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Heart failure (HF) affects more than 15 million people in Europe and North America. Most of the studies performed in HF patients have been conducted in middle-aged adults. However, patients with HF are mainly elderly patients in whom management is complicated by comorbid conditions and the risk of adverse drug reactions. Little is known about the quality of care among this population. The aim of this prospective and multicenter study was to describe the in-hospital management in routine clinical settings of elderly patients over 75 years presenting to the emmergency department with pulmonary edema. During the 12-month study period, 398 patients were enrolled in five french emmergency departments. 96 % had at least one major comorbid condition and the prevalence of cognitive impairment was high (63 % of patients with a Mini Mental State Examination, MMSE<20). 33.6 % of patients were admitted to cardiology units and 66.3 % to non-cardiology departments. Admission in cardiology departments (33.7 %) was associated with previous cardiologic assessment (OR, 2.32, 95 %-CI, 1.33-4.07), prior coronary artery disease (OR, 2.39, 95 %-CI, 1.47-3.87), elevated troponin (OR 1.67, 95 %-CI, 1.03-2.70) and functional independence (OR 1.57, 95 %-CI, 0.96-2.57). By contrast, cognitive impairment (OR 0.39, 95 %-CI, 0.24-0.62) was associated with noncardiology department admission. 64.1 % of patients admitted to cardiology department underwent echocardiographic assessment versus 23.7 % of the others (p<0.01). A preserved left ventricular ejection fraction (>45 %) was found in 70.5 % of patients. Recommended treatments were under-prescribed at admission (48.1 %) and were more likely to be delivered at discharge to patients admitted to cardiology departments (OR 1.51 (95 %-CI 1.01-2.23). In-hospital mortality (11.0 %) was not associated with department speciality. However, the two years survival of patients treated with recommended medications at discharge was significantly improved compared with patients treated by symptomatic drugs. Conclusion: Routine care of HF was dependant on noncardiology factors (e.g. cognitive impairment) in this elderly population and aimed symptom relief rather than compliance with guidelines which reduce mortality. Our findings suggest that the institution of protocols to standardize care could improve compliance with guidelines and long-term outcomes. [Copyright &y& Elsevier]