Importance of in-hospital initiation of evidence-based medical therapies for heart failure-a review

Patients who have had heart failure (HF) face very high risks of hospitalization and mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, aldosterone antagonists, and beta blockers decrease rates of hospitalization and mortality in patients who have had HF, these life-prolonging therapies continue to be underused. Many studies in a variety of clinical settings have documented that important numbers of patients who have had HF are not receiving treatment with these evidence-based therapies, which are recommended by national guidelines, when guided by conventional care. This HF treatment gap results from a variety of complex issues, including lack of systems and disease management programs. This gap in beta-blocker therapy may be due in part to persisting perceptions, despite recent evidence to the contrary, that it should be delayed until patients who developed HF have been stable for 2 to 4 weeks after hospital discharge and that its initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence has substantiated that beta blockers can be safely initiated for patients with HF in the hospital and that there are early benefits, including decreased risks of mortality and hospitalization for worsening HF. It has become increasingly evident that in-hospital initiation of evidence-based cardiovascular therapies and patient education have a positive effect on long-term patient compliance and clinical outcomes. Adopting in-hospital initiation of these therapies as the standard of care (in the absence of contraindications or intolerance) in patients who have HF and stabilized systolic dysfunction could substantially improve treatment rates, decrease the risk of future hospitalizations, and prolong life in the large number of patients who are hospitalized each year for HF.     

Overview of acutely decompensated congestive heart failure (ADHF): a report from the ADHERE registry

Acute decompensated heart failure (ADHF) has emerged as a major public health problem, and HF has become the leading cause of hospitalization in persons over 65 years of age. It is estimated that there are 6.5 million hospital days attributed to ADHF each year. Patients hospitalized with ADHF face a substantial risk of readmission, as high as 50% by 6 months after discharge. Despite the large number of patients hospitalized and this substantial risk, data on these patients have been limited and there has been little effort to improve the quality of care for patients hospitalized with ADHF. The Acute Decompensated Heart Failure National Registry (ADHERE) was designed to bridge this gap in knowledge and care by prospectively studying the characteristics, management, and outcomes of a broad spectrum of patients hospitalized with ADHF. Participating community and university hospitals identified patients with a primary or secondary discharge diagnosis of HF and collected medical history, management, treatments, and health outcomes via secure Web browser technology. As of October 2004, more than 160,000 patients from 281 hospitals have been enrolled. These patients differ substantially from those typically enrolled in randomized clinical trials. Initial data from the ADHERE registry have provided important insights into the clinical characteristics, patterns of care, and outcomes of patients with ADHF. ADHERE has documented significant delays in diagnosis and initiation of ADHF therapies as well as a substantial under-use of evidenced-based, guideline-recommended chronic HF therapies at hospital discharge. As such, there are substantial opportunities to improve the quality of care for ADHF patients in the nation's hospitals.     

Heart Failure and Its Management With β-Blockade: Potential Applications of Once-Daily Therapy

Heart failure (HF) due to left ventricular (LV) systolic dysfunction is a progressive disease beginning with a primary injury that activates compensatory cardiovascular mechanisms including varying degrees of neurohormonal activation. Within the neurohormonal cascade, activation of the sympathetic nervous system is in part responsible for ongoing myocardial injury, progressive LV remodeling, and functional deterioration eventually leading to symptomatic HF. Large randomized clinical trials of certain β-blockers added to standard therapies have shown unequivocal benefits in patients with chronic systolic HF resulting in reduced remodeling, fewer total and cardiovascular deaths, and less risk of hospitalization for worsening HF. Evidence-based clinical guidelines recommend β-blockers as part of the regimen for patients with systolic HF as well as LV dysfunction following myocardial infarction. Based on published clinical trial results, bisoprolol, carvedilol, and sustained-release metoprolol succinate are recommended for systolic HF. Carvedilol, propranolol, and timolol are recommended for post-myocardial infarction LV dysfunction. Unfortunately, these evidence-based therapies are often underused in actual practice. Various strategies to increase β-blocker use in HF have been attempted, including in-hospital initiation of β-blocker therapy. Simplifying dosing regimens may also improve adherence to prescribed medications. Use of controlled-release carvedilol may encourage better adherence in patients with LV dysfunction and help overcome at least one barrier to optimal evidence-based care.     

Patient characteristics from a regional multicenter database of acute decompensated heart failure in Asia Pacific (ADHERE International-Asia Pacific)

BackgroundHeart failure (HF) is a leading cause of hospitalization. Although a number of multicenter international HF hospital registries have been published, there are limited data for the Asia Pacific region.MethodsADHERE (ie, Acute Decompensated Heart Failure Registry) International–Asia Pacific is an electronic web-based observational database of 10,171 patients hospitalized with a principal diagnosis of HF from 8 Asia-Pacific countries between January 2006 and December 2008.ResultsThe median age (67 years) varied by more than 2 decades across the region. Fifty-seven percent of patients were male. Ninety percent of patients were Asian and 8.4% were white. Dyspnea was the presenting symptom in 95%, with 80% having documented rales. During the index hospitalization, left ventricular function was assessed in 50%, and intravenous therapies included diuretics (85%), vasodilators (14%), and positive inotropes (15%). In-hospital mortality was 4.8%. Discharge medications included angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (63%), β-blockers (41%), and aldosterone antagonists (31%).ConclusionsCompared with other multicenter registries, patients hospitalized with acute HF in the Asia Pacific region tend to present with more severe clinical symptoms and signs and are younger, especially in countries at an earlier stage in their epidemiological transition. Echocardiography and disease-modifying medications are used less often, highlighting potential opportunities to improve outcomes.     

Overview of Acutely Decompensated Congestive Heart Failure (ADHF): A Report from the ADHERE Registry

Acute decompensated heart failure (ADHF) has emerged as a major public health problem, and HF has become the leading cause of hospitalization in persons over 65 years of age. It is estimated that there are 6.5 million hospital days attributed to ADHF each year. Patients hospitalized with ADHF face a substantial risk of readmission, as high as 50% by 6 months after discharge. Despite the large number of patients hospitalized and this substantial risk, data on these patients have been limited and there has been little effort to improve the quality of care for patients hospitalized with ADHF. The Acute Decompensated Heart Failure National Registry (ADHERE®) was designed to bridge this gap in knowledge and care by prospectively studying the characteristics, management, and outcomes of a broad spectrum of patients hospitalized with ADHF. Participating community and university hospitals identified patients with a primary or secondary discharge diagnosis of HF and collected medical history, management, treatments, and health outcomes via secure Web browser technology. As of October 2004, more than 160,000 patients from 281 hospitals have been enrolled. These patients differ substantially from those typically enrolled in randomized clinical trials. Initial data from the ADHERE registry have provided important insights into the clinical characteristics, patterns of care, and outcomes of patients with ADHF. ADHERE has documented significant delays in diagnosis and initiation of ADHF therapies as well as a substantial under-use of evidenced-based, guideline-recommended chronic HF therapies at hospital discharge. As such, there are substantial opportunities to improve the quality of care for ADHF patients in the nations hospitals.Dr. Fonarow has received research grants, is a consultant for, and is a member of the Speakers Bureau of, Scios Inc. ADHERE is sponsored by Scios Inc., Fremont, CA.     

Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial

OBJECTIVES: The Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial was an investigator-initiated study to evaluate if predischarge carvedilol initiation in stabilized patients hospitalized for heart failure (HF) increased the number of patients treated with beta-blockade at 60 days after randomization without increasing side effects or length of hospital stay. BACKGROUND: Beta-blockers are underused in HF. Predischarge initiation may improve the use of evidence-based beta-blockade. METHODS: The IMPACT-HF was a prospective, randomized open-label trial conducted in 363 patients hospitalized for HF. Patients were randomized to carvedilol initiation pre-hospital discharge or to postdischarge initiation (>2 weeks) of beta-blockade at the physicians' discretion. The primary end point of the study was the number of patients treated with beta-blockade at 60 days after randomization. Secondary end points included the number of patients discontinuing beta-blockade, median dose achieved, and a composite of death, rehospitalization, unscheduled visit for HF, or > or =50% increase in oral diuretic, new oral diuretic, or any intravenous therapy with diuretics, inotropes, or other vasoactive agents. RESULTS: At 60 days 165 patients (91.2%) randomized to predischarge carvedilol initiation were treated with a beta-blocker, compared with 130 patients (73.4%) randomized to initiation postdischarge (p < 0.0001). Predischarge initiation was not associated with an increased risk of serious adverse events. The median length of stay was five days in both groups. CONCLUSIONS: Predischarge initiation of carvedilol in stabilized patients hospitalized for HF improved the use of beta-blockade at 60 days without increasing side effects or length of stay. Predischarge initiation may be one approach to improve beta-blocker use in this population.     

When to initiate beta-blockers in heart failure: Is it ever too early?

Overwhelming clinical trial evidence confirms the efficacy and safety of β-blockers in patients with heart failure (HF) caused by systolic dysfunction. β-Blockers are recommended in national HF guidelines as standard of care therapy. Yet there is also a large body of evidence demonstrating that the use of β-blockers for HF is seriously inadequate under conventional care. This HF treatment gap is due, in part, to the persistence of perceptions—despite recent evidence to the contrary—that β-blocker therapy should be delayed until HF patients have been titrated to target doses of angiotensin-converting enzyme inhibitors and have been stable for at least 2 to 4 weeks after hospital discharge, and that early β-blocker initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence substantiates that β-blockers significantly reduce the risk of mortality and morbidity, including hospitalization for worsening HF, and have produced early survival benefits in patients with HF. It has also become evident that in-hospital initiation of lifeprolonging cardiovascular therapies, including β-blockers, has a positive impact on clinical outcomes and on longterm patient compliance. Overwhelming clinical evidence suggests that β-blockers should be administered to all stable HF patients without contraindication and that this therapy should be initiated as soon as possible to ensure that patients derive early and long-term improvements in clinical outcomes.     

COPD Predicts Mortality in HF: The Norwegian Heart Failure Registry

BackgroundChronic obstructive pulmonary disease (COPD) and chronic heart failure (HF) are common clinical conditions that share tobacco as a risk factor. Our aim was to evaluate the prognostic impact of COPD on HF patients.Methods and ResultsThe Norwegian Heart Failure Registry was used. The study included 4132 HF patients (COPD, n = 699) from 22 hospitals (mean follow-up, 13.3 months). COPD patients were older, more often smokers and diabetics, less often on β-blockers and had a higher heart rate. They were more often in New York Heart Association (NYHA) Class III or IV (COPD, 63%; no COPD, 51%), although left ventricular ejection fraction (LVEF) distribution was similar. COPD independently predicted death (adjusted hazard ratio [HR], 1.188; 95% CI: 1.015 to 1.391; P = 0.03) along with age, creatinine, NYHA Class III/IV (HR, 1.464; 95% CI: 1.286 to 1.667) and diabetes. β-blockers at baseline were associated with improved survival in patients with LVEF ≤40% independently of COPD.ConclusionCOPD is associated with a poorer survival in HF patients. COPD patients are overrated in terms of NYHA class in comparison with patients with similar LVEF. Nonetheless, NYHA class remains the strongest predictor of death in these patients.     

Evaluation of 6 prognostic models used to calculate mortality rates in elderly heart failure patients with a fatal heart failure admission

The objective was to evaluate 6 commonly used heart failure (HF) prognostic models in an elderly, fatal HF population. Predictive models have been established to quantify risk among HF patients. The validation of these models has not been adequately studied, especially in an elderly cohort. Applying a single-center, retrospective study of serially admitted HF patients who died while in the hospital or within 30 days of discharge, the authors evaluated 6 prognostic models: the Seattle Heart Failure Model (SHFM), Heywood's model, Classification and Regression Tree (CART) Analysis, the Heart Failure Survival Score (HFSS), Heart Failure Risk Scoring System, and Pocock's score. Eighty patients were included (mean age, 82.7 ± 8.2 years). Twenty-three patients (28.75%) died in the hospital. The remainder died within 30 days of discharge. The models' predictions varied considerably from one another and underestimated the patients' actual mortality. This study demonstrates that these models underestimate the mortality risk in an elderly cohort at or approaching the end of life. Moreover, the predictions made by each model vary greatly from one another. Many of the models used were not intended for calculation during hospitalization. Development of improved models for the range of patients with HF syndromes is needed.     

Hospital-Level Variation in Use of Cardiovascular Testing for Adults With Incident Heart Failure: Findings From the Cardiovascular Research Network Heart Failure Study

ObjectivesThis study aimed to characterize the use of cardiovascular testing for patients with incident heart failure (HF) hospitalization who participated in the National Heart, Lung, and Blood Institute sponsored Cardiovascular Research Network (CVRN) Heart Failure study.BackgroundHF is a common cause of hospitalization, and testing and treatment patterns may differ substantially between providers. Testing choices have important implications for the cost and quality of care.MethodsCrude and adjusted cardiovascular testing rates were calculated for each participating hospital. Cox proportional hazards regression models were used to examine hospital testing rates after adjustment for hospital-level patient case mix.ResultsOf the 37,099 patients in the CVRN Heart Failure study, 5,878 patients were hospitalized with incident HF between 2005 and 2008. Of these, evidence of cardiovascular testing was available for 4,650 (79.1%) patients between 14 days before the incident HF admission and ending 6 months after the incident discharge. We compared crude and adjusted cardiovascular testing rates at the hospital level because the majority of testing occurred during the incident HF hospitalization. Of patients who underwent testing, 4,085 (87.9%) had an echocardiogram, 4,345 (93.4%) had a systolic function assessment, and 1,714 (36.9%) had a coronary artery disease assessment. Crude and adjusted testing rates varied markedly across the profiled hospitals, for individual testing modalities (e.g., echocardiography, stress echocardiography, nuclear stress testing, and left heart catheterization) and for specific clinical indications (e.g., systolic function assessment and coronary artery disease assessment).ConclusionsFor patients with newly diagnosed HF, we did not observe widespread overuse of cardiovascular testing in the 6 months following incident HF hospitalization relative to existing HF guidelines. Variations in testing were greatest for assessment of ischemia, in which testing guidelines are less certain.     

Medication dosing in outpatients with heart failure after implementation of a practice-based performance improvement intervention: findings from IMPROVE HF

Eligible outpatients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF) frequently do not receive target doses of HF medications. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) evaluated the effect of a practice-based performance improvement intervention on treatment of outpatients with LVEF ≤35%. Specific agent and dose were collected at baseline and 24?months for angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β-blockers, and aldosterone antagonists. Changes in dosing over time were analyzed for each medication class. Data were available for 7605 patients. At baseline, target dose treatment rates were 36.1%, 20.5%, and 74.4%, respectively. Absolute and relative improvements of 9.8% and 47.7% (?P<.001) were achieved for β-blocker dosing at 24?months. The IMPROVE HF intervention was associated with significantly increased treatment of eligible patients with target doses of β-blockers but not ACE inhibitors/ARBs or aldosterone antagonists. Additional research to determine barriers to use of target doses of HF medications may be necessary.     

Benefits of inpatient initiation of beta-blockers

Clinical trials have demonstrated that β-blockers effectively reduce mortality in patients after a myocardial infarction (MI) and in patients with chronic heart failure. Treatment guidelines recommend that all patients after MI without a contraindication receive early β-blocker treatment. Initiation of β-blockers also should be considered for stable patients who are hospitalized with heart failure. Despite well-documented benefits, however, β-blockers are still underused. Barriers that cause reluctance by physicians to initiate therapy include the traditional belief that β-blockers are contraindicated in patients with left ventricular dysfunction, complexity of management, perceived risk of adverse events, and potential for short-term clinical deterioration. Intervention programs promoting β-blockers for inpatients have increased their use at discharge and after long-term follow-up. Because of pharmacologic differences, agent selection is also critical. Agents must have proven clinical efficacy, an established dose-titration regimen, and desirable pharmacokinetic properties. Increasing the use of these life-saving agents has the potential for substantial clinical impact.     

Relation of low hemoglobin and anemia to morbidity and mortality in patients hospitalized with heart failure (insight from the OPTIMIZE-HF registry)

Anemia in heart failure (HF) is increasingly recognized and treated, but little is known about the prevalence and its relation to outcomes in patients hospitalized for decompensated HF in a situation of both reduced and preserved systolic function. We hypothesized that lower hemoglobin is correlated with death during hospitalization and 60 to 90 days postdischarge in patients with HF. The Organized Program to Initiate Lifesaving Treatment in Patients with Heart Failure is a registry and performance improvement program for hospitalized patients with HF. Study cohorts were defined by admission hemoglobin quartile. Data from 48,612 patients at 259 hospitals showed that half of the total cohort had low hemoglobin (<12.1 g/dl) and that 25% were moderately to severely anemic (lowest hemoglobin quartile, 5 to 10.7 g/dl). Patients with low hemoglobin were older, were more often women and Caucasian, and had preserved systolic function and elevated creatinine. They were also less likely to receive angiotensin-converting enzyme inhibitors and beta blockers at discharge. Anemic patients had higher in-hospital mortality (4.8% vs 3.0%, lowest vs highest quartile), longer hospital length of stay (6.5 vs 5.3 days), and more readmissions by 90 days (33.1% vs 24.2%) (all p <0.0001). In conclusion, these data reveal a higher prevalence of low hemoglobin in hospitalized patients than noted in randomized HF trials and outpatient registries. Lower hemoglobin is associated with higher morbidity and mortality in hospitalized patients with HF.     

Lessons learned in acute heart failure

Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post‐discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.     

Reducing the risk of sudden death in heart failure with beta-blockers

BackgroundHeart failure (HF) is a serious cardiovascular syndrome that affects nearly 5 million people in the United States. A review of clinical data demonstrates that sudden cardiac death (SCD) accounts for approximately one-third of all HF deaths. This fatal outcome typically involves an unexpected electrical event leading to sustained cardiac arrhythmias resulting in cardiovascular collapse.Methods and ResultsA systematic review of the literature was performed to serve as the basis for this review. Factors contributing directly to incidence of SCD in the HF population may include significant remodeling of the left ventricle (hypertrophy, dilation, and fibrosis) in addition to increased sympathetic activation. Using specific therapies to limit these mechanisms are beneficial in the HF patient by preventing SCD. β-blockers play a key role in the prevention of SCD for patients with HF by limiting the effects of circulating norepinephrine and by reducing left ventricular remodeling.ConclusionsThis review outlines the potential mechanisms and contributing factors of SCD in patients with HF and the impact of β-blocker usage in the prevention of this fatal outcome for this growing patient population.     

A novel prognostic index to determine the impact of cardiac conditions and co-morbidities on one-year outcome in patients with heart failure

Prognostic stratification is relevant in clinical decision making in heart failure (HF). Predictors identified during hospitalization or in clinical trials may be unrepresentative of HF in the community. The aim of this study was to derive and validate, in different clinical settings, a risk stratification model for the prediction of stable HF outcomes. The study included 807 patients, 350 enrolled at discharge from the hospital (44%), 309 in the outpatient clinic (38%), and 148 in the home-care setting (18%). There were 292 patients in the derivation cohort and 515 in the validation cohort. A multivariate logistic analysis was performed to obtain the CardioVascular Medicine Heart Failure (CVM-HF) index. One-year mortality was 20.8% in the derivation cohort and 20.7% in the validation cohort. The CVM-HF index included cardiac conditions and co-morbidities and stratified the 1-year mortality risk as low (death rate 4%), average (32%), high (63%), and very high (96%). The area under the curve of the receiver-operating characteristic curve was 0.844 (95% confidence interval [CI] 0.779 to 0.89) for the derivation cohort and 0.812 (95% CI 0.76 to 0.86) for the validation cohort. Model performance was equally good in the 3 different HF settings. In a subgroup of 409 patients, the CVM-HF index (area under the curve 0.821, 95% CI 0.79 to 0.89) outperformed the most-used prognostic models (the Charlson index and the Heart Failure Risk Scoring System). In conclusion, the CVM-HF index, a novel prognostic model that is easy to derive and applicable to unselected patients, may represent a valuable tool for the prognostication of stable HF outcomes.     

Demographics, clinical characteristics, and outcomes of patients hospitalized for decompensated heart failure: observations from the IMPACT-HF registry

BACKGROUND: Hospitalizations for decompensated heart failure are frequent. The Initiation Management Pre-discharge Assessment of Carvedilol Heart Failure (IMPACT-HF) registry collected observational data in patients hospitalized for worsening heart failure to characterize an unselected group of patients and to confirm the generalizability of the IMPACT-HF main trial population. METHODS AND RESULTS: The IMPACT-HF registry was conducted concurrently with the IMPACT-HF study, a randomized trial of in-hospital initiation of carvedilol compared with the standard practice of postdischarge beta-blocker initiation. Patients were eligible for registry enrollment if they were hospitalized for heart failure regardless of ejection fraction. There were no exclusions to participation. Patients were followed for 60 days. The IMPACT-HF Registry enrolled 567 patients. The mean age was 71 years, 52% of the patients were men and 82% were Caucasian. At discharge, 71% received an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, 41% received digoxin, and 62% received beta-blockers. The 60-day rate of rehospitalization or death was 31%. CONCLUSION: The IMPACT-HF registry enrolled elderly patients admitted for worsening heart failure primarily resulting from progressive volume overload. The 60-day rate of death or rehospitalization was high despite the use of evidence-based therapies. New treatments for this population are needed to decrease the morbidity and mortality associated with decompensated heart failure.     

Hospital Management of Acute Decompensated Heart Failure

Heart failure (HF) is one of the leading causes of hospitalizations for elderly adults in the United States. One in 5 Americans will be >65 years of age by 2050. Because of the high prevalence of HF in this group, the number of Americans requiring hospitalization for this disorder is expected to rise significantly. We reviewed the most recent and ongoing studies and recommendations for the management of patients hospitalized due to decompensated HF. The Acute Decompensated Heart Failure National Registry, together with the 2013 American College of Cardiology Foundation and American Heart Association heart failure guidelines, earlier retrospective and prospective studies including the Diuretic Optimization Strategies Evaluation (DOSE), the Trial of Intensified vs Standard Medical Therapy in the Elderly Patients With Congestive Heart Failure (TIME-CHF), the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE–HF), the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) and the Comparison of Medical, Pacing and Defibrillation Therapies in Heart Failure (COMPANION) trial were reviewed for current practices pertaining to these patients. Gaps in our knowledge of optimal use of patient-specific information (biomarkers and comorbid conditions) still exist.     

Clinical characteristics and outcome of hospitalized patients with heart failure in Japan.

BACKGROUND: Heart failure (HF), defined as a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood, is a leading cause of mortality and hospitalization for adults older than 65 years in the industrialized countries. The characteristics and outcome of patients with HF have been described by several epidemiological studies and large scale clinical trials, performed mainly in the United States and Europe. Very little information is available on this issue in Japan. METHODS AND RESULTS: The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) is designed to prospectively study the characteristics, treatment, and outcomes of a broad sample of patients hospitalized with HF at teaching hospitals throughout Japan between January 2004 to June 2005 and the outcomes, including death and hospital readmission, will be followed through 2006 (mean follow-up at least 1 year). Participating cardiologists identify patients admitted for worsening of HF symptoms. Demographics, medical history, severity, treatment, and outcome data are collected and entered into a database via secure web browser technology. As of June 2005, baseline data for 2,676 patients with HF have been registered from 164 participating hospitals. CONCLUSIONS: The JCARE-CARD will provide important insights into the management of patients with HF in routine clinical practice in Japan, thus providing the framework for improved management strategies for these patients.