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Renal impairment confers worse prognosis in patients with atrial fibrillation (AF) but there is scarce evidence about the influence of direct-acting oral anticoagulants in routine clinical practice. Herein, we compared clinical outcomes between patients with AF with and without renal impairment on rivaroxaban and investigated predictors for clinical outcomes in patients with AF with renal impairment. This was a multicenter study including patients with AF on rivaroxaban for at least 6 months. During 2.5 years follow-up, ischemic strokes (IS)/transient ischemic attacks (TIA)/systemic embolisms (SE)/myocardial infarctions (MI), major bleeding, and major adverse cardiovascular events (MACE) were recorded. Creatinine clearance (CrCl) was estimated using the Cockroft-Gault equation, renal impairment was defined as a CrCl <60 ml/min, and 1,433 patients (34.8% with CrCl <60 ml/min) were included. Patients with CrCl <60 ml/min showed higher event rates for major bleeding (1.87%/year vs 0.62%/year; p = 0.003) and MACE (1.97%/year vs 0.62%/year; p = 0.002) but similar event rates for IS/TIA/SE/MI (0.66%/year vs 0.67%/year; p = 0.955). In patients with renal impairment, CHA 2 DS 2 -VASc was associated with higher risk of IS/TIA/SE/MI; HAS-BLED and any dependency level were associated with higher risk of major bleeding; and male gender and heart failure were associated with higher risk of MACE. Antiplatelets were independently associated with increased risk of IS/TIA/SE/MI and MACE. In conclusion, in patients with AF on rivaroxaban, the incidence of IS/TIA/SE/MI did not increase in those with renal impairment, suggesting that rivaroxaban may be an effective option in this subgroup. In patients with AF, male gender, heart failure, dependency, antiplatelets, CHA 2 DS 2 -VASc, and HAS-BLED were associated with increased risk of adverse outcomes., Competing Interests: Declaration of Competing Interest JM Rivera-Caravaca is a consultant for Idorsia Pharmaceuticals LTD. M. Anguita Sanchez has received financial compensation from Bayer for participating in the EMIR registry. M. Sanmartín Fernández has received speaker and advisory fees from the following companies in the past 3 years: Bayer, Boehringer-Ingelheim, BMS, and Pfizer. C. Rafols is an employee of the Medical Department, Bayer Hispania S.L, which is the sponsor of the EMIR study. G. Barón-Esquivias has received lecture fees from Bayer, Boehringer-Ingelheim, Daiichi Sankyo, Pfizer-BMS, Sanofi, Novartis, and Rovi; and financial compensation from Bayer for participating in the EMIR study and an institutional grant from Novartis. J. Cosín-Sales has received financial compensation from Bayer for participating in the EMIR registry. R. Freixa-Pamias has received consultancy/lecturing fees from Bayer, BMS/Pfizer, Boehringer-Ingelheim, and Daiichi Sankyo; and financial compensation from Bayer for participating in the EMIR study. I. Lekuona Goya has received financial compensation from Bayer for participating in the EMIR study. JM Vázquez Rodríguez has received lecture fees from Bayer, Boehringer-Ingelheim, Pfizer, Bristol Myers Squibb, and Daiichi Sankyo; and financial compensation from Bayer for participating in the EMIR study. AI Pérez-Cabeza has received consultancy/lecturing fees from Bayer, Boehringer-Ingelheim, Pfizer, Bristol Myers Squibb, and Daiichi Sankyo. I. Ureña Montilla has received financial compensation from Bayer for participating in The EMIR study; speaker and advisory fees from the following companies: Bayer, Novartis, Daiichi Sankyo, Vifor, Boehringer-Ingelheim, and Amgen. A. Alvarez-Vieitez Blanco has received financial compensation from Bayer for participating in the EMIR study. F. Arribas Ynsaurriaga has received consultancy/lecture fees and research funding from Daiichi Sankyo, Pulse Dynamics, Medtronic, Boston Scientific, Bayer, Bristol Myers Squibb, Arrhythmia Network Technology SL/BAROSTIM, Abbott, Novartis, Janssen-Cilag, Biosensors, and Edwards Lifesciences; and received financial compensation from Bayer for participating in the EMIR registry. F Marín has received consultancy/lecturing fees from Bayer, Boehringer-Ingelheim, Pfizer, Bristol Myers Squibb, and Daiichi Sankyo., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Heart failure (HF) is the major contributor to cardiovascular morbidity and mortality. Given its rising prevalence, the costs of HF care can be expected to increase. Multidisciplinary management of HF can improve quality of care and survival. However, specialized HF programmes are not widely available in most European countries. These circumstances underlie the suggestion of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) for the development of quality of care centres (QCCs). These are defined as health care institutions that provide multidisciplinary HF management at all levels of care (primary, secondary and tertiary), are accredited by the HFA/ESC and are implemented into existing health care systems. Their major goals are to unify and improve the quality of HF care, and to promote collaboration in education and research activities. Three types of QCC are suggested: community QCCs (primary care facilities able to provide non-invasive assessment and optimal therapy); specialized QCCs (district hospitals with intensive care units, able to provide cardiac catheterization and device implantation services), and advanced QCCs (national reference centres able to deliver advanced and innovative HF care and research). QCC accreditation will require compliance with general and specific HFA/ESC accreditation standards. General requirements include confirmation of the centre's existence, commitment to QCC implementation, and collaboration with other QCCs. Specific requirements include validation of the centre's level of care, service portfolio, facilities and equipment, management, human resources, process measures, quality indicators and outcome measures. Audit and recertification at 4-6-year intervals are also required. The implementation of QCCs will evolve gradually, following a pilot phase in selected countries. The present document summarizes the definition, major goals, development, classification and crucial aspects of the accreditation process of the HFA/ESC QCC Programme., (© 2020 European Society of Cardiology.)

Background: We estimated the effectiveness of serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication compared with symptom-guided up-titration of medication in patients with heart failure (HF)., Methods: Systematic review and meta-analysis of randomised controlled trials (RCTs). We searched: MEDLINE (Ovid) 1950 to 9/06/2016; Embase (Ovid), 1980 to 2016 week 23; the Cochrane Library; ISI Web of Science (Citations Index and Conference Proceedings). The primary outcome was all-cause mortality; secondary outcomes were death related to HF, cardiovascular death, all-cause hospital admission, hospital admission for HF, adverse events, and quality of life. IPD were sought from all RCTs identified. Random-effects meta-analyses (two-stage) were used to estimate hazard ratios (HR) and confidence intervals (CIs) across RCTs, including HR estimates from published reports of studies that did not provide IPD. We estimated treatment-by-covariate interactions for age, gender, New York Heart Association (NYHA) class, HF type; diabetes status and baseline BNP subgroups. Dichotomous outcomes were analysed using random-effects odds ratio (OR) with 95% CI., Results: We identified 14 eligible RCTs, five providing IPD. BNP-guided therapy reduced the hazard of hospital admission for HF by 19% (13 RCTs, HR 0.81, 95% CI 0.68 to 0.98) but not all-cause mortality (13 RCTs; HR 0.87, 95% CI 0.75 to 1.01) or cardiovascular mortality (5 RCTs; OR 0.88, 95% CI 0.67 to 1.16). For all-cause mortality, there was a significant interaction between treatment strategy and age (p = 0.034, 11 RCTs; HR 0.70, 95% CI 0.53-0.92, patients < 75 years old and HR 1.07, 95% CI 0.84-1.37, patients ≥ 75 years old); ejection fraction (p = 0.026, 11 RCTs; HR 0.84, 95% CI 0.71-0.99, patients with heart failure with reduced ejection fraction (HFrEF); and HR 1.33, 95% CI 0.83-2.11, patients with heart failure with preserved ejection fraction (HFpEF)). Adverse events were significantly more frequent with BNP-guided therapy vs. symptom-guided therapy (5 RCTs; OR 1.29, 95% CI 1.04 to 1.60)., Conclusion: BNP-guided therapy did not reduce mortality but reduced HF hospitalisation. The overall quality of the evidence varied from low to very low. The relevance of these findings to unselected patients, particularly those managed by community generalists, are unclear., Systematic Review Registration: PROSPERO CRD42013005335.