Search

International audience; Background: Renin-angiotensin aldosterone system inhibitors (RAASi) are commonly used among patients hospitalized with a severe acute respiratory syndrome coronavirus 2 infection (COVID-19). We evaluated whether continuation versus discontinuation of RAASi were associated with short term clinical or biochemical outcomes. Methods: The RAAS-COVID-19 trial was a randomized, open label study in adult patients previously treated with RAASi who are hospitalized with COVID-19 (NCT04508985). Participants were randomized 1:1 to discontinue or continue RAASi. The primary outcome was a global rank score calculated from baseline to day 7 (or discharge) incorporating clinical events and biomarker changes. Global rank scores were compared between groups using the Wilcoxon test statistic and the negative binomial test (using incident rate ratio [IRR]) and the intention-totreat principle. Results: Overall, 46 participants were enrolled; 21 participants were randomized to discontinue RAASi and 25 to continue. Patients' mean age was 71.5 years and 43.5% were female. Discontinuation of RAASi, versus continuation, resulted in a non-statistically different mean global rank score (discontinuation 6 [standard deviation [SD] 6.3] vs continuation 3.8 (SD 2.5); p= 0.60). The negative binomial analysis identified that discontinuation increased the risk of adverse outcomes (IRR 1.67 [95% CI 1.06 to 2.62]; p=0.027); RAASi discontinuation increased brain natriuretic peptide (BNP) levels (% change from baseline: +16.7% vs.-27.5%; p= 0.024) and the incidence of acute heart failure (33% vs. 4.2%, p=0.016). Conclusion: RAASi continuation in participants hospitalized with COVID-19 appears safe; discontinuation increased BNP levels and may increase risk of acute heart failure; where possible, RAASi should be continued.

Aims The goal of the global congestive heart failure (G-CHF) registry is to collect comparative international data on heart failure characteristics, management and outcomes; and to better understand the determinants that impact the clinical course of heart failure. Methods G-CHF is a multi-center, prospective cohort study of adult patients with a new or prior clinical diagnosis of heart failure. We have enrolled 23,047 participants from 257 centers in 40 countries from eight major geographic regions of the world, with recruitment ongoing. Approximately 4000 participants will also participate in sub-studies to assess frailty, comorbidity, diet, barriers to care, biomarkers, and planned detailed echocardiographic analyses. Follow up is planned for a period of 5 years. The primary outcome is cause-specific mortality. Key secondary outcomes include hospitalizations, quality of life, major cardiovascular and non-cardiovascular outcomes. 31.9% of participants were enrolled as inpatients. Thus far, mean age of the cohort at baseline is 63.1 years, and 60.8% are male. Participants most commonly have heart failure with reduced ejection fraction (53.6%), followed by preserved ejection fraction (24.2%), and mid-range ejection fraction (20.6%). The most common causes of heart failure are ischemic (37.8%), followed by hypertensive (20.0%), idiopathic (15.1%), and valvular disease (8.8%). Conclusion G-CHF will provide a greater understanding of the characteristics of the global heart failure population, variations in its management, clinical outcomes, and what continues to impact morbidity and mortality in this high-risk population.

Although the Get with the Guidelines-Heart Failure (GWTG-HF) group recently reported no association between hospital volume and 30-day outcomes in their registry, GWTG-HF hospitals are self-selected and tend to be higher-volume hospitals with active quality improvement departments. Thus, we explored the volume-outcome relationship for HF in an unselected population-based cohort of 241,533 adults admitted with HF as the most responsible diagnosis to any of 591 acute care institutions in Canada-none participate in GWTG-HF. We found inverse associations between volume and in-patient mortality (11.3% in low-volume hospitals compared to 9.0% in high-volume hospitals, adjusted odds ratio 0.90 [0.80-1.00]) and 30-day readmission rates (19.3% in low-volume hospitals versus 17.3% in high-volume hospitals, adjusted odds ratio 0.91 [0.85-0.97]).

Patients with heart failure (HF) remain at high risk for future events despite medical and device therapy. Dietary sodium reduction is often recommended based on limited evidence. However, it is not known whether dietary sodium reduction reduces the morbidity or mortality associated with HF.The SODIUM study is a pragmatic, randomized, open-label trial assessing the efficacy of dietary sodium reduction to1500 mg daily counseling compared to usual care for patients with chronic HF. The intervention is provided by trained personnel at the site and uses 3-day food records for directing counseling. The primary outcome is an intention-to-treat analysis on the time to first cardiovascular event or death measured at 12 months. Secondary end points include the change in quality of life (using the Kansas City Cardiomyopathy Questionnaire), change in New York Heart Association class, and change in 6-minute walk test. The first patient was enrolled in March 2014, and subsequently, 27 sites in 6 countries enrolled patients.The SODIUM-HF trial will provide a robust evaluation of the effects of dietary sodium reduction in patients with HF. Results are expected in 2020.

There is substantial variability among hospitals in critical care unit (CCU) utilization for patients admitted with non-ST-Segment Elevation Acute Coronary Syndromes (NSTE ACS). We estimated the potential cost saving if all hospitals adopted low CCU utilization practices for patients with NSTE ACS.National hospital claims data were used to identify all patients with a primary diagnosis of NSTE ACS initially admitted to an acute care hospital between 2007 and 2013. Hospital CCU utilization was classified as low (30%), medium (30-70%), or high (70%).Among the 270,564 NSTE ACS hospitalizations (71.6% non-ST-segment elevation myocardial infarction; 28.4% unstable angina) admitted to 261 hospitals, 41.9% (inter-hospital range 0.3%-95.1%) were admitted to a CCU. The proportion of patients admitted to a CCU in low, medium and high utilization hospitals was 16.3%, 49.5%, and high 81.1%, respectively. No differences in adjusted inpatient mortality were observed by hospital CCU utilization. The overall inpatient costs of caring for NSTE ACS were $1.1 billion. CCU care accounted for 45.2% of all hospitalization costs including 22.6%, 49.9%, and 69.0% (P .001) of costs in low, medium and high utilization centers. The national potential direct cost savings of medium and high CCU utilization centers adopting low NSTE ACS CCU utilization practices was $113.4 million over the study period.In a population-based contemporary cohort, CCU utilization for patients with NSTE ACS varied widely and in-hospital mortality was similar between low, medium and high utilization centers. CCU care accounted for 45% of hospitalization costs; thus, implementing policies and admission practices to align hospital resources with patient care needs have the potential to reduce overall health care costs.

Electronic health records (EHRs) can be a major tool in the quest to decrease costs and timelines of clinical trial research, generate better evidence for clinical decision making, and advance health care. Over the past decade, EHRs have increasingly offered opportunities to speed up, streamline, and enhance clinical research. EHRs offer a wide range of possible uses in clinical trials, including assisting with prestudy feasibility assessment, patient recruitment, and data capture in care delivery. To fully appreciate these opportunities, health care stakeholders must come together to face critical challenges in leveraging EHR data, including data quality/completeness, information security, stakeholder engagement, and increasing the scale of research infrastructure and related governance. Leaders from academia, government, industry, and professional societies representing patient, provider, researcher, industry, and regulator perspectives convened the Leveraging EHR for Clinical Research Now! Think Tank in Washington, DC (February 18-19, 2016), to identify barriers to using EHRs in clinical research and to generate potential solutions. Think tank members identified a broad range of issues surrounding the use of EHRs in research and proposed a variety of solutions. Recognizing the challenges, the participants identified the urgent need to look more deeply at previous efforts to use these data, share lessons learned, and develop a multidisciplinary agenda for best practices for using EHRs in clinical research. We report the proceedings from this think tank meeting in the following paper.

Recent developments have highlighted the challenges facing cardiovascular clinical research in global contemporary practice, particularly in North America, including shifting priorities for drug development targets, increasing regulatory requirements, and expensive operational approaches for conducting randomized clinical trials. Nonetheless, emerging trends such as the consolidation of practices and hospitals into integrated health systems, the integration of electronic health records from thousands of practices into large data repositories to support prospective research studies, and streamlined operational approaches such as registry-based trials and risk-based monitoring have created numerous opportunities to disrupt the clinical research paradigm. Within this context, academic research organizations around the globe, particularly a strengthened collaboration of 3 established academic research organizations in North America, are uniquely positioned to promote and develop grassroots collaborations across all types of clinical practices, to delineate successful solutions to obstacles that limit clinical research initiatives, and to guide the future of cardiovascular research in the global research environment.

Background Most patients with acute heart failure (AHF) admitted to critical care units (CCUs) are low acuity and do not require CCU-specific therapies, suggesting that they could be managed in a lower-cost ward environment. This study identified the predictors of clinical events and the need for CCU-specific therapies in patients with AHF. Methods Model derivation was performed using data from patients in the ASCEND-HF trial cohort (n=7,141), and the Acute Heart Failure Emergency Management community-based registry (n=666) was used to externally validate the model and to test the incremental prognostic utility of 4 variables (heart failure etiology, troponin, B-type natriuretic peptide [BNP], ejection fraction) using net reclassification index and integrated discrimination improvement. The primary outcome was an in-hospital composite of the requirement for CCU-specific therapies or clinical events. Results The primary composite outcome occurred in 545 (11.4%) derivation cohort participants (n=4,767) and 7 variables were predictors of the primary composite outcome: body mass index, chronic respiratory disease, respiratory rate, resting dyspnea, hemoglobin, sodium, and blood urea nitrogen ( c index=0.633, Hosmer-Lemeshow P =.823). In the validation cohort (n=666), 87 (13.1%) events occurred ( c index=0.629, Hosmer-Lemeshow P =.386) and adding ischemic heart failure, troponin, and B-type natriuretic peptide improved model performance (net reclassification index 0.79, 95% CI 0.046-0.512; integrated discrimination improvement 0.014, 95% CI 0.005-0.0238). The final 10-variable clinical prediction model demonstrated modest discrimination ( c index=0.702) and good calibration (Hosmer-Lemeshow P =.547). Conclusions We derived, validated, and improved upon a clinical prediction model in an international trial and a community-based cohort of AHF. The model has modest discrimination; however, these findings deserve further exploration because they may provide a more accurate means of triaging level of care for patients with AHF who need admission.

Background The accuracy of current models to predict the risk of unplanned readmission or death after a heart failure (HF) hospitalization is uncertain. Methods We linked four administrative databases in Alberta to identify all adults discharged alive after a HF hospitalization between April 1999 and 2009. We randomly selected one episode of care per patient and evaluated the accuracy of five administrative data-based models (4 already published, 1 new) for predicting risk of death or unplanned readmission within 30 days of discharge. Results Over 10 years, 59652 adults (mean age 76, 50% women) were discharged after a HF hospitalization. Within 30 days of discharge, 11199 (19%) died or had an unplanned readmission. All 5 administrative data models exhibited moderate discrimination for this outcome ( c -statistic between 0.57 and 0.61). Neither Centers for Medicare and Medicaid Services (CMS)–endorsed model exhibited substantial improvements over the Charlson score for prediction of 30-day post-discharge death or unplanned readmission. However, a new model incorporating length of index hospital stay, age, Charlson score, and number of emergency room visits in the prior 6 months (the LaCE index) exhibited a 20.5% net reclassification improvement (95% CI, 18.4%-22.5%) over the Charlson score and a 19.1% improvement (95% CI, 17.1%-21.2%) over the CMS readmission model. Conclusions None of the administrative database models are sufficiently accurate to be used to identify which HF patients require extra resources at discharge. Models which incorporate length of stay such as the LaCE appear superior to current CMS-endorsed models for risk adjusting the outcome of "death or readmission within 30 days of discharge".

Background ST-elevation myocardial infarction (STEMI) patients with a prior MI history have worse outcomes. The prognostic significance of silent MI (pathologic Q waves outside the ST-elevation territory) in STEMI is unclear. Methods A total of 5,733 STEMI patients from 296 clinical centers in 17 countries were classified as (1) silent MI—baseline Q waves outside the infarct-related artery territory and no history of prior MI, (2) history of prior MI (HxMI), or (3) no prior MI. Results Of 5,733 STEMI patients, 419 (7.3%) had silent MI, 693 (12.1%) had HxMI, and 4,621 (80.6%) had no prior MI. Ninety-day death and death/congestive heart failure/shock were higher in patients with HxMI (8.4% and 15.3%, respectively) and silent MI (6.7% and 13.9%, respectively) compared with patients with no prior MI (4.0% and 9.1%, respectively) ( P ≤ .001 for all). After baseline adjustment, patients with HxMI were at increased risk for 90-day death (adjusted hazard ratio [HR] 1.62, 95% CI 1.18-2.21), whereas both those with HxMI and those with silent MI had increased risk of 90-day death/congestive heart failure/shock compared with those with no prior MI (adjusted HR 1.54, 95% CI 1.23-1.93 and adjusted HR 1.46, 95% CI 1.10-1.93, respectively). Conclusions Seven percent of STEMI patients had a silent MI. They represent a novel subgroup at increased risk comparable to those with known prior MI. Hence, in future studies, acquiring baseline Q wave data outside the distribution of acute injury should broaden the prognostic insights from STEMI patients with a prior MI.

The purpose of this study was to determine predictors of 90-day left ventricular function following acute ST-segment elevation myocardial infarction (STEMI) using variables from clinical presentation, biomarker testing, and cardiovascular magnetic resonance imaging (CMR).Identifying patients with acute STEMI who experience adverse remodeling and develop left ventricular dysfunction 3 months post-MI is a priority for guiding subsequent therapy.The Assessment of Pexelizumab in Acute Myocardial Infarction trial tested pexelizumab treatment in STEMI patients presenting within 6 hours of symptom onset who were to undergo primary percutaneous coronary intervention. We studied 64 patients within this trial according to a prespecified substudy that included paired core laboratory delayed-enhancement CMR at days 3 and 90 as well as plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP; in picograms per milliliter) measured at randomization and 24 hours. A multivariable model predicting day 90 left ventricular ejection fraction (LVEF) was developed from clinical, biomarker, and imaging findings.Patients had a median age of 60 years (52-68), 89% were male, and 60% had anterior STEMI. Time from symptom onset to percutaneous coronary intervention was 3 hours. The median baseline LVEF was 48% (38%-56%) and was 50% (40%-54%) at 90 days: 7 patients (11%) had an LVEF35% at 90 days. Patients with a lower 90-day LVEF (as a continuous variable) had a higher 24-hour NT-proBNP (P = .02) and a larger baseline infarct size by CMR (median 15% LV [8%-20% LV]) (P.01). Microvascular obstruction (no reflow) was greater as measured by CMR (median 2.8% [1.4%-6.1%]) in patients with a lower 90-day LVEF (P.01). Median baseline and 24-hour NT-proBNP levels were 94 pg/mL (54-292 pg/mL) and 1,448 pg/mL (958-2,599 pg/mL), respectively. In a multivariable model with clinical, biomarker, and imaging variables, only 3 variables independently predicted 90-day LVEF: 24-hour NT-proBNP, baseline CMR infarct size, and microvascular obstruction.Three key pathophysiologic variables of the post-STEMI myocardium measuring baseline infarct size and the extent of microvascular obstruction on CMR and wall tension (24-hour NT-proBNP) independently predicted 90-day LVEF. Further studies linking these measures with earlier use of clinical therapies may be warranted.

We investigated the prognostic significance of plasma N-terminal fragment of the prohormone B-type natriuretic peptide (Nt-proBNP) concentrations in addition to time to reperfusion and Thrombolysis in Myocardial Infarction (TIMI) flow before and after coronary intervention in patients with ST elevation myocardial infarction (STEMI) from the database of the Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT IV-PCI) trial.Plasma Nt-proBNP was available in 1,037 patients with STEMI. Patients were randomized either to primary (p-PCI) or to full-dose tenecteplase before PCI (f-PCI).The study end point was the composite of death, cardiogenic shock, or congestive heart failure at 90 days.According to classification tree analysis, patients with Nt-proBNP levels694 pg/mL had the highest primary end point rates (33.8% vs 11%, P.001). In Cox regression analysis, Nt-proBNP694 pg/mL strongly predicted 90-day survival even among patients with short treatment delay (f-PCIor =3 hours: hazard ratio [HR] 2.63, P = .002 and p-PCIor =3 hours: HR 4.87, P.001, respectively). Patients with TIMI 3 flow after coronary intervention were at significantly higher risk of the primary end point if admission Nt-proBNP exceeded 694 pg/mL (f-PCI: HR 2.88, P.001 and p-PCI: HR 3.84, P.001, respectively). In multivariable analysis, Nt-proBNP694 pg/mL significantly (P = .001) predicted 90-day survival in addition to age (P.001), TIMI flow after PCI (P.001), body mass index (P = .026), anterior wall infarction (P = .035), and systolic blood pressure at randomization (P = .036), respectively.Elevated plasma concentrations of Nt-proBNP in the early phase of STEMI determine in-hospital and 90-day outcome after infarction irrespective of time to treatment and pre- or postinterventional TIMI flow.

Acute decompensated heart failure (ADHF) is a major public health issue and remains a heterogeneous, complex, and difficult condition to manage. Although novel acute therapies are being tested in large randomized clinical trials, opportunities exist to improve the standard of care by ensuring optimal adherence to currently established evidence-based interventions for HF. Consideration of the goals of therapy and practical application of current methods to assess for clinical improvement may lead to improved patient management and possibly improved outcomes for patients with ADHF. This review provides key practical information regarding the current standard of care for patients with ADHF including the goals of therapy, management of acute and chronic medications, and discharge/transition of care planning.

Previous studies on atrial fibrillation (AF) epidemiology have used various case definitions for AF, but the effect of location of diagnosis on the apparent epidemiology of AF is unknown.Population-based study of 46,440 consecutive patients with newly diagnosed AF in Alberta, Canada, from 2000 to 2005.Of adults newly diagnosed with AF (52.8% men, median 73 years), 51.8% were first diagnosed in hospital, 19.2% in emergency department (ED), and 29.0% in outpatient clinics. Prevalence of AF increased from 613 per 100,000 to 1,148 per 100,000 population over 5 years; however, the age- and sex-standardized incidence of AF remained relatively stable (350 per 100,000 in 2000 and 352 per 100,000 in 2005). The proportion of AF cases diagnosed in hospital declined 21% between 2000 and 2005, whereas the proportion of cases diagnosed in the outpatient setting rose by 50% (P.0001). Patients diagnosed with AF in the hospital or the ED had more comorbidities and higher CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) scores than those diagnosed in the outpatient setting (all P.0001). Multivariate adjusted risk of cerebrovascular events or mortality (adjusted odds ratios 4.3, 95% CI 3.9-4.7) was significant for hospital and ED AF diagnosis (adjusted odds ratios 2.4, 95% CI 2.2-2.7) compared with those diagnosed in primary care clinics. New heart failure in the year after diagnosis of AF was 4.5% for inpatients, 3.8% in ED patients, and 2.5% in outpatients.Use of hospitalizations alone to define an AF cohort may underestimate incidence while overestimating comorbiditities, thromboembolic risk, and outcomes.

Background Traditionally, clinical outcomes comprising composite end points in cardiovascular trials are assigned equal weights in statistical analyses. However, the importance of weighting outcomes according to their relative severity is now recognized. This study aimed to elicit patients' perceptions of the importance of cardiovascular outcomes and treatment complications and compare them with those of clinicians. Methods and Results Interviewer-administered surveys, including rating, ranking, point-allocation and trade-off exercises, were conducted in 52 adults with confirmed coronary disease or previous myocardial infarction. Patients viewed "death" as the most severe cardiovascular outcome, followed by cardiogenic shock, congestive heart failure (CHF), and repeat myocardial infarction (re-MI), the same pattern observed in clinician responses in a previous study. Most patients were willing to accept a 3-fold increase in risk of systemic bleed (SB) or nonfatal intracranial hemorrhage (ICH) for a 20% reduction in risk of cardiogenic shock or 60% reduction in risk of CHF, but only a 2-fold increase in the risk of SB or ICH for a 20% reduction in risk of CHF or 60% reduction in risk of re-MI and no increase in risk of SB or ICH for a 20% reduction in risk of re-MI. Similar patterns were seen in a previous study of trade-offs in clinicians. Conclusions Although patients' preferences appear to be comparable with those of clinicians, patients may be less willing than clinicians to tolerate potential treatment complications. The methods used in this study offer a feasible approach to incorporating patient preferences into cardiovascular trials and warrant further investigation in broader patient populations.

Background Patients with nonvalvular atrial fibrillation (NVAF) are at increased risk for adverse events after noncardiac surgery. The Revised Cardiac Index (RCI) is commonly used to predict perioperative events; however, the prognostic utility of NVAF risk scores (CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 ) has not been evaluated in patients undergoing noncardiac surgery. Methods Using a population-based data set of NVAF patients (n = 32,160) who underwent major or minor noncardiac surgery between April 1, 1999, and November 30, 2009, in Alberta, Canada, we examined the incremental prognostic value of the CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores over the RCI using continuous net reclassification improvement (NRI). The primary composite outcome was 30-day mortality, stroke, transient ischemic attack, or systemic embolism. Results The median age was 73 years, 55.1% were male, 6.6% had a previous thromboembolism, 17% of patients underwent major surgery, and the median risk scores were as follows: RCI=1, CHADS 2 = 1, CHA 2 DS 2 -VASc = 3, and R 2 CHADS 2 = 2. The incidence of our 30-day composite was 4.2% (mortality 3.3%; stroke, transient ischemic attack, or systemic embolism 1.2%); and c indices were 0.65 for the RCI, 0.67 for the CHADS 2 (NRI 14.3%, P 2 DS 2 -VASc (NRI 10.7%, P 2 CHADS 2 (NRI 11.4%, P 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores were also all significantly better than the RCI for mortality risk prediction (NRI 12.3%, 8.4%, and 13.3%, respectively; all P s Conclusions In NVAF patients undergoing noncardiac surgery, the CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores all improved the prediction of major perioperative events including mortality compared to the RCI.

Background Symptomatic heart failure (HF) and reduced ejection fraction (REF) are both associated with mortality, but the long-term outcomes associated with the development of HF in older non–ST-segment elevation myocardial infarction (NSTEMI) patients with preserved systolic function and REF are uncertain. Methods We analyzed a total of 26,291 NSTEMI patients ≥65 years discharged alive in the CRUSADE Registry who had linked Medicare data. We evaluated 30-day and 1-year risks of mortality and HF readmission in 4 cohorts of patients stratified by symptomatic HF and ejection fraction: (1) no HF-PEF, (2) no HF-REF, (3) HF-PEF, and (4) HF-REF. Results A total of 14,280 NSTEMI patients (54.3%) had no HF-PEF, 3,345 (12.7%) had no HF-REF, 4,913 (18.7%) had HF-PEF, and 3,753 (14.3%) had HF-REF. Compared with no HF-PEF patients, the 30-day mortality risk was higher among patients with no HF-REF (4.9% vs 1.7%, adjusted hazard ratio 2.11, 95% CI 1.69-2.63), HF-PEF (5.9% vs 1.7%, adjusted hazard ratio 1.99, 95% CI 1.64-2.41), and highest among those with HF-REF (9.3% vs 1.7%, adjusted hazard ratio 2.70, 95% CI 2.23-3.26). Similar relationships were noted in the adjusted 1-year mortality and the risks of 30-day and 1-year HF readmission. Conclusions Symptomatic HF and REF during the index NSTEMI hospitalization are both associated with an increased risk of short- and long-term mortality as well as HF readmission with an apparent additive prognostic impact of both factors.

The long-term incidence of heart failure (HF) in ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), or unstable angina (UA) patients is uncertain. We examined the 1-year incidence of HF and its association with mortality among patients surviving their first acute coronary syndrome (ACS) hospitalization.A retrospective cohort study of patients, aged ≥20 years, with no prior HF, hospitalized for the first time with ACS between April 1, 2002, and December 31, 2008, in Alberta, Canada, and followed up for 1 year. Index HF was defined as HF that developed as a complication during the index ACS hospitalization, and post-discharge HF, as HF developing after discharge from the index ACS hospitalization. Among 9,406 STEMI, 11,008 NSTEMI, and 4,910 UA patients, 13.6%, 14.8%, and 5.2% had index HF, respectively (P.01). At 1-year, cumulative HF rates were 23.4% in STEMI, 25.4% in NSTEMI, and 16% in UA patients. Among hospital survivors, 1-year mortality rate was 13.9% in patients with index HF, 10.6% in patients with postdischarge HF, and 2.4% in patients with no HF. In multivariable analysis, both index HF (adjusted hazard ratio 3.2, 95% CI 2.7-3.7) and postdischarge HF (adjusted hazard ratio 4.6, 95% CI 3.9-5.4) were associated with 1-year mortality.There are significant differences in the incidence of HF among STEMI, NSTEMI, and UA patients. The increased mortality risk associated with index HF and postdischarge HF suggests a need for vigilant follow-up of all ACS patients for prompt detection and treatment of HF.