Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes: Observations From the Global Registry of Acute Coronary Events (GRACE) Telemedical Interventional Monitoring in Heart Failure (TIM-HF), a randomized, controlled intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with heart failure: study design. Web-based Internet telemedicine management of patients with heart failure. Influence of Nonfatal Hospitalization for Heart Failure on Subsequent Mortality in Patients With Chronic Heart Failure Managing heart failure care using an internet-based telemedicine system. 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Background —Few data are available on the impact of heart failure ( HF ) across all types of acute coronary syndromes ( ACS ) . Methods and Results —The Global Registry of Acute Coronary Events ( GRACE ) is a prospect i ve study of patients hospitalized with ACS . Data from 16 166 patients were analyzed : 13 707 patients without prior HF or cardiogenic shock at presentation were identified . Of these , 1778 ( 13 % ) had an admission diagnosis of HF ( Killip class II or III ) . HF on admission was associated with a marked increase in mortality rates during hospitalization ( 12.0 % versus 2.9 % [ with versus without HF ] , P < 0.0001 ) and at 6 months after discharge ( 8.5 % versus 2.8 % , P < 0.0001 ) . Of note , HF increased mortality rates in patients with unstable angina ( defined as ACS with normal biochemical markers of necrosis ; mortality rates : 6.7 % with versus 1.6 % without HF at admission , P < 0.0001 ) . By logistic regression analysis , admission HF was an independent predictor of hospital death ( odds ratio , 2.2 ; P < 0.0001 ) . Admission HF was associated with longer hospital stay and higher readmission rates .  Patients with HF had lower rates of catheterization and percutaneous cardiac intervention , and fewer received & bgr;-blockers and statins . Hospital development of HF ( versus HF on presentation ) was associated with an even higher in-hospital mortality rate ( 17.8 % versus 12.0 % , P < 0.0001 ) . In patients with HF , in-hospital revascularization was associated with lower 6-month death rates ( 14.0 % versus 23.7 % , P < 0.0001 ; adjusted hazard ratio , 0.5 ; 95 % CI , 0.37 to 0.68 , P < 0.0001 ) . Conclusions —In this observational registry , heart failure was associated with reduced hospital and 6-month survival across all ACS subsets , including patients with normal markers of necrosis . More aggressive treatment of these patients may be warranted to improve prognosis AIMS Remote patient management ( telemonitoring ) may help to detect early signs of cardiac decompensation , allowing optimization of and adherence to treatments in chronic heart failure ( CHF ) . Two meta-analyses have suggested that telemedicine in CHF can reduce mortality by 30 - 35 % . The aim of the TIM-HF study was to investigate the impact of telemedical management on mortality in ambulatory CHF patients . Methods CHF patients [ New York Heart Association ( NYHA ) II/III , left ventricular ejection fraction (LVEF)≤35 % ] with a history of cardiac decompensation with hospitalization in the past or therapy with intravenous diuretics in the prior 24 months ( no decompensation required if LVEF≤25 % ) were r and omized 1:1 to an intervention group of daily remote device monitoring ( electrocardiogram , blood pressure , body weight ) coupled with medical telephone support or to usual care led by the patients ' local physician . In the intervention group , 24/7 physician-led medical support was provided by two central telemedical centres . A clinical event committee blinded to treatment allocation assessed cause of death and reason for hospitalization . The primary endpoint was total mortality . The first secondary endpoint was a composite of cardiovascular mortality or hospitalization due to heart failure . Other secondary endpoints included cardiovascular mortality , all-cause and cause-specific hospitalizations ( all time to first event ) as well as days lost due to heart failure hospitalization or cardiovascular death ( in % of follow-up time ) , and changes in quality of life and NYHA class . Overall , 710 CHF patients were recruited . The mean follow-up was 21.5±7.2 months , with a minimum of 12 months . Perspective The study will provide important prospect i ve outcome data on the impact of telemedical management in patients with CHF An Internet-based store- and -retrieval telemedicine system to communicate between patients and their healthcare provider was tested . The system requires no specialized equipment , is Web-based , and allows frequent surveillance of the health status of the patients with heart failure ( HF ) . Thirty six patients were recruited to evaluate a Web-based telemedicine system for reducing care encounters . Eighteen patients were r and omized to the telemedicine arm ( group T ) , and 18 were given usual clinical care ( group C ) in our HF center . Patients in group T reported three times weekly via a secure Internet site for telemedicine intervention . We studied patients with HF with New York Heart Association ( NYHA ) class 2 to 4 with hospitalization within past 6 months . Mean age was 56.1 + /- 12.6 years ( 66.7 % male ; 66.7 % Caucasian , 27.8 % African American , and 5.6 % Hispanic ) .  Mean ejection fraction ( EF ) was 23.9 % + /- 17.6 % in group T and 26.6 % + /- 16.4 % in group C. Over an 8-month period , unscheduled ( group T-3 ; group C-5 ) , and scheduled clinic visits ( group T-11 , group C-7 ) were similar ( p = NS ) ; one group T patient was transplanted , one group C patient died . Total hospital days were lower with group T ( 44 days ) compared to group C ( 133 days ) , p < 0.05 . An Internet-based telemedicine system was able to closely monitor patients with HF . Surveillance through Internet-based telemedicine result ed in less hospitalization compared to control patients . This system may be helpful in reducing the cost of HF patient care Background — Patients with chronic heart failure ( HF ) are at increased risk of both fatal and nonfatal major adverse cardiovascular events . We used data from the C and esartan in Heart failure : Assessment of Reduction in Mortality and morbidity ( CHARM ) trials to assess the influence of nonfatal hospitalizations for HF on subsequent mortality rates in a broad spectrum of HF patients . Methods and Results — In the present study , 7599 patients with New York Heart Association class II to IV HF and reduced or preserved left ventricular ejection fraction were r and omized to placebo or c and esartan . We assessed the risk of death after discharge from a first hospitalization for HF using time-up date d Cox proportional-hazards models on 7572 patients for whom discharge data were available . Of 7572 patients , 1455 ( 19 % ) had at least 1 HF hospitalization , and 586 of 1819 deaths occurred after discharge from an HF hospitalization . The mortality rate was increased after HF hospitalizations , even after adjustment for baseline predictors of death ( hazard ratio , 3.15 ; 95 % confidence interval , 2.83 to 3.50 ) . Longer duration of HF hospitalization enhanced the risk of dying , as did repeat HF hospitalizations . Moreover , risk of death was highest within a month of discharge and then declined progressively over time , particularly for death result ing from HF progression and for sudden cardiac death . We observed a similar pattern of risk associated with all-cause hospitalization , although the magnitude was less than that with HF hospitalization . Conclusions — In patients with chronic HF , the risk of death is greatest in the early period after discharge after a hospitalization for HF and is directly related to the duration and frequency of HF hospitalizations . These findings suggest a role for increased surveillance in the early postdischarge period of greatest vulnerability after an HF admission BACKGROUND Managing patients with heart failure ( HF ) is labor intensive , and follow-up is often inadequate to detect day-to-day changes that ultimately lead to decompensation . We tested the effect of an Internet-based telemedicine ( T ) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF . METHODS AND RESULTS HF patients in NYHA Class II-IV were r and omized to usual care ( UC , n = 24 ) or T ( T plus UC , n = 24 ) and followed for 1 year .  Office visits , emergency department visits , hospitalizations , telephone calls , and number of Internet communications were measured over the 1-year period . Left ventricular ejection fraction ( EF ) was assessed by echocardiography in both groups . For T , mean age was 53.2 + /- 2.0 years ( 72 % male , 61 % Caucasian , 39 % African American ) . For UC , mean age was 54.1 + /- 2.6 years ( 76 % male , 72 % Caucasian , 14 % African American , and 14 % Hispanic ) .  HF etiologies and EF were similar in both groups . During the 12-month period , UC had 74 total phone calls to the practice , whereas T had 88 telephone calls plus 1887 telemedicine data messages ( 6.5 messages/patient/month ) . ER visits were lower in the T group ( T 5 , UC 12 ; P < .05 ) . Hospital admissions ( T 24 , C 40 ; P = .025 ) and total hospital days ( T 84 , UC 226 days ; P < .005 ) were lower in T. Unscheduled clinic visits ( T 13 , UC 13 ; P = NS ) and scheduled clinic visits ( T 78 , UC 94 ; P = NS ) were similar in both groups . CONCLUSIONS Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations , hospital days , and emergency department visits AIMS Hospitalizations for heart failure ( HF ) are common and are associated with significant morbidity , mortality and cost . However , precipitating factors leading to HF hospitalization and their importance with respect to subsequent outcomes are not well understood . METHODS AND RESULTS The symptoms and signs present at admission and investigator-identified factors thought to have contributed to the first adjudicated HF hospitalization in the C and esartan in Heart Failure : Assessment of Reduction in Mortality and Morbidity ( CHARM ) programme were prospect ively collected and stratified by ejection fraction ( EF ) . Potential precipitants were collected using a specifically design ed case report form and categorized according to the presence of cardiovascular ( CV ) , non-CV and unknown factors . Associations between these factors and subsequent rehospitalization and mortality rates were examined . Of 1668 patients who experienced HF hospitalization , 1152 had reduced EF ( ≤40 % , HFrEF ) and 516 had preserved EF ( HFpEF ) . Overall , 54 % had CV , 32 % had non-CV and 14 % had unknown factors thought to have precipitated HF , with similar proportions in the HFrEF and HFpEF groups . The most common precipitants were arrhythmia ( 15 % ) , other non-CV factors ( 11 % ) and respiratory infection ( 10 % ) . Subsequent CV readmission rates were highest in those whose initial HF hospitalization was precipitated by CV factors . However , mortality rates were similar among patients with any of the three categories of precipitating factors . Results were similar in HFrEF and HFpEF . CONCLUSIONS Among chronic HF patients hospitalized for decompensation , the investigator-reported precipitating factor was not associated with the subsequent mortality rate , but was associated with type of readmission : readmissions for CV reasons were more likely when the index precipitant was CV Background —&bgr;-Blockade – induced benefit in heart failure ( HF ) could be related to baseline heart rate and treatment-induced heart rate reduction , but no such relationships have been demonstrated . Methods and Results —In CIBIS II , we studied the relationships between baseline heart rate ( BHR ) , heart rate changes at 2 months ( HRC ) ,  nature of cardiac rhythm ( sinus rhythm or atrial fibrillation )  , and outcomes ( mortality and hospitalization for HF ) . Multivariate analysis of CIBIS II showed that in addition to & bgr;-blocker treatment , BHR and HRC were both significantly related to survival and hospitalization for worsening HF , the lowest BHR and the greatest HRC being associated with best survival and reduction of hospital admissions . No interaction between the 3 variables was observed , meaning that on one h and , HRC-related improvement in survival was similar at all levels of BHR , and on the other h and , bisoprolol-induced benefit over placebo for survival was observed to a similar extent at any level of both BHR and HRC . Bisoprolol  reduced mortality in patients with sinus rhythm ( relative risk 0.58 , P < 0.001 ) but not in patients with atrial fibrillation ( relative risk 1.16 , P = NS ) . A similar result was observed for cardiovascular mortality and hospitalization for HF worsening . Conclusions —BHR and HRC are significantly related to prognosis in heart failure . & bgr;-Blockade with bisoprolol further improves survival at any level of BHR and HRC and to a similar extent . The benefit of bisoprolol is question able , however , in patients with atrial fibrillation BACKGROUND Heart failure ( HF ) is common in long-term care facilities ( LTCs ) . This study compared mortality and hospitalization rates and examined predictors of these outcomes among new LTC residents with and without HF . METHODS AND RESULTS This prospect i ve cohort study followed 546 newly admitted residents from 42 LTCs for up to 1 year . Health information was collected from participant and caregiver interviews , physicians ' records , diagnostic procedures , and hospitalization records . Multivariate logistic regression modeling determined predictors of hospitalization among residents , and Cox proportional hazards regression determined predictors for time to mortality . HF prevalence was 21.4 % . The sample was predominantly ( > 70 % ) female , and individuals with HF were significantly older with higher prevalence of reduced left ventricular ejection fraction . Overall annual mortality and hospitalization rates were 24 % and 27 % , respectively . Among residents with HF , 42 % died and 31 % were hospitalized within 1 year . Among residents with HF , use of major tranquilizers was the strongest predictor of sooner mortality ; use of anticoagulants and major tranquilizers also increased mortality risk , whereas higher baseline function was associated with longer time to mortality . History of peripheral vascular disease was the strongest predictor of hospitalizations among residents with HF , and use of antiplatelet agents and history of any smoking exposure increased this risk . CONCLUSIONS Among LTC residents , HF is associated with high mortality and hospitalization rates . Many factors contribute to mortality and hospitalizations among residents with HF , and comprehensive HF management programs are needed to improve outcomes BACKGROUND Patients with heart failure ( HF ) and anaemia have greater functional impairment , worse symptoms , increased rates of hospital admission , and a higher risk of death , compared with non-anaemic HF patients . Whether correcting anaemia can improve outcomes is unknown . OBJECTIVE The Reduction of Events with Darbepoetin alfa in Heart Failure trial ( RED-HF ; Clinical Trials.gov NCT 003 58215 ) was design ed to evaluate the effect of the long-acting erythropoietin-stimulating agent darbepoetin alfa on mortality and morbidity ( and quality of life ) in patients with HF and anaemia . METHODS Approximately 2600 patients with New York Heart Association class II-IV , an ejection fraction < or = 40 % , and a haemoglobin ( Hb ) consistently < or = 12.0 g/dL but > or = 9.0 g/dL will be enrolled . Patients are r and omized 1:1 to double-blind subcutaneous administration of darbepoetin alfa or placebo . Investigators are also blinded to Hb measurements and darbepoetin alfa is dosed to achieve an Hb concentration of 13.0 g/dL ( but not exceeding 14.5 g/dL ) with sham adjustments of the dose of placebo . The primary endpoint is the time to death from any cause or first hospital admission for worsening HF , whichever occurs first . The study will complete when approximately 1150 subjects experience a primary endpoint BACKGROUND Hospital admissions for acute decompensated heart failure ( ADHF ) are frequent and are accompanied by high percentages of mortality and readmissions . Brain natriuretic peptide ( BNP ) and the inactive N-terminal fragment of its precursor proBNP ( NT-proBNP ) are currently the best predictors of prognosis in heart failure ( HF ) patients . In the setting of chronic HF , studies that performed guidance of therapy by NT-proBNP have had only limited success . For patients with ADHF , retrospective studies have shown that a reduction in NT-proBNP of ≤30 % during admission is a significant predictor of HF readmissions and mortality . These data suggest a role for NT-proBNP guidance in the setting of ADHF admissions . STUDY DESIGN The PRIMA II is an investigator-initiated , multicenter , r and omized , controlled , prospect i ve 2-arm trial that investigates the impact of inhospital guidance for ADHF treatment by a predefined NT-proBNP target ( > 30 % reduction during admission ) on the reduction of readmission and mortality rates within 180 days . Consenting ADHF patients with NT-proBNP levels of > 1,700 ng/L are eligible . After achieving clinical stability , a total of 340 patients are r and omized to either NT-proBNP-guided or conventional treatment ( 1:1 ) . The primary end point is dual , that is , a composite of all-cause mortality and readmission for HF in 180 days and the number of days alive out of hospital in 180 days . Secondary end points are readmissions and /or mortality in 180 days , cost effectiveness of hospitalization days in 180 days , readmissions and mortality in 90 days , and quality of life . CONCLUSION The PRIMA II trial aims at providing scientific evidence for the use of NT-proBNP-guided therapy compared with conventional treatment in patients admitted for ADHF OBJECTIVES The purpose of this study was to assess the rate of death and hospitalization for heart failure ( HF ) 1 and 3 years after a r and omized trial of telephone intervention aim ed to improve education and compliance in stable patients with HF ended . BACKGROUND The long-term effects of HF programs are not well known . METHODS In all , 1,518 patients with HF were r and omized into the DIAL ( R and omized Trial of Phone Intervention in Chronic Heart Failure ) . After completion of the trial , patients were followed up to 3 years to assess major outcomes . Compliance with diet , weight control , and treatment was evaluated . The effect of the intervention on mortality and HF hospitalizations was assessed using relative risk ( RR ) , relative risk reduction , and Cox proportional hazards model for adjusting by potential confounders . RESULTS The rate of death or hospitalization for HF was lower in the intervention group ( 37.2 % vs. 42.6 % , RR : 0.81 , 95 % confidence interval [ CI ] : 0.69 to 0.96 ; p = 0.013 ) 1 and 3 years ( 55.7 % vs. 57.5 % , RR : 0.88 , 95 % CI : 0.77 to 1.00 ; p = 0.05 ) after the intervention ended . This benefit was mainly caused by a reduction in admission for HF ( 28.5 % vs. 35.1 % after 3 years , RR : 0.72 , 95 % CI : 0.60 to 0.87 ; p = 0.0004 ) . Patients who showed improvement in 1 or more of 3 key compliance indicators ( diet , weight control , and medication ) had lower risks of events . CONCLUSIONS The benefit observed during the intervention period persisted and was sustained 1 and 3 years after the intervention ended . This effect may be explained by the impact of the educational intervention on patients ' behavior and habits BACKGROUND Decompensated heart failure ( HF ) is among the most common indications for hospitalization in the United States , but little is known about features on admission that predict adverse events . We used data from the Outcomes of a Prospect i ve Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure ( OPTIME-CHF ) study to develop a model that would predict outcomes in patients with decompensated HF . METHODS AND RESULTS OPTIME-CHF r and omized 949 patients hospitalized with decompensated HF for 48 to 72 hours of infusion of either milrinone or placebo .  We used multivariable modeling to evaluate variables on admission that would be predictive of 60-day mortality or the composite of death or rehospitalization at 60 days . Variables at presentation that predicted death at 60 days were increased age , lower systolic blood pressure , New York Heart Association class IV symptoms , elevated blood urea nitrogen ( BUN ) , and decreased sodium . Predictors of the composite of death or rehospitalization within 60 days were the number of HF hospitalizations in the preceding 12 months , elevated BUN , lower systolic blood pressure , decreased hemoglobin , and a history of percutaneous coronary intervention ( PCI ) . The discriminatory power of the model was substantial for the mortality model ( c-index .77 ) but less for the composite endpoint ( c-index .69 ) . CONCLUSIONS Risk stratification of patients with decompensated HF may be accomplished using easily assessed clinical variables . Further research into the validity of this model in independent sample s will potentially aid in the development of risk stratification strategies BACKGROUND Patients with heart failure ( HF ) are at high risk for mortality and rehospitalization in the early period after hospital discharge . We developed clinical models predictive of short-term clinical outcomes in a broad patient population discharged after hospitalization for HF . METHODS The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure ( OPTIMIZE-HF ) registry is a comprehensive hospital-based registry and performance-improvement program for patients hospitalized with HF . Follow-up data were scheduled to be prospect ively collected at 60 to 90 days postdischarge in a prespecified 10 % sample . For the 4,402 patients included in this analysis , 19 prespecified potential predictor variables were used in a stepwise Cox proportional hazards model for all-cause mortality . Logistic regression including 45 potential variables was used to model mortality or rehospitalization . RESULTS The 60- to 90-day postdischarge mortality rate was 8.6 % ( n = 481 ) , and 29.6 % ( n = 1,715 ) were rehospitalized . Factors predicting early postdischarge mortality include age , serum creatinine , reactive airway disease , liver disease , lower systolic blood pressure , lower serum sodium , lower admission weight , and depression . Use of statins and beta-blockers at discharge was associated with significantly decreased mortality . The C-index of the model was 0.74 . The most important predictors for the combined end point of death or rehospitalization were admission serum creatinine , systolic blood pressure , admission hemoglobin , discharge use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker , and pulmonary disease . From this analysis , 8 factors identified to carry significant risk were selected for use in a point scoring system to predict the risk of mortality within 60 days after discharge , with a C-index of 0.72 . CONCLUSIONS A substantial risk of mortality and mortality or rehospitalization is present in the first 60 to 90 days after discharge from a hospitalization for HF . Several factors were identified that signal high-risk patients . Application of these findings with a simple algorithm can distinguish patients who are low risk from those at high risk who may benefit from closer monitoring and aggressive evidence -based treatment AIMS More treatments are needed to improve clinical outcomes in chronic heart failure ( HF ) . It is , however , important that treatments for a condition as common as HF are affordable . We have carried out a prospect i ve economic analysis of the C and esartan in Heart failure : Assessment of Reduction in Mortality and morbidity ( CHARM ) programme . METHODS AND RESULTS Patients with NYHA class II-IV HF and LVEF < or = 0.40 were r and omized to CHARM-Alternative if intolerant of an ACE-inhibitor or to CHARM-Added if taking an ACE-inhibitor . Patients with a LVEF > 0.40 were r and omized in CHARM-Preserved . Each trial compared the effect of c and esartan to placebo on the primary outcome of cardiovascular death or HF hospitalization . Detailed information was prospect ively collected on hospital admissions , procedures /operations and drugs . A cost-consequence analysis was performed for France , Germany and the UK for CHARM-Overall and a cost-effectiveness analysis for the low LVEF trials . The cost of c and esartan was substantially offset by a reduction in hospital admissions , especially for HF . In the cost-consequence analysis , c and esartan was cost-saving in most scenarios for CHARM-Alternative and Added but the marginal annual net cost per patient was upto 372 euros per year in CHARM-Preserved , in which c and esartan did not reduce the primary outcome significantly . In the cost-effectiveness analysis of patients with a LVEF < or = 0.40 , c and esartan was cost-saving in some scenarios and in the others the maximum cost per life year gained was 3881 euros . CONCLUSION C and esartan improves functional class , reduces the risk of hospital admission , and increases survival in patients with a HF and a LVEF < or = 0.40 at an acceptable cost This article provides information and a commentary on key trials relevant to the pathophysiology , prevention , and treatment of heart failure ( HF ) presented at the European Society of Cardiology Heart Failure meeting held in Gothenburg , Sweden in May 2011 . Unpublished reports should be considered as preliminary , since analyses may change in the final publication . In the TEHAF study , use of the Health Buddy ( ® ) monitoring system failed to reduce the number of HF admissions compared with usual care but a subgroup of patients with more recently diagnosed HF may have benefited . In the WHICH study , some reductions in the rate of hospital stay were observed in patients who underwent a  nurse-led home-based intervention programme following a hospital admission for an acute HF exacerbation , compared with patients who were followed in a specialized outpatient clinic . Results from CARVIVA-HF suggest that ivabradine alone or in combination with carvedilol  is safe and effective for improving exercise capacity and quality of life in HF patients on optimized angiotensin-converting enzyme inhibitor therapy . In the GISSI-HF study there was no difference in atrial fibrillation ( AF ) occurrence between the n-3 polyunsaturated fatty acids and placebo groups . In EMPHASIS-HF the incidence of new onset AF or flutter was reduced in patients with mild HF r and omized to eplerenone compared with placebo OBJECTIVES The purpose of this study was to assess whether management of heart failure ( HF ) guided by an individualized N-terminal pro-B-type natriuretic peptide ( NT-proBNP ) target would lead to improved outcome compared with HF management guided by clinical assessment alone . BACKGROUND Natriuretic peptides may be attractive biomarkers to guide management of heart failure ( HF ) and help select patients in need of more aggressive therapy . The PRIMA ( Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality ? ) study is , to our knowledge , the first large , prospect i ve r and omized study to address whether management of HF guided by an individualized target NT-proBNP level improves outcome . METHODS A total of 345 patients hospitalized for decompensated , symptomatic HF with elevated NT-proBNP levels at admission were included . After discharge , patients were r and omized to either  clinical ly-guided outpatient management ( n = 171 ) , or management guided by an individually set NT-proBNP  ( n = 174 ) defined by the lowest level at discharge or 2 weeks thereafter . The primary end point was defined as number of days alive outside the hospital after index admission . RESULTS HF management guided by this individualized NT-proBNP target increased the use of HF medication ( p = 0.006 ) , and 64 % of HF-related events were preceded by an increase in NT-proBNP . Nevertheless , HF management guided by this individualized NT-proBNP target did not significantly improve the primary end point ( 685 vs. 664 days , p = 0.49 ) , nor did it significantly improve any of the secondary end points . In the NT-proBNP-guided group mortality was lower , as 46 patients died ( 26.5 % ) versus 57 ( 33.3 % ) in the clinical ly-guided group , but this was not statistically significant ( p = 0.206 ) . CONCLUSIONS Serial NT-proBNP measurement and targeting to an individual NT-proBNP value did result in advanced detection of HF-related events and importantly influenced HF-therapy , but failed to provide significant clinical improvement in terms of mortality and morbidity . ( Effect of NT-proBNP Guided Treatment of Chronic Heart Failure [ PRIMA ] ; NCT00149422 ) Background Recent increasing prevalence of heart failure ( HF ) patients leads to an increasing burden to the health care system . Consequently , there is a need for innovative strategies to reduce HF hospitalizations . Methods We performed a multicentre r and omized controlled trial to test the hypothesis that telemonitoring in patients with HF , by means of the Health Buddy ® system ( HB ) , will reduce HF hospitalizations and number of contacts with caregivers as compared to care as usual ( CAU ) during 1 year follow-up , from October 1 , 2007 , through December 31 , 2008 . Results Among 382 patients —197 in the HB and 185 in the CAU-group—226 ( 59 % ) were male , mean age was 71.5 ( SD 11.2 ) , 45.5 % being ≥75 years of age ; 57 % of the patients were in NYHA HF class 2 , 40 % in class 3 and 3 % in class 4 . Both study groups were similar for demographic and clinical characteristics . Mean time to first heart failure related hospitalization was 161 days for the intervention group and 139 days for the usual-care group ; hospitalizations occurred in 18 ( 9.1 % ) compared to 25 patients ( 13.5 % ) respectively ( Kaplan – Meier p=0.151 , hazard ratio 0.65 , CI 0.35–1.17 ) . Combined endpoint of heart failure admission and all cause mortality was similar for both groups ( Kaplan – Meier p=0.641 hazard ratio 0.89 , CI 0.69–1.83 ) . Cox regression analysis disclosed an important interaction between group assignment and heart failure duration , p=0.007 , OR=0.983 , CI 0.970–0.995 indicating a significant decrease in heart failure hospitalizations in the intervention group if heart failure duration was < 18 months , p=0.026 , hazard ratio 0.26 , CI 0.07–0.94 . Contacts with the heart-failure-nurse were mean 1.36 ( range 0–11 ) in the intervention group vs. 1.74 ( 0–8 ) in the usual-care group ( Mann-Whitney p<0.001 ) . Mortality was 18 ( 9.1 % ) in the intervention-group and 12 ( 6.5 % ) in the usual-care-group ( Mann – Whitney p=0.34 , Cox-regression analysis p=0.82 ) . Conclusion Telemonitoring tends to reduce heart failure admissions and decreases contacts with specialized nurses . If heart failure duration is < 18 months heart failure admissions and readmissions are significantly reduced AIMS To determine the prevalence and risk factors for worsening renal function ( WRF ) among patients hospitalized for decompensated heart failure ( HF ) and the association with subsequent re-hospitalization and mortality . METHODS AND RESULTS We prospect ively enrolled 299 patients across eight European countries ( mean age 68 , 74 % men ) . HF was defined using the European Society of Cardiology criteria , but only patients with a history of ejection fraction < or = 40 % on echocardiography were recruited .  WRF was defined as an increase in serum creatinine > 26 micromol/L ( approximately 0.3 mg/dL ) from admission . Follow-up was 95 % complete to 6 months . Nearly one-third of patients [ 72 of 248 patients , 29 % ( 95 % CI 26 - 32 % ) ] developed WRF during hospitalization , excluding patients who had a major in-hospital complication likely to compromise renal function . The risk of WRF in this group was independently associated with serum creatinine levels on admission [ odds ratio ( OR ) 3.02 ( 95 % CI 1.58 - 5.76 ) ] , pulmonary oedema [ OR 3.35 ( 1.79 - 6.27 ) ] , and a history of atrial fibrillation [ OR 0.35 ( 0.18 - 0.67 ) ] . Although the mortality of WRF patients was not increased significantly , the length of stay was 2 days longer [ median 11 days ( 90 % range ( 4 - 41 ) vs. 9 days ( 4 - 34 ) , P=0.006 ] . The re-hospitalization rate was similar in both groups . CONCLUSION WRF is common in patients admitted to European hospitals with decompensated HF . Such patients have longer duration admissions , but a similar mortality and re-hospitalization rate to those without WRF ( if patients experiencing a major in-hospital complication are excluded ) INTRODUCTION AND OBJECTIVES To determine the effectiveness of a primarily educational intervention in heart failure ( HF ) patients implemented in a home care unit . METHODS This r and omized controlled clinical trial involved 279 HF patients who were discharged from a tertiary-care hospital between February 2001 and June 2002 . Patients with dementia , terminal non-cardiac disease , or chronic obstructive pulmonary disease were excluded . Data collected included the cause of cardiac decompensation . A primarily educational intervention was implemented in the patient 's home for up to 15 days after hospital discharge . Treatment was adjusted during the first week if necessary . The primary outcome measure was the 1-year cumulative incidence of readmission or death . Secondary measures were the incidence of readmission , mortality , and emergency department admission .  Telephone interviews were carried out 3 , 6 and 12 months after discharge , and clinical records were up date d when necessary . Emergency department admission in the first 6 months was monitored . RESULTS At 1-year follow-up , 62 of the 137 patients ( 45.3 % ) in the intervention group had been readmitted or died , compared with 75 of the 142 ( 52.8 % ) in the control group , ( relative risk=0.86 , P=.232 ) . Among patients who suffered decompensation because failure to adhere to treatment , 16 of the 45 ( 35.6 % ) in the intervention group were readmitted or died , compared with 34 of the 56 ( 60.7 % ) control group patients ( relative risk=0.59 , P=.016 ) . CONCLUSIONS This intervention is feasible but , when applied indiscriminately to every discharged heart failure patient , the best that can be expected is only a modest reduction in readmission and death rates , which , in this study in particular , did not achieve statistical significance Background : Telemedicine can be useful for managing heart failure ( HF ) , but patient acceptance of telemedicine and its impact on patient behavior are unclear . Aims : To assess a telemedicine program in a HF Unit . Methods and results : This sub- analysis of the CARME study assessed the use of an interactive telemedicine platform . This prospect i ve intervention study had a before/after design with HF patients r and omized 1:1 into two groups : A ) Motiva system ( educational videos , motivational messages , and question naires ) ; and B ) Motiva system + telemonitoring of blood pressure  , heart rate and weight .  Of 211 patients screened , 44 were excluded , 62 did not consent to participate and 8 withdrew consent prior to installation of the system . The final study population included 97 patients . During 1 year of follow-up , 22 patients voluntarily discontinued use of the system , 5 died ( three after early discontinuation ) and 5 withdrew consent before the last evaluation . A total of 15,017 question naires were sent to patients , with a median response rate of 88 % . Satisfaction with the system and tools was high ( median score 8.4/10 ) , especially with the self-monitoring chart , scale and sphygmomanometer . Positive changes were observed in patient behavior , especially for blood pressure and weight control ( p < 0.001 ) . After the study , 65 % of the patients wished to continue with telemonitoring , particularly those in Group B ( p = 0.004 ) . Conclusion : Less than half of our patients participated in the telemedicine study . However , those who completed the study had confidence in the system , a high degree of satisfaction with the tools and positive behavioral changes Background —Underrepresentation of women in heart failure clinical trials has limited conclusions regarding the effect of various management strategies on survival in women with heart failure and decreased left ventricular ejection fraction ( LVEF ) . Methods and Results —MERIT-HF ( Metoprolol Extended-Release R and omized Intervention Trial in Heart Failure ) was a r and omized , placebo-controlled study , the purpose of which was to evaluate the effect of metoprolol controlled-release/extended-release ( CR/XL ) in 3991 patients with New York Heart Association class II to IV heart failure and LVEF ≤0.40 . We performed a post hoc analysis to evaluate the effect of metoprolol CR/XL on outcome in women ( n=898 ) , including the outcome in 183 women with severe heart failure ( New York Heart Association class III/IV and LVEF < 0.25 ) . Treatment with metoprolol CR/XL in women result ed in a 21 % reduction in the primary combined end point of all-cause mortality/all-cause hospitalizations ( 164 versus 137 patients ; P = 0.044 ) . The number of cardiovascular hospitalizations was reduced by 29 % ( 164 versus 120;P = 0.013 ) , and hospitalization for worsening heart failure was reduced by 42 % ( 95 versus 56;P = 0.021 ) . Similar results were noted in the subgroup of women with severe heart failure , with a 57 % reduction in cardiovascular hospitalizations ( 63 versus 30;P = 0.005 ) and a 72 % reduction in hospitalization due to worsening heart failure ( 46 versus 14;P = 0.0004 ) . A pooling of mortality results from MERIT-HF , the Cardiac Insufficiency Bisoprolol Study ( CIBIS II ) , and the Carvedilol Prospect i ve R and omized Cumulative Survival Study ( COPERNICUS ) showed very similar survival benefits in women and men . Conclusions —The beneficial effects of metoprolol CR/XL extend to women with heart failure , including women with clinical ly stable severe heart failure We prospect ively evaluated whether the N-terminal brain natriuretic peptide ( NT-ProBNP ) reduction percentage , during hospitalization for acutely decompensated heart failure ( HF ) , has a prognostic significance in 6-month follow-up . In 120 patients consecutively admitted for acute HF to an internal medicine unit , plasma NT-ProBNP was measured on admission and at discharge . During a 6-month follow-up 52 ( 43.3 % ) patients had events : 9 ( 7.5 % ) died from cardiovascular causes , and 43 ( 35.8 % ) were readmitted for HF . In patients without events , the mean reduction percentage of NT-ProBNP was greater than in patients with events ( 39.5 ± 7.4 versus 26.3 ± 5.9 % ; P = 0.04 ) . In receiver operating characteristic curve analysis , the mean area under the curve for NT-ProBNP reduction percentage was 0.63 ( 95 % CI , 0.51–0.75 ; P = 0.04 ) for the composite end point ( death or readmission ) , and 0.81 ( 95 % CI , 0.65–0.97 , P = 0.01 ) for cardiovascular mortality . NT-ProBNP reduction percentage less than 30 % was the best cut-off for the identification of patients at risk of events . We suggest that in clinical practice the evaluation of change of NT-ProBNP levels during admission is probably more helpful than predischarge NT-ProBNP absolute value Background Frequent rehospitalisations and poorer survival chances in heart failure ( HF ) patients may partly be explained by poor medication adherence . There are multiple medication-related reasons for suboptimal adherence , but psychological reasons may also be important . A novel TELEmonitoring device may improve MEDication adherence in HF patients ( TELEMED-HF ) . TELEMED-HF is a r and omized , controlled clinical intervention trial design ed to examine ( 1 ) the efficacy and cost-efficiency of an electronic medication adherence support system in improving and monitoring HF patients ' medication adherence ; ( 2 ) the effect of medication adherence on hospitalizations and health care consumption ; as well as on ( 3 ) clinical characteristics , and Quality of Life ( QoL ) ; and ( 4 ) clinical , sociodemographic , and psychological determinants of medication adherence . Methods / Design Consecutive patients with chronic , systolic HF presenting to the outpatient clinic of the TweeSteden Hospital , The Netherl and s , will be approached for study participation and r and omly assigned ( 1:1 ) following blocked r and omization procedures to the intervention ( n = 200 ) or usual care arm ( n = 200 ) . Patients in the intervention arm use the medication support device for six months in addition to usual care . Post-intervention , patients return to usual care only and all patients participate in four follow-up occasions over 12 months . Primary endpoints comprise objective and subjective medication adherence , healthcare consumption , number of hospitalizations , and cost-effectiveness . Secondary endpoints include disease severity , physical functioning , and QoL. Discussion The TELEMED-HF study will provide us a comprehensive underst and ing of medication adherence in HF patients , and will show whether telemonitoring is effective and cost-efficient in improving adherence and preventing hospitalization in HF patients .Trial registration numberNCT01347528 OBJECTIVES This study determined whether greater volumes of exercise were associated with greater reductions in clinical events . BACKGROUND The HF-ACTION ( Heart Failure : A Controlled Trial Investigating Outcomes of Exercise Training ) trial showed that among patients with heart failure ( HF ) , regular exercise confers a modest reduction in the adjusted risk for all-cause mortality or hospitalization . METHODS Patients r and omized to the exercise training arm of HF-ACTION who were event-free at 3 months after r and omization were included ( n = 959 ) . Median follow-up was 28.2 months . Clinical endpoints were all-cause mortality or hospitalization and cardiovascular mortality or HF hospitalization . RESULTS A reverse J-shaped association was observed between exercise volume and adjusted clinical risk . On the basis of Cox regression , exercise volume was not a significant linear predictor but was a logarithmic predictor ( p = 0.03 ) for all-cause mortality or hospitalization . For cardiovascular mortality or HF hospitalization , exercise volume was a significant ( p = 0.001 ) linear and logarithmic predictor . Moderate exercise volumes of 3 to < 5 metabolic equivalent (MET)-h and 5 to < 7 MET-h per week were associated with reductions in subsequent risk that exceeded 30 % . Exercise volume was positively associated with the change in peak oxygen uptake at 3 months ( r = 0.10 ; p = 0.005 ) . CONCLUSIONS In patients with chronic systolic HF , volume of exercise is associated with the risk for clinical events , with only moderate levels ( 3 to 7 MET-h per week ) of exercise needed to observe a clinical benefit . Although further study is warranted to confirm the relationship between volume of exercise completed and clinical events , our findings support the use of regular exercise in the management of these patients INTRODUCTION AND OBJECTIVES Multidisciplinary strategies for the management of heart failure ( HF ) improve outcomes . We aim ed to evaluate the effectiveness of noninvasive home telemonitoring in ambulatory patients with HF already included in a structured multidisciplinary HF program . METHODS Prospect i ve intervention study with before/after comparison design of an interactive telemedicine platform in HF patients , r and omized 1:1 into two groups : A ) Motiva System with educational videos , motivational messages , and question naires , and B ) Motiva System + self monitoring of blood pressure , heart rate , and weight . Hospitalizations were compared over 12 months prior to and post study inclusion . Quality of life was evaluated using the generic EuroQoL visual analogue scale and the specific question naire Minnesota Living With Heart Failure Question naire . RESULTS There were 92 patients included ( 71 % male ; 66.3 ± 11.5 years ; 71 % ischemic aetiology ) . During real-time telemonitoring over 11.8 months ( interquartile range 8.6 - 12 ) , 14,730 question naires were administered with 89 % median response rate . Hospitalizations for HF decreased by 67.8 % ( P = .010 ) and for other cardiac causes by 57.6 % ( P = .028 ) . The number of days in hospital for HF decreased by 73.3 % ( P = .036 ) , without statistically significant differences between groups , and for other cardiac causes by 82.9 % ( P = .008 ) . The perception of quality of life improved significantly both for the generic scale ( P < .001 ) and for the HF specific question naire ( P=.005 ) . CONCLUSIONS HF patients who used an interactive telehealth system with motivational support tools at home spent less time in hospital and felt their quality of life had significantly improved . No significant differences were observed between groups AIMS To determine whether the risk of adverse cardiovascular ( CV ) outcomes associated with diabetes differs in patients with low and preserved ejection fraction ( EF ) heart failure ( HF ) . METHODS AND RESULTS We analysed outcomes in the C and esartan in Heart failure- Assessment of Reduction in Mortality and morbidity ( CHARM ) programme which r and omized 7599 patients with symptomatic HF and a broad range of EF . The prevalence of diabetes was 28.3 % in patients with preserved EF ( > 40 % ) and 28.5 % in those with low EF ( < or=40 % ) . Diabetes was associated with a greater relative risk of CV death or HF hospitalization in patients with preserved EF [ hazard ratio ( HR ) 2.0 ( 1.70 - 2.36 ) ] than in patients with low EF [ HR 1.60 ( 1.44 - 1.77 ) ; interaction test P = 0.0009 ] . For all-cause mortality , the risk conferred by diabetes was similar in both low and preserved EF groups . The effect of c and esartan in reducing CV morbidity and mortality outcomes was not modified by having diabetes at baseline ( P = 0.09 test for interaction ) . CONCLUSION Diabetes was an independent predictor of CV morbidity and mortality in patients with HF , regardless of EF . The relative risk of CV death or HF hospitalization conferred by diabetes was significantly greater in patients with preserved when compared with those with low EF HF BACKGROUND Telehealth has the potential to improve chronic disease management and outcomes , but data regarding direct benefit of telehealth in patients with heart failure ( HF ) have been mixed . The objective of this study was to determine whether the Health Buddy Program ( HBP ) ( Bosch Healthcare , Palo Alto , CA ) , a content-driven telehealth system coupled with care management , is associated with improved outcomes in Medicare beneficiaries with HF . MATERIAL S AND METHODS This was a retrospective cohort study of 623 Medicare beneficiaries with HF offered HBP enrollment compared with a propensity score-matched control group of Medicare beneficiaries with HF from the Medicare 5 % sample . Associations between availability of the HBP and all-cause mortality , hospitalization , hospital days , and emergency department visits were evaluated . RESULTS Beneficiaries offered enrollment in the HBP  had 24.9 % lower risk-adjusted all-cause mortality over 3 years of follow-up ( hazard ratio [ HR ] = 0.75 ; 95 % confidence interval [ CI ] , 0.63 - 0.89 ; p = 0.001 ) . Patients who used the HBP at least once ( 36.9 % ) had 57.2 % lower mortality compared with matched controls ( HR = 0.43 ; 95 % CI , 0.31 - 0.60 ; p < 0.001 ) , whereas patients who did not use the HBP had no significant difference in survival ( HR = 0.96 ; 95 % CI , 0.78 - 1.19 ; p = 0.69 ) . Patients offered the HBP also had fewer hospital admissions following enrollment ( Δ = -0.05 admissions/quarter ; p = 0.011 ) , which was primarily observed in patients who used the HBP at least once ( Δ = -0.10 admissions/quarter ; p < 0.001 ) . CONCLUSIONS The HBP , a content-driven telehealth system coupled with care management , was associated with significantly better survival and reduced hospitalization in Medicare beneficiaries with HF . Prospect i ve study is warranted to determine the mechanism of this association and opportunities for optimization Background Telemonitoring technology offers one of the most promising alternatives for the provision of health care services at the patient 's home . The primary aim of this study is to evaluate the impact of a primary care-based telemonitoring intervention on the frequency of hospital admissions . Methods / design A primary care-based r and omised controlled trial will be carried out to assess the impact of a telemonitoring intervention aim ed at home care patients with heart failure ( HF ) and /or chronic lung disease ( CLD ) . The results will be compared with those obtained with st and ard health care practice . The duration of the study will be of one year . Sixty patients will be recruited for the study . In-home patients , diagnosed with HF and /or CLD , aged 14 or above and with two or more hospital admissions in the previous year will be eligible . For the intervention group , telemonitoring will consist of daily patient self- measurements of respiratory-rate , heart-rate , blood pressure , oxygen saturation , weight and body temperature . Additionally , the patients will complete a qualitative symptom question naire daily using the telemonitoring system . Routine telephone contacts will be conducted every fortnight and additional telephone contacts will be carried out if the data received at the primary care centre are out of the established limits . The control group will receive usual care . The primary outcome measure is the number of hospital admissions due to any cause that occurred in a period of 12 months post-r and omisation . The secondary outcome measures are : duration of hospital stay , hospital admissions due to HF or CLD , mortality rate , use of health care re sources , quality of life , cost-effectiveness , compliance and patient and health care professional satisfaction with the new technology . Discussion The results of this study will shed some light on the effects of telemonitoring for the follow-up and management of chronic patients from a primary care setting . The study may contribute to enhance the underst and ing of alternative modes of health care provision for medically unstable elderly patients , who bear a high degree of physical and functional deterioration . Trial Registration IS RCT N : IS RCT INTRODUCTION Recent trials have demonstrated the effectiveness of multidisciplinary care ( MDC ) for patients with chronic heart failure ( CHF ) . However , results of the assessment of different programmes in individual countries could be different because of local specificities of health care systems . AIM We sought to determine whether MDC for patients with CHF has an influence on mortality , rate of rehospitalisation , quality of life ( QoL ) and self-care ( SC ) during a one-year study period . METHODS 160 patients with CHF treated in our unit were r and omly assigned to receive either MDC or routine care ( RC ) .  Patients from the MDC group ( n=80 ; mean age 67+/-10.2 years ) attended follow-up visits at the heart failure clinic after 14 days and 3 , 6 , 9 and 12 months after discharge . They were cared for by a team which consisted of a cardiologist , a heart failure nurse ( HF nurse ) , a psychologist and a physiotherapist . This group of patients received comprehensive education from the HF nurse and the cardiologist . Telephone counselling and home-based interventions by the HF nurse were also available daily . Patients from the RC group ( n=80 , mean age 69.5+/-10.7 years ) were cared for by their primary care physician only . In both groups QoL and SC scores were calculated based on a 21 and 12-item question naire completed by the patients at discharge and after one year . RESULTS After one-year follow-up the two groups did not differ in terms of either total and HF mortality or number of sudden deaths . In the MDC group when compared to the RC group we observed a significant decrease in the total number of hospital readmissions ( by 37 % , p < 0.05 ) , a decrease in hospital admissions due to HF ( by 48 % ; p < 0.05 ) and decreased length of stay during both all-cause readmissions and those due to HF ( p < 0.05 ) . After one year of follow-up both QoL and SC scores were significantly lower in the MDC group than in the RC group ( p < 0.001 ) , indicating improved QoL in the MDC group . CONCLUSIONS The one-year multidisciplinary care programme for patients with chronic heart failure in Poznań demonstrated significant improvement of treatment results in terms of frequency of readmissions and length of hospital stay as well as improved Qol . A tendency to decreased total and heart failure related mortality and decreased number of sudden deaths was also observed Aim : To determine whether an intensive intervention at a heart failure ( HF ) clinic by a combination of a clinician and a cardiovascular nurse , both trained in HF , reduces the incidence of hospitalisation for worsening HF and /or all-cause mortality ( primary end point ) and improves functional status ( including left ventricular ejection fraction , New York Heart Association ( NYHA ) class and quality of life ) in patients with NYHA class III or IV . Setting : Two regional teaching hospitals in The Netherl and s. Methods : 240 patients were r and omly allocated to the 1-year intervention  ( n = 118 ) or usual care ( n = 122 ) . The intervention consisted of 9 scheduled patient contacts — at day 3 by telephone , and at weeks 1 , 3 , 5 , 7 and at months 3 , 6 , 9 and 12 by a visit — to a combined , intensive physician- and -nurse-directed HF outpatient clinic , starting within a week after hospital discharge from the hospital or referral from the outpatient clinic . Verbal and written comprehensive education , optimisation of treatment , easy access to the clinic , recommendations for exercise and rest , and advice for symptom monitoring and self-care were provided . Usual care included outpatient visits initialised by individual cardiologists in the cardiology departments involved and applying the guidelines of the European Society of Cardiology . Results : During the 12-month study period , the number of admissions for worsening HF and /or all-cause deaths in the intervention group was lower than in the control group ( 23 vs 47 ; relative risk ( RR ) 0.49 ; 95 % confidence interval ( CI ) 0.30 to 0.81 ; p = 0.001 ) . There was an improvement in left ventricular ejection fraction ( LVEF ) in the intervention group ( plus 2.6 % ) compared with the usual care group ( minus 3.1 % ; p = 0.004 ) . Patients in the intervention group were hospitalised for a total of 359 days compared with 644 days for those in the usual care group . Beneficial effects were also observed on NYHA classification , prescription of spironolactone , maximally reached dose of β-blockers , quality of life , self-care behaviour and healthcare costs . Conclusion : A heart failure clinic involving an intensive intervention by both a clinician and a cardiovascular nurse substantially reduces hospitalisations for worsening HF and /or all-cause mortality and improves functional status , while decreasing healthcare costs , even in a country with a primary -care-based healthcare system AIMS The ' Hospital at home ' ( HaH ) model avoids hospital admission by transferring healthcare and treatment to the patient 's home . We aim ed to compare the effectiveness and direct healthcare costs of treating elderly patients with decompensated heart failure ( HF ) using HaH care vs. inpatient hospital care ( IHC ) in a cardiology unit . METHODS AND RESULTS Eighty patients aged over 65 years who presented at the emergency department with decompensated HF were r and omly assigned to IHC or HaH.  All patients were studied for 1 year . Seventy-one patients completed the study , of these 34 were admitted to cardiology and 37 received HaH care . No significant differences were found in baseline characteristics , including comorbidity , functional status , and health-related quality of life . Clinical outcomes were similar after initial admission and also after the 12 months of follow-up . Death or re-admission due to HF or another cardiovascular event occurred in 19 patients in IHC and 20 in HaH ( P = 0.88 ) . Changes in functional status and health-related quality of life over the follow-up period were not significantly different . The average cost of the initial admission was 4502 + /- 2153 euro in IHC and 2541 + /- 1334 euro in HaH ( P < 0.001 ) . During 12 months of follow-up , the average expenditure was 4619 + /- 7679 euro and 3425 + /- 4948 euro ( P = 0.83 ) respectively . CONCLUSION Hospital at home care allows an important reduction in the costs during the index episode compared with hospital care , whilst maintaining similar outcomes with respect to cardiovascular mortality and morbidity and quality of life at 1 year follow-up Patients admitted with heart failure have disproportionately high readmission rates , most recently ranging from 17.5 % to 30.3 % nationally.1 The Affordable Care Act penalizes hospitals with higher than average readmission rates after admissions for heart failure . However , clinicians remain uncertain , which strategies are associated with reducing readmissions in this population .2 Experts have proposed that the creation and transmission of a high- quality discharge summary to outpatient clinicians may improve the transition from hospital to home . Discharge summaries may facilitate safer transitions in care by informing outpatient clinicians about the course of hospitalization , identifying pending studies requiring follow-up , suggesting further follow-up testing , and clarifying changes in medications and treatments after discharge . Nonetheless , despite widespread enthusiasm for improving the quality of discharge summaries , there have been few studies of the effectiveness of discharge summaries in helping to avoid readmissions , and those few have found no association of timeliness,3,4 transmission,5,6 or content5 with readmission . To determine the association of discharge quality and readmission in a large national sample , we examined discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes ( Tele-HF ) r and omized controlled trial . # # # Study Cohort and Setting The  Tele-HF study included patients living at home and hospitalized for heart failure in the previous 30 days.7 Patients in Tele-HF were recruited from 33 cardiology practice s in 21 states and the District of Columbia . We obtained discharge summaries for the index hospitalization . Wherever possible , we obtained BACKGROUND The MERIT-HF trial demonstrated improved survival and fewer hospitalizations for worsening heart failure with extended-release ( ER ) metoprolol succinate in patients with heart failure . This study sought to estimate the economic implication s of this trial from a US perspective . METHODS AND RESULTS A discrete event simulation was developed to examine the course of patients with heart failure . Characteristics of the population modeled , probabilities of hospitalization and death with st and ard therapy , and risk reductions with ER metoprolol succinate were obtained from Metoprolol CR/XL R and omized Intervention Trial in Chronic Heart Failure ( MERIT-HF ) and evaluated in weekly cycles . Direct medical costs were estimated from US data bases in 2001 US dollars . Uncertainty in inputs was incorporated and analyses were carried out to estimate events prevented total and net costs . The model predicts that ER metoprolol succinate will prevent approximately 7 deaths and 15 hospitalizations from heart failure per 100 patients over 2 years . Compared with st and ard therapy alone , this translates to a cost reduction between $ 395 and $ 1112 per patient , depending on whether the costs of hospitalizations for other causes are included . Savings were maintained in 90 % of the simulations . CONCLUSION This analysis predicts that the positive effect of ER metoprolol succinate on mortality and morbidity demonstrated in MERIT-HF leads to substantial savings Background — This study was design ed to determine whether physician-led remote telemedical management ( RTM ) compared with usual care would result in reduced mortality in ambulatory patients with chronic heart failure ( HF ) . Methods and Results — We enrolled 710 stable chronic HF patients in New York Heart Association functional class II or III with a left ventricular ejection fraction ⩽35 % and a history of HF decompensation within the previous 2 years or with a left ventricular ejection fraction ⩽25 % . Patients were r and omly assigned ( 1:1 ) to RTM or usual care . Remote telemedical management used portable devices for ECG , blood pressure , and body weight measurements connected to a personal digital assistant that sent automated encrypted transmission via cell phones to the telemedical centers . The primary end point was death from any cause . The first secondary end point was a composite of cardiovascular death and hospitalization for HF . Baseline characteristics were similar between the RTM ( n=354 ) and control ( n=356 ) groups . Of the patients assigned to RTM , 287 ( 81 % ) were at least 70 % compliant with daily data transfers and no break for > 30 days ( except during hospitalizations ) . The median follow-up was 26 months ( minimum 12 ) , and was 99.9 % complete . Compared with usual care , RTM had no significant effect on all-cause mortality ( hazard ratio , 0.97 ; 95 % confidence interval , 0.67 to 1.41 ; P=0.87 ) or on cardiovascular death or HF hospitalization ( hazard ratio , 0.89 ; 95 % confidence interval , 0.67 to 1.19 ; P=0.44 ) . Conclusions — In ambulatory patients with chronic HF  , RTM compared with usual care was not associated with a reduction in all-cause mortality . Clinical Trial Registration : — URL : http://www . Clinical Trials.gov . Unique identifier : NCT00543881 BACKGROUND Heart failure ( HF ) disease management programs are widely implemented , but data about their effect on outcome have been inconsistent . METHODS The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure ( COACH ) was a multicenter , r and omized , controlled trial in which 1023 patients were enrolled after hospitalization because of HF . Patients were assigned to 1 of 3 groups : a control group ( follow-up by a cardiologist ) and 2 intervention groups with additional basic or intensive support by a nurse specializing in management of patients with HF .  Patients were studied for 18 months . Primary end points were time to death or rehospitalization because of HF and the number of days lost to death or hospitalization . RESULTS Mean patient age was 71 years ; 38 % were women ; and 50 % of patients had mild HF and 50 % had moderate to severe HF . During the study , 411 patients ( 40 % ) were readmitted because of HF or died  from  any cause : 42 % in the control group , and 41 % and 38 % in the basic and intensive support groups , respectively ( hazard ratio , 0.96 and 0.93 , respectively ; P = .73 and P = .52 , respectively ) . The number of days lost to death or hospitalization was 39 960 in the control group , 33 731 days for the basic intervention group ( P = .81 ) , and 34 268 for the intensive support group ( P = .49 ) . All-cause mortality occurred in 29 % of patients in the control group , and there was a trend toward lower mortality in the intervention groups combined ( hazard ratio , 0.85 ; 95 % confidence interval , 0.66 - 1.08 ; P = .18 ) . There were slightly more hospitalizations in the 2 intervention groups ( basic intervention group , P = .89 ; and intensive support group , P = .60 ) . CONCLUSIONS Neither moderate nor intensive disease management by a nurse specializing in management of patients with HF reduced the combined end points of death and hospitalization because of HF compared with st and ard follow-up . There was a nonsignificant , potentially relevant reduction in mortality , accompanied by a slight increase in the number of short hospitalizations in both intervention groups . Clinical Trial Registry http://trialregister.nl Identifier : NCT 98675639 Background Heart failure ( HF ) is a chronic condition affecting nearly 5.7 million Americans and is a leading cause of morbidity and mortality . With an aging population , the cost associated with managing HF is expected to more than double from US $ 31 billion in 2012 to US $ 70 billion by 2030 . Readmission rates for HF patients are high—25 % are readmitted at 30 days and nearly 50 % at 6 months . Low medication adherence contributes to poor HF management and higher readmission rates .  Remote telehealth monitoring programs aim ed at improved medication management and adherence may improve HF management and reduce readmissions . Objective The primary goal of this r and omized controlled pilot study is to compare the MedSentry remote medication monitoring system versus usual care in older HF adult patients who recently completed a HF telemonitoring program .  We hypothesized that remote medication monitoring would be associated with fewer unplanned hospitalizations and emergency department ( ED ) visits , increased medication adherence , and improved health-related quality of life ( HRQoL ) compared to usual care . Methods Participants were r and omized to usual care or use of the remote medication monitoring system for 90 days . Twenty-nine participants were enrolled and the final analytic sample consisted of 25 participants . Participants completed question naires at enrollment and closeout to gather data on medication adherence , health status , and HRQoL. Electronic medical records were review ed for data on baseline classification of heart function and the number of unplanned hospitalizations and ED visits during the study period . Results Use of the medication monitoring system was associated with an 80 % reduction in the risk of all-cause hospitalization and a significant decrease in the number of all-cause hospitalization length of stay in the intervention arm compared to usual care . Objective device data indicated high adherence rates ( 95%-99 % ) among intervention group participants despite finding no significant difference in self-reported adherence between study arms . The intervention group had poorer heart function and HRQoL at baseline , and HRQoL declined significantly in the intervention group compared to controls . Conclusions The MedSentry medication monitoring system is a promising technology that merits continued development and evaluation . The MedSentry medication monitoring system may be useful both as a st and alone system for patients with complex medication regimens or used to complement existing HF telemonitoring interventions . We found significant reductions in risk of all-cause hospitalization and the number of all-cause length of stay in the intervention group compared to controls . Although HRQoL deteriorated significantly in the intervention group , this may have been due to the poorer HF-functioning at baseline in the intervention group compared to controls . Telehealth medication adherence technologies , such as the MedSentry medication monitoring system , are a promising method to improve patient self-management , the quality of patient care , and reduce health care utilization and expenditure for patients with HF and other chronic diseases that require complex medication regimens . Trial Registration Clinical Trials.gov NCT01814696 ; https:// clinical trials.gov/ct2/show/ study /NCT01814696 ( Archived by WebCite ® at http://www.webcitation.org/6giqAVhno AIMS This study investigates the 10-year survival in the ECHOES ( Echocardiographic Heart of Engl and Screening ) study and examines factors associated with prognosis . METHODS AND RESULTS A prospect i ve study was carried out to investigate 10-year survival in those with heart failure ( HF ) and /or left ventricular systolic dysfunction ( LVSD ) . The mean age of participants in ECHOES was 64 , and 50 % were male . Records of all 6162 screened participants were flagged , and deaths up to 25 February 2009 were coded . Causes of death were categorized according to diagnosis on death certificate . Kaplan-Meier curves and log rank tests were used to compare survival times of participants with HF and LVSD in different diagnostic groups . A Cox proportional hazards regression model was used to identify variables associated with risk of death . A total of 2062 of the 6162 ( 33.5 % ) participants had died at the census date in February 2009 . Of these deaths , 902 ( 43.7 % ) were due to cardiovascular disease , including 263 ( 12.8 % ) due to HF . Ten-year survival was 75 % for participants without HF , 26.7 % for those with HF , 37.6 % for those with LVSD , and 27.4 % for those with HF and LVSD . Multiple-cause HF had a 10-year survival of 11.6 % . Multiple variables including diabetes , valvular disease , diuretic use , and a previous label of HF , as well as lifestyle factors such as smoking and obesity , were associated with increased risk of death . CONCLUSIONS Patients with HF and LVSD have a poor prognosis . However , the mortality rates of all-cause , all-stage HF as measured in the ECHOES cohort are around half those reported for patients diagnosed for the first time with HF during hospital admission Background —The determinants of prognosis in patients with heart failure and preserved ejection fraction ( HF-PEF ) are poorly documented . Methods and Results —We evaluated data from 4128 patients in the I-PRESERVE trial ( Irbesartan in Heart Failure with Preserved Ejection Fraction Study ) . Multivariable Cox regression models were developed using 58 baseline demographic , clinical , and biological variables to model the primary outcome of all-cause mortality or cardiovascular hospitalization ( 1505 events ) , all-cause mortality ( 881 events ) , and HF death or hospitalization ( 716 events ) . Log N-terminal pro – B-type natriuretic peptide , age , diabetes mellitus , and previous hospitalization for HF were the most powerful factors associated with the primary outcome and with the HF composite . For all-cause mortality , log N-terminal pro – B-type natriuretic peptide , age , diabetes mellitus , and left ventricular EF were the strongest independent factors . Other independent factors associated with poor outcome included quality of life , a history of chronic obstructive lung disease , log neutrophil count , heart rate , and estimated glomerular filtration rate . The models accurately stratified the actual 3-year rate of outcomes from 8.1 % to 59.9 % ( primary outcome ) 2.7 % to 36.5 % ( all-cause mortality ) , and 2.1 % to 38.9 % ( HF composite ) for the lowest to highest septiles of predicted risks . Conclusions —In a large sample of elderly patients with HF and preserved EF enrolled in I-Preserve , simple clinical , demographic , and biological variables were associated with outcome and identified subgroups at very high and very low risk of events . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00095238 BACKGROUND The effect of treatment with statins on the prognosis of newly diagnosed heart failure ( ndHF ) is not established . We evaluate the relationship of commencing treatment with statins ( CTS ) with the mortality and the morbidity of ndHF , systolic ( HF-DSF ) and non-systolic ( HF-PSF ) . METHODS Prospect i ve propensity-adjusted cohort study over 5 years on 2573 patients with ndHF . The main outcomes were all-cause and cardiovascular mortality , hospitalizations and visits . We analyze the independent relationship of CTS with the mortality and the morbidity , stratifying patients for cardiovascular co-morbidity , after adjusting for potential confounders . RESULTS 1343 patients ( 52.2 % ) CTS , 1071 ( 39.5 % ) died , and 1729 ( 67.2 % ) were hospitalized . CTS was associated not only with a lower mortality : RR for HF-overall ( CI 95 % ) 0.23 ( 0.10 to 0.36 ) , RR for HF-PSF 0.34 ( 0.21 to 0.47 ) , and RR for HF-DSF 0.20 ( 0.09 to 0.31 ) , but with dose-dependency ( statin>20 mg/day vs. statin<=20 mg/day ) : RR for HF-overall 0.49 ( 0.33 to 0.67 ) , RR for HF-PSF 0.53 ( 0.39 to 0.70 ) , and RR for HF-DSF 0.37 ( 0.26 to 0.52 ) , and with a lower rate of hospitalization ( per 100 persons-year ) : HF-overall ( 13.3 vs. 18.2 ) , HF-PSF ( 13.9 vs. 19.7 ) , and HF-DSF ( 12.7 vs. 16.6 ) , ( P<0.001 in all cases ) , even after adjustment for the propensity to take statins , or other medications , and other potential confounders . CONCLUSION The commencement of treatment with statins is associated with a dose-dependent reduction of the mortality and of the morbidity of patients with ndHF ( systolic or non-systolic ) IMPORTANCE Hospitalizations for heart failure ( HHF ) represent a major health burden , with high rates of early postdischarge rehospitalization and mortality . OBJECTIVE To investigate whether aliskiren , a direct renin inhibitor , when added to st and ard therapy , would reduce the rate of cardiovascular ( CV ) death or HF rehospitalization among HHF patients . DESIGN , SETTING , AND PARTICIPANTS International , double-blind , placebo-controlled study that r and omized hemodynamically stable HHF patients a median 5 days after admission . Eligible patients were 18 years or older with left ventricular ejection fraction ( LVEF ) 40 % or less , elevated natriuretic peptides ( brain natriuretic peptide [ BNP ] ≥ 400 pg/mL or N -terminal pro-BNP [ NT-proBNP ] ≥ 1600 pg/mL ) , and signs and symptoms of fluid overload . Patients were recruited from 316 sites across North and South America , Europe , and Asia between May 2009 and December 2011 . The follow-up period ended in July 2012 . INTERVENTION All patients received 150 mg ( increased to 300 mg as tolerated ) of aliskiren or placebo daily , in addition to st and ard therapy . The study drug was continued after discharge for a median 11.3 months . MAIN OUTCOME MEASURES Cardiovascular death or HF rehospitalization at 6 months and 12 months . RESULTS In total , 1639 patients were r and omized , with 1615 patients included in the final efficacy analysis cohort ( 808  aliskiren  , 807  placebo ) . Mean age was 65 years ; mean LVEF , 28 % ; 41 % of patients had diabetes mellitus , mean estimated glomerular filtration rate , 67 mL/min/1.73 m2 . At admission and r and omization , median NT-proBNP levels were 4239 pg/mL and 2718 pg/mL , respectively . At r and omization , patients were receiving diuretics ( 95.9 % ) , β-blockers ( 82.5 % ) , angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers ( 84.2 % ) , and mineralocorticoid receptor antagonists ( 57.0 % ) . In total , 24.9 % of patients receiving aliskiren ( 77 CV deaths , 153 HF rehospitalizations ) and 26.5 % of patients receiving placebo ( 85 CV deaths , 166 HF rehospitalizations ) experienced the primary end point at 6 months ( hazard ratio [ HR ] , 0.92 ; 95 % CI , 0.76 - 1.12 ; P = .41 ) . At 12 months , the event rates were 35.0 % for the aliskiren group ( 126 CV deaths , 212 HF rehospitalizations ) and 37.3 % for the placebo group ( 137 CV deaths , 224 HF rehospitalizations ; HR , 0.93 ; 95 % CI , 0.79 - 1.09 ; P = .36 ) . The rates of hyperkalemia , hypotension , and renal impairment/renal failure were higher in the aliskiren group compared with placebo . CONCLUSION AND RELEVANCE Among patients hospitalized for HF with reduced LVEF , initiation of aliskiren in addition to st and ard therapy did not reduce CV death or HF rehospitalization at 6 months or 12 months after discharge . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00894387 OBJECTIVE The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life ( QoL ) , readmission rates and healthcare costs for adults with heart failure ( HF ) living independently in the community . METHOD A systematic review of r and omised control trials was undertaken . Using the search terms nurse , education , heart failure , hospitalisation , readmission , rehospitalisation , economic burden , cost , expenditure and quality of life in PubMed , CINAHL and Google Scholar data bases were search ed . Papers pertaining to  nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were review ed . RESULT The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions , reduction in hospitalisation and a cost benefit . Additionally , higher functioning and improved QoL were also identified . CONCLUSION These results suggest that nurse-led patient education for adults with HF  improves QoL and reduces hospital admissions and readmissions . PRACTICE IMPLICATION S Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation CONTEXT Results from recent studies on the effects of beta1-blockade in patients with heart failure demonstrated a 34 % reduction in total mortality . However , the effect of beta1-blockade on the frequency of hospitalizations , symptoms , and quality of life in patients with heart failure has not been fully explored . OBJECTIVE To examine the effects of the beta1-blocker controlled-release/extended-release metoprolol succinate ( metoprolol CR/XL ) on mortality , hospitalization , symptoms , and quality of life in patients with heart failure . DESIGN R and omized , double-blind controlled trial , preceded by a 2-week single-blind placebo run-in period , conducted from February 14 , 1997 , to October 31 , 1998 , with a mean follow-up of 1 year . SETTING Three hundred thirteen sites in 14 countries . PARTICIPANTS Patients ( n = 3991 ) with chronic heart failure , New York Heart Association ( NYHA ) functional class II to IV , and ejection fraction of 0.40 or less who were stabilized with optimum st and ard therapy . INTERVENTIONS Patients were r and omized to metoprolol CR/XL , 25 mg once per day ( NYHA class II ) , or 12.5 mg once per day ( NYHA class III or IV ) , titrated for 6 to 8 weeks up to a target dosage of 200 mg once per day ( n = 1990 ) ; or matching placebo ( n = 2001 ) . MAIN OUTCOME MEASURES Total mortality or any hospitalization ( time to first event ) , number of hospitalizations for worsening heart failure , and change in NYHA class , by intervention group ; quality of life was assessed in a sub study of 741 patients . RESULTS The incidence of all predefined end points was lower in the metoprolol CR/XL group than in the placebo group , including total mortality or all-cause hospitalizations ( the prespecified second primary end point ; 641 vs 767 events ; risk reduction , 19 % ; 95 % confidence interval [ CI ] , 10%-27 % ; P<.001 ) ; total mortality or hospitalizations due to worsening heart failure ( 311 vs 439 events ; risk reduction , 31 % ; 95 % CI , 20%-40 % ; P<.001 ) , number of hospitalizations due to worsening heart failure ( 317 vs 451 ; P<.001 ) ; and number of days in hospital due to worsening heart failure ( 3401 vs 5303 days ; P<.001 ) . NYHA functional class , assessed by physicians , and McMaster Overall Treatment Evaluation score , assessed by patients , both improved in the metoprolol CR/XL group compared with the placebo group ( P = .003 and P = .009 , respectively ) . CONCLUSIONS In this study of patients with symptomatic heartfailure , metoprolol CR/XL improved survival , reduced the need for hospitalizations due to worsening heart failure , improved NYHA functional class , and had beneficial effects on patient well-being
Overall , telemedicine was shown to be beneficial , with home-based teletransmission effectively reducing all-cause mortality and HF-related hospital admission , length of stay and mortality in patients with HF
Telemedicine interventions may be associated with reductions in hospital admission rate and mortality in patients with heart failure ( HF ) .