of performance rates, and linear trends in the 10th percentile (lowest) of performance over time for both individual measures and a created composite measure for each condition., Results: More than 4000 hospitals submitted measure data each year. There were marked improvements in hospital performance measures (median performance for composite measures: AMI: 96%-99%, HF: 85%-98%, PN: 83%-97%). A greater number of hospitals reached the 100% performance level over time for all individual and composite measures. For the composite measures, the 10th percentile significantly improved (AMI: 90%-98%, P<0.0001 for trend; HF: 70%-92%, P=0.0002; PN: 71%-92%, P=0.0003); the variation (90th percentile rate minus 10th percentile rate) decreased from 9% in 2006 to 2% in 2011 for AMI, 25%-8% for HF, and 20%-7% for PN., Conclusions: From 2006 to 2011, not only did the median performance improve but the distribution of performance narrowed. Focus needs to shift away from processes measures to new measures of quality.

Background: Women have been under-represented in trials of cardiac resynchronization therapy-defibrillators (CRT-D). Previous studies suggest that women benefit from CRT-D at shorter QRS duration than men and that there may be no benefit of CRT-D in patients without left bundle branch block (LBBB) regardless of patient sex., Methods and Results: We compared sex-specific death risk in 75 079 patients with New York Heart Association class III or IV heart failure, reduced left ventricular ejection fraction, and prolonged QRS duration (≥120 ms) receiving either CRT-D or implantable cardioverter defibrillator in subgroups according to QRS morphology and 10-ms increments in QRS duration. We applied propensity score weighting to control for differences between treatments. Among patients with LBBB, women receiving CRT-D had a lower relative death risk than those receiving an implantable cardioverter-defibrillator (absolute difference, 11%; hazard ratio=0.74 [95% confidence interval, 0.68-0.81]). In men, the lower mortality with CRT-D versus implantable cardioverter defibrillator was less pronounced (absolute difference, 9%; hazard ratio=0.84 [0.79-0.89]; sex×device interaction P=0.025). In those without LBBB, the mortality difference was modest and did not differ between women and men (absolute difference, 3%; hazard ratio=0.88 [0.79-0.97] in women and absolute difference, 2%; hazard ratio=0.95 [0.91-0.998] in men; interaction P=0.17). In subgroups according to QRS duration, CRT-D was associated with better survival in both sexes with LBBB and QRS ≥130 ms, whereas there was no clear relation between QRS duration and survival in patients without LBBB regardless of patient sex., Conclusions: In a large real-world population CRT-D was associated with a lower mortality risk in both sexes with LBBB, although more pronounced among women. Only among those with LBBB, both sexes had better survival with longer QRS duration. The mortality differences in patients without LBBB were attenuated in both sexes., (© 2015 American Heart Association, Inc.)

Background: Cardiac resynchronization therapy with defibrillator (CRT-D) reduces morbidity and mortality among selected patients with heart failure in clinical trials. The effectiveness of this therapy in clinical practice has not been well studied., Methods and Results: We compared a cohort of 4471 patients from the National Cardiovascular Data Registry's Implantable Cardioverter-Defibrillator (ICD) Registry hospitalized primarily for heart failure and who received CRT-D between April 1, 2006, and December 31, 2009, to a historical control cohort of 4888 patients with heart failure without CRT-D from the Acute Decompensated Heart Failure National Registry (ADHERE) hospitalized between January 1, 2002, and March 31, 2006. Both registries were linked with Medicare claims to evaluate longitudinal outcomes. We included patients from the ICD Registry with left ventricular ejection fraction ≤35% and QRS duration ≥120 ms who were admitted for heart failure. We used Cox proportional hazards models to compare outcomes with and without CRT-D after adjustment for important covariates. After multivariable adjustment, CRT-D was associated with lower 3-year risks of death (hazard ratio, 0.52; 95% confidence interval, 0.48-0.56; P<0.001), all-cause readmission (hazard ratio, 0.69; 95% confidence interval, 0.65-0.73; P<0.001), and cardiovascular readmission (hazard ratio, 0.60; 95% confidence interval, 0.56-0.64; P<0.001). The association of CRT-D with mortality did not vary significantly among subgroups defined by age, sex, race, QRS duration, and optimal medical therapy., Conclusions: CRT-D was associated with lower risks of mortality, all-cause readmission, and cardiovascular readmission than medical therapy alone among patients with heart failure in community practice., (© 2014 The Authors. published on behalf of the American Heart Association, Inc., by Wolters Kluwer.)

Background: Contemporary patterns of use and outcomes of implantable cardioverter-defibrillators (ICDs) in community practice settings are not well characterized. We assessed temporal trends in patient characteristics and outcomes among older patients undergoing primary prevention ICD therapy in US hospitals between 2006 and 2010., Methods and Results: Using the National Cardiovascular Data Registry's ICD Registry, we identified Medicare fee-for-service beneficiaries aged ≥65 years and older with left ventricular ejection fraction ≤35% who underwent primary prevention ICD implantation, including those receiving concomitant cardiac resynchronization therapy between 2006 and 2010 and could be matched to Medicare claims. Outcomes were mortality and hospitalization (all-cause and heart failure) at 180 days, and device-related complications. We used multivariable hierarchical logistic regression to assess temporal trends in outcomes accounting for changes in patient, physician, and hospital characteristics. The cohort included 117 100 patients. Between 2006 and 2010, only modest changes in patient characteristics were noted. Fewer single lead devices and more cardiac resynchronization therapy devices were used over time. Between 2006 and 2010, there were significant improvements in all outcomes, including 6-month all cause mortality (7.1% in 2006, 6.5% 2010; adjusted odds ratio, 0.88; 95% confidence interval, 0.82-0.95), 6-month rehospitalization (36.3% in 2006, 33.7% in 2010; adjusted odds ratio, 0.87; 95% confidence interval, 0.83-0.91), and device-related complications (5.8% in 2006, 4.8% in 2010; adjusted odds ratio, 0.80; 95% confidence interval, 0.74-0.88)., Conclusions: The clinical characteristics of this national population of Medicare patients undergoing primary prevention ICD implantation were stable between 2006 and 2010. Simultaneous improvements in outcomes suggest meaningful advances in the care for this patient population., (© 2014 American Heart Association, Inc.)

Background: Patients with heart failure and atrial fibrillation are at higher risk of thromboembolic events than patients with heart failure alone. Yet, the use of anticoagulation therapy varies in clinical practice, especially among older patients, for whom its effectiveness is poorly understood., Methods and Results: Using clinical registry data linked to Medicare claims from 2005 to 2011, we examined outcomes of older patients hospitalized with heart failure and atrial fibrillation who newly initiated anticoagulation therapy at discharge. We used Cox proportional hazards models and inverse probability-weighted treatment estimates to adjust for selection bias. Main outcomes were mortality and readmission at 1 and 3 years. Among 5105 patients in 195 hospitals, 1623 (31.8%) started anticoagulation therapy at discharge. Treated patients had lower unadjusted rates of all-cause mortality (26.4% versus 42.8%; P<0.001) and all-cause readmission (58.4% versus 63.7%; P<0.001) at 1 year. After inverse weighting for the probability of treatment and adjustment for other discharge medications, anticoagulation therapy was associated with significantly lower 1-year mortality (hazard ratio, 0.70; 99% confidence interval, 0.59-0.82), but there was no statistically significant difference in the risk of all-cause readmission (hazard ratio, 0.89; 99% confidence interval, 0.78-1.01) or other readmission outcomes. Results were similar at 3 years., Conclusions: Initiation of anticoagulation therapy at hospital discharge was associated with improved mortality at 1 and 3 years but was not associated with improved cardiovascular readmission among older patients with heart failure and atrial fibrillation., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wolters Kluwer.)

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality among selected patients with left ventricular systolic dysfunction and severe heart failure symptoms despite guideline-directed medical therapy (GDMT). Contemporaneous guidelines provided clear recommendations regarding selection of patients for CRT, including that all patients should first receive GDMT with β blockers and renin-angiotensin axis antagonists. Prevalence of GDMT among real-world patients receiving CRT defibrillators (CRT-D) has not been well studied. We identified 45,392 patients in the National Cardiovascular Data Registry Implantable Cardioverter-Defibrillator Registry who underwent first CRT-D implantation for primary prevention of sudden death from January 2006 to June 2008. We calculated the proportion of patients with contemporaneous class I guideline indications for CRT-D, the proportion receiving GDMT for heart failure, and the proportion receiving GDMT who had class I guideline indications for CRT-D. Among patients without contraindications, 87% were prescribed β blockers, 78% an angiotensin-converting enzyme inhibitor or an angiotensin II receptor inhibitor, and 70% both a β blocker and an angiotensin-converting enzyme or angiotensin II receptor inhibitor at discharge. Finally, 50% of patients met class I guideline indications and were prescribed GDMT at discharge; 9% neither met class I indications nor were prescribed GDMT at discharge. The major limitation of this study is the lack of dosage information in the Implantable Cardioverter-Defibrillator Registry and lack of prescribing information at times other than discharge. In conclusion, many patients receiving CRT-D are not receiving GDMT at discharge. Ensuring that all patients receiving CRT-D are also receiving GDMT appears to be a quality improvement target., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience., Objective: To compare outcomes after CRT-D versus ICD therapy in contemporary practice., Design: Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims., Setting: 780 U.S. hospitals implanting both CRT-D and ICD devices., Patients: 7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (&lt;0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009., Measurements: Risks for death, readmission, and device-related complications over 3 years., Results: Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women., Limitations: Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare., Conclusion: In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone., Primary Funding Source: Agency for Healthcare Research and Quality.

Objectives: This study sought to examine the long-term outcomes of patients hospitalized with heart failure and atrial fibrillation., Background: Atrial fibrillation is common among patients hospitalized with heart failure. Associations of pre-existing and new-onset atrial fibrillation with long-term outcomes are unclear., Methods: We analyzed 27,829 heart failure admissions between 2006 and 2008 at 281 hospitals in the American Heart Association's Get With The Guidelines-Heart Failure program linked with Medicare claims. Patients were classified as having pre-existing, new-onset, or no atrial fibrillation. Cox proportional hazards models were used to identify factors that were independently associated with all-cause mortality, all-cause readmission, and readmission for heart failure, stroke, and other cardiovascular disease at 1 and 3 years., Results: After multivariable adjustment, pre-existing atrial fibrillation was associated with greater 3-year risks of all-cause mortality (hazard ratio [HR]: 1.14 [99% confidence interval (CI): 1.08 to 1.20]), all-cause readmission (HR: 1.09 [99% CI: 1.05 to 1.14]), heart failure readmission (HR: 1.15 [99% CI: 1.08 to 1.21]), and stroke readmission (HR: 1.20 [99% CI: 1.01 to 1.41]), compared with no atrial fibrillation. There was also a greater hazard of mortality at 1 year among patients with new-onset atrial fibrillation (HR: 1.12 [99% CI: 1.01 to 1.24]). Compared with no atrial fibrillation, new-onset atrial fibrillation was not associated with a greater risk of the readmission outcomes. Stroke readmission rates at 1 year were just as high for patients with preserved ejection fraction as for patients with reduced ejection fraction., Conclusions: Both pre-existing and new-onset atrial fibrillation were associated with greater long-term mortality among older patients with heart failure. Pre-existing atrial fibrillation was associated with greater risk of readmission., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown., Methods and Results: Using electronic data from 3 health systems 2005 to 2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for heart failure with reduced ejection fraction who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years, and 37.1% were women. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Preinitiation K was >5.0 mmol/L in 1.4% and Cr>2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of postinitiation K testing (c-statistic, 0.67)., Conclusions: Although laboratory monitoring before MRA initiation for heart failure with reduced ejection fraction is common, laboratory monitoring after MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.

Background: Previous studies have reported conflicting findings regarding how the incidence of heart failure (HF) after acute myocardial infarction (AMI) has changed over time, and data on contemporary national trends are sparse., Methods and Results: Using a complete national sample of 2 789 943 AMI hospitalizations of Medicare fee-for-service beneficiaries from 1998 through 2010, we evaluated annual changes in the incidence of subsequent HF hospitalization and mortality using Poisson and survival analysis models. The number of patients hospitalized for HF within 1 year after AMI declined modestly from 16.1 per 100 person-years in 1998 to 14.2 per 100 person years in 2010 (P<0.001). After adjusting for demographic factors, a relative 14.6% decline for HF hospitalizations after AMI was observed over the study period (incidence risk ratio, 0.854; 95% confidence interval, 0.809-0.901). Unadjusted 1-year mortality following HF hospitalization after AMI was 44.4% in 1998, which decreased to 43.2% in 2004 to 2005, but then increased to 45.5% by 2010. After adjusting for demographic factors and clinical comorbidities, this represented a 2.4% relative annual decline (hazard ratio, 0.976; 95% confidence interval, 0.974-0.978) from 1998 to 2007, but a 5.1% relative annual increase from 2007 to 2010 (hazard ratio, 1.051; 95% confidence interval, 1.039-1.064)., Conclusions: In a national sample of Medicare beneficiaries, HF hospitalization after AMI decreased from 1998 to 2010, which may indicate improvements in the management of AMI. In contrast, survival after HF following AMI remains poor, and has worsened from 2007 to 2010, demonstrating that challenges still remain for the treatment of this high-risk condition after AMI.