European Journal of Heart Failure (2013) 15, 808–817

doi:10.1093/eurjhf/hft050

EURObservational Research Programme:

regional differences and 1-year follow-up results
of the Heart Failure Pilot Survey (ESC-HF Pilot)
Aldo P. Maggioni 1*, Ulf Dahlström2, Gerasimos Filippatos 3, Ovidiu Chioncel 4,
Marisa Crespo Leiro5, Jaroslaw Drozdz 6, Friedrich Fruhwald7, Lars Gullestad 8,
Damien Logeart 9, Gianna Fabbri 1, Renato Urso 1, Marco Metra10, John Parissis 11,
Hans Persson 12, Piotr Ponikowski 13, Mathias Rauchhaus 14, Adriaan A. Voors 15,
Olav Wendelboe Nielsen 16, Faiez Zannad 17, and Luigi Tavazzi 18 on behalf of the
Heart Failure Association of the European Society of Cardiology (HFA)†
1
ANMCO Research Center, Florence, Italy; 2Department of Cardiology, Linkoping University Hospital, Linkoping, Sweden; 3Athens University Hospital Attikon, Athens, Greece;
4
Cardiology 1, Institut de Boli Cardiovasculare C.C.Iliescu, Bucuresti, Romania; 5Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario A Coruña,
La Coruña, Spain; 6Department of Cardiology, Medical University of Lodz, Poland; 7Department of Cardiology, Medical University, Graz, Austria; 8Department of Cardiology,
Rikshospitalet University Hospital, Oslo, Norway; 9Service de cardiologie, Hôpital Lariboisière, Paris, France; 10Cattedra di Cardiologia, Dipartimento di medicina sperimentale ed
applicata, Spedali Civili, Università di Brescia, Italy; 11Second Department of Cardiology, Attikon University Hospital, University of Athens, Greece; 12Department of Cardiology,
Danderyd Hospital, Stockholm, Sweden; 13Department of Cardiology, Military Hospital, Wroclaw, Poland; 14Department of Cardiology, Center for Internal Medicine I, University
Hospital Rostock, Germany; 15University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; 16Department of Cardiology, Bispebjerg University
Hospital, Copenhagen, Denmark; 17INSERM, Centre d’Investigation Cliniques CIC 9501 and U961, CHU and Department of Cardiology, Nancy University, Nancy, France; and
18
Maria Cecilia Hospital, GVM Care and Research, Ettore Sansavini Health Science Foundation Cotignola, Italy

Received 18 December 2012; revised 18 February 2013; accepted 22 February 2013; online publish-ahead-of-print 28 March 2013

Aims The ESC-HF Pilot survey was aimed to describe clinical epidemiology and 1-year outcomes of outpatients and
inpatients with heart failure (HF). The pilot phase was also specifically aimed at validating structure, performance,
and quality of the data set for continuing the survey into a permanent Registry.
.....................................................................................................................................................................................
Methods The ESC-HF Pilot study is a prospective, multicentre, observational survey conducted in 136 Cardiology Centres in 12
European countries selected to represent the different health systems across Europe. All outpatients with HF and patients
admitted for acute HF on 1 day per week for eight consecutive months were included. From October 2009 to May 2010,
5118 patients were included: 1892 (37%) admitted for acute HF and 3226 (63%) patients with chronic HF. The all-cause
mortality rate at 1 year was 17.4% in acute HF and 7.2% in chronic stable HF. One-year hospitalization rates were 43.9%
and 31.9%, respectively, in hospitalized acute and chronic HF patients. Major regional differences in 1-year mortality were
observed that could be explained by differences in characteristics and treatment of the patients.
.....................................................................................................................................................................................
Conclusion The ESC-HF Pilot survey confirmed that acute HF is still associated with a very poor medium-term prognosis, while
the widespread adoption of evidence-based treatments in patients with chronic HF seems to have improved their
outcome profile. Differences across countries may be due to different local medical practice as well to differences
in healthcare systems. This pilot study also offered the opportunity to refine the organizational structure for a
long-term extended European network.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Acute heart failure † Chronic heart failure † Prognosis † Observational studies † Pharmacological treatments

* Corresponding author. EURObservational Research Programme Department, European Society of Cardiology, The European Heart House, 2035 Route des Colles–Les
Templiers, 06903 Sophia Antipolis, France. Tel: +33 489 87 20 37, Fax: +33 492 94 76 29, Email: maggioni@anmco.it
†
See Appendix 1 for a complete list of participating Centres and Investigators.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013. For permissions please email: journals.permissions@oup.com.
A.P. Maggioni et al.
Introduction
Heart failure (HF) remains a clinical condition determining a rele-
vant global burden for both the quality and duration of life of the
patients and health expenditure.1 – 3 Several registries have been
formed in the last decades, but further, more specific, information
is needed.4 – 13
Few prospective data are available on both hospitalized and
ambulatory patients and, on the medium-long term outcomes of
these patients. Also, large differences across Europe in terms of
patients’ characteristics, management strategies, and outcome
may exist, but are not frequently reported. The European
Society of Cardiology (ESC) Heart Failure Pilot Registry was
planned to improve knowledge on the epidemiology, clinical
characteristics, and outcomes of real-world patients with HF in
12 participating European countries. Baseline characteristics and
in-hospital mortality of hospitalized patients have already been
reported.14 This current analysis of this registry aims to report:
(i) the 1-year outcomes of both hospitalized and ambulatory
patients with HF; and (ii) differences across four different geo-
graphical areas of Europe in terms of patients’ characteristics,
use of resources, and outcomes.
Methods
Study design and clinical setting
The general policy of the new EURObservational Research Programme
of the ESC has been previously published, as have the results of the
enrolment phase of the ESC-HF Pilot study.14
In brief, the ESC-HF Pilot study is a prospective, multicentre,
observational survey of patients presenting to 136 Cardiology
Centres in 12 European countries: (i) Northern Europe (Denmark,
Norway, and Sweden); (ii) Eastern Europe (Romania and Poland);
(iii) Western Europe (Austria, France, Germany, and The Nether-
lands); and (iv) Southern Europe (Greece, Italy, and Spain).
Figure 1 Flow diagram. AHF, acute heart failure; pts, patients.
809
The National Cardiology Societies of each country were asked to
select hospitals of different levels of complexity from which patients
would have been recruited. The aim was to involve a broad spectrum
of cardiology and/or HF units following outpatients with HF and admit-
ting patients with acute HF to build up a network of centres represen-
tative of the European reality.
The number of participating centres per country was decided
according to the number of inhabitants of each participating country
and, as far as possible, the centres should also respect geographical
criteria within each country. This included a balanced proportion of
centres with a different range of cardiology facilities.
The EURObservational Research Programme (EORP) Department
at European Heart House was appointed to coordinate the project
operationally, provide support to the Committees, National Coordina-
tors, and participating centres, and oversee the methodological
concepts of the survey. The database has been set up at European
Heart House, according to the requirements defined by the appointed
Executive Committee with the support of the EORP Department.
The statistical analysis was performed at the ANMCO Research
Center, Florence, Italy.
Inclusion criteria
All outpatients with HF seen at the clinics and those admitted to hos-
pital for acute, pre-existing, or new-onset HF were included during the
enrolment period (on 1 day per week for eight consecutive months).
There were no specific exclusion criteria, with the exception of age
which had to be higher than 18 years.
The survey was approved by each local Institutional Review Board
according to the rules of each participating country. No data were
collected before detailed information was provided to the patient
and a signed informed consent was obtained.
Statistical analysis
Categorical variables are presented as percentages, while continuous
variables are presented as means and standard deviation (SD) plus
median and interquartile range (IQR). Categorical variables were com-
pared by the x2 test and continuous variables by analysis of variance
(ANOVA) or t-test if normally distributed, and by Kruskol –Wallis
810 Acute and chronic heart failure outcomes

or Mann– Whitney U-test, if not. Plots of the Kaplan– Meier curves for
time to all-cause death, time to admission to hospital for HF, and time
to all-cause death or HF hospitalization were performed. Baseline
characteristics and type of treatments are also reported stratified
by area of Europe of enrolment: Northern, Eastern, Western, or
Sourthern.
All the variables at entry which were statistically significant at
univariate analysis and variables considered of relevant clinical interest
were included in the multivariable model (Cox model) to identify the
independent predictors of all-cause death from study entry to 1-year
follow-up, separately for acute and chronic HF. These variables are
listed in the Table footnotes. Age, systolic blood pressure, and heart
rate (considered only for patients with chronic HF) were considered
as continuous variables, while body mass index and laboratory mea-
sures, not being available for all patients, were considered as categor-
ical variables, using clinical cut-offs and defining a dummy variable for
missing values. A P-value ,0.05 was considered statistically significant.
All tests were two-sided. Analyses were performed with SAS system
software, version 9.2.
Results
From October 2009 to May 2010, 5118 patients have been
included in this ESC-HF Pilot Survey; 3226 (63%) were ambulatory
patients with chronic HF and 1892 (37%) were patients admitted
with a diagnosis of acute HF. Loss to follow-up at 1 year was
1.1% and 4.9% of patients with chronic HF and with acute HF, re-
spectively (Figure 1). The median follow-up period was 356 days
(IQR 325–366) for patients hospitalized for HF and 364 days
(IQR 337–368) for those with chronic HF.
The characteristics of patients with acute and chronic HF are
reported in Table 1. In-hospital patients were generally older

Table 1 Characteristics of the study population

Acute HF (n 5 1892) Chronic HF (n 5 3226) P-value

...............................................................................................................................................................................
Age (years), mean + SD; median (IQR) 69 + 13; 71 (61– 79) 66 + 13; 68 (58–76) ,0.0001
Age ≥70 years, % 54.2 46.5 ,0.0001
Females, % 37.4 29.7 ,0.0001
Ischaemic aetiology, % 50.7 40.5 ,0.0001
BMI (kg/m2), mean + SD; median (IQR)a 28 + 6; 28 (25– 31) 28 + 5; 27 (24– 30) 0.0005
SBP (mmHg), mean + SD; median (IQR) 133 + 29; 130 (113–150) 125 + 20; 123 (110–140) ,0.0001
HR (b.p.m.), mean + SD; median (IQR) 88 + 24; 80 (70– 100) 72 + 14; 70 (61–80) ,0.0001
EF (%), mean + SD; median (IQR)b 38.3 + 14.2; 37 (26–50) 38.0 + 12.8; 36 (30– 46) 0.60
EF ≥45% (%), %b 35.5 30.5 0.0008
Treated hypertension, % 61.8 58.3 0.015
Diabetes mellitus, % 35.1 29.0 ,0.0001
History of AF, % 43.7 38.6 0.0003
Previous stroke/TIA, % 9.8 10.5 0.42
PVD, % 9.9 11.2 0.16
Renal dysfunction, % 26.0 18.5 ,0.0001
COPD, % 15.2 15.1 0.96
ICD, % 6.0 13.3 ,0.0001
CRT-P, % 0.4 1.0 0.02
CRT-D, % 2.9 8.8 ,0.0001
Anaemia, %c 42.1 28.8 ,0.0001
Creatinine .1.5 mg/dL, %d 23.0 18.3 0.0001
eGFR ,60 mL/min/1.73 m2, % 49.3 40.6 ,0.0001
eGFR ,30 mL/min/1.73 m2, % 9.9 5.1 ,0.0001
Glycaemia (mg/dL), median (IQR)e 110 (95– 143) 105 (93– 125) ,0.0001
Sodium ,136 mmol/L, %f 21.9 12.4 ,0.0001
BUN .50 mg/dL, %g 48.6 44.7 0.03

BMI, body mass index; BUN, blood urea nitrogen; CRT-P, CRT pacemaker; CRT-D, CRT defibrillator; eGFR, estimated glomerular filtration rate using the Modificiation of Diet in
Renal Disease formula; HF, heart failure; HR, heart rate; ICD, implantable cardioverter defibrillator; IQR, interquartile range; PVD, peripheral vascular disease; SBP, systolic blood
pressure; SD, standard deviation.
a
Available for 4530 patients.
b
Available for 4347 patients.
c
Anaemia was reported according to the World Health Organization definition (,13 g/dL in men, ,12 g/dL in women); available for 4370 patients.
d
Available for 4375 patients.
e
Available for 3431 patients.
f
Available for 4250 patients.
g
Available for 3060 patients.
 A.P. Maggioni et al.
Table 2 Patients’ characteristics by different European regions

Characteristics Northern Eastern Western Southern P-value

.............................................................................................................................................................................................................................................
Hospitalized patients with acute HF (n 5 1892) n ¼ 140 n ¼ 991 n ¼ 218 n ¼ 543
Age (years), mean + SD; median (IQR) 69 + 13; 71 (62–79) 67 + 13; 69 (58– 77) 71 + 13; 73 (64–81) 72 + 12; 74 (65–81) ,0.0001
Age ≥70 years, % 54.3 47.5 60.6 63.9 ,0.0001
Females, % 38.6 36.0 37.6 39.4 0.61
Ischaemic aetiology, % 52.9 56.7 49.5 39.6 ,0.0001
BMI (kg/m2), mean + SD; median (IQR) 28 + 6; 27 (24– 31) 29 + 6; 28 (25–32) 28 + 5; 28 (24–32) 28 + 5; 27 (24– 30) 0.04
SBP (mmHg), mean + SD; median (IQR) 128 + 31; 122 (106 –147) 137 + 30; 135 (120– 150) 132 + 26; 130 (111 –148) 128 + 25; 125 (110 –142) ,0.0001
HR (b.p.m.), mean + SD; median (IQR) 86 + 24; 81 (68–98) 90 + 25; 85 (71– 102) 81 + 22; 76 (65–93) 85 + 22; 81 (70–96) ,0.0001
EF (%), mean + SD; median (IQR) 31.9 + 13.0; 30 (20–40) 38.0 + 13.3; 38 (28–50) 39.7 + 16.6; 40 (25N55) 39.7 + 15.0; 36 (26–54) ,0.0001
Treated hypertension, % 29.7 61.9 78.7 63.0 ,0.0001
Diabetes mellitus, % 30.7 33.2 38.5 38.3 0.10
History of AF, % 42.1 42.3 44.5 46.4 0.47
ACE-I/ARBs, % 74.3 79.6 79.4 70.3 0.0004
Beta-blockers, % 79.3 85.2 82.1 66.4 ,0.0001
Aldosterone blockers, % 34.3 65.2 32.1 45.3 ,0.0001
ICD, % 7.9 3.9 11.5 7.0 0.0001
CRT-P, % 0.7 0.3 0.9 0.4 0.59
CRT-D, % 4.3 1.8 4.1 4.1 0.03
Ambulatory patients with chronic HF (n 5 3226) n ¼ 501 n ¼ 363 n ¼ 337 n ¼ 2025
Age (years), mean + SD; median (IQR) 68 + 13; 70 (60–78) 64 + 12; 64 (55– 74) 63 + 14; 66 (55–74) 67 + 14; 69 (59–77) ,0.0001
Age ≥70 years, % 52.3 35.3 37.4 48.5 ,0.0001
Females, % 28.5 32.8 30.9 29.2 0.49
Ischaemic aetiology, % 42.9 39.9 40.1 40.0 0.68
BMI (kg/m2), mean + SD; median (IQR) 27 + 5; 27 (23– 30) 29 + 5; 28 (25–32) 28 + 6; 27 (24–31) 28 + 5; 27 (24– 30) ,0.0001
SBP (mmHg), mean + SD; median (IQR) 126 + 21; 125 (110 –140) 132 + 22; 130 (120– 140) 123 + 21; 120 (109 –138) 124 + 19; 120 (110 –140) ,0.0001
HR (b.p.m.), mean + SD; median (IQR) 72 + 15; 70 (60–80) 77 + 16; 75 (65– 83) 71 + 13; 68 (60–78) 71 + 13; 70 (60–78) ,0.0001
EF (%), mean + SD; median (IQR) 33.5 + 10.6; 35 (25–40) 44.0 + 13.0; 45 (35–55) 34.2 + 12.9; 32 (25– 41) 38.7 + 12.7; 37 (30–47) ,0.0001
Treated hypertension, % 35.7 61.1 65.1 62.3 ,0.0001
Diabetes mellitus, % 16.0 28.7 32.9 31.6 ,0.0001
History of AF, % 37.0 47.7 36.7 37.7 0.003
ACE-I/ARBs, % 91.2 91.5 91.1 86.9 0.003
Beta-blockers, % 90.6 89.8 91.4 84.4 ,0.0001
Aldosterone blockers, % 33.3 60.1 45.4 43.1 ,0.0001
ICD, % 6.6 4.7 18.4 15.6 ,0.0001
CRT-P, % 2.4 0.3 0.6 0.9 0.006
CRT-D, % 5.2 1.7 11.9 10.5 ,.0001

811
ACE-I, ACE inhibitors; CRT-D, CRT, defibrillator; CRT-P, CRT pacemaker; HR, heart rate; ICD, implantable cardioverter-defibrillator; IQR, interquartile range; SBP, systolic blood pressure; SD, standard deviation.
812 Acute and chronic heart failure outcomes

than ambulatory patients with chronic HF and more often of

female gender. As expected, some co-morbidities were more fre-
quent in patients admitted for acute HF, while implanted devices
were more common in patients with chronic HF. More than half
of the patients with acute HF had an ischaemic aetiology, con-
firmed by coronary angiography in 64% of the cases. In patients
with chronic HF, ischaemic aetiology accounted for just 41% of
the cases, but the angiographic confirmation was available for
85% of the cases. The percentages of patients with HF with
preserved EF (HF-PEF) (EF ≥ 45%) were 35.5% and 30.5%,
respectively, in hospitalized and in chronic HF patients.
Table 2 reports the baseline characteristics stratified by geo-
graphical area for hospitalized and ambulatory patients.
Regarding hospitalized patients, relevant differences were
observed across the different areas with respect to demographic
and clinical characteristics as well as for pharmacological treat-
ments. Patients from Eastern countries were younger, with more fre-
quent ischaemic aetiology, with a higher systolic blood pressure, and
more frequently treated with blockers of the renin–angiotensin–
aldosterone system. Patients enrolled in Northern countries
showed a significantly lower EF. A significantly lower rate of implan-
table cardioverter defibrillator (ICD) implantation was observed in
Eastern countries.
Similar findings were observed for ambulatory patients, but, in
contrast to hospitalized patients, the use of ACE inhibitors/ARBs
and beta-blockers, even if nominally different, was quite homoge-
neous across all geographical areas, demonstrating a good adher-
ence to current guidelines.
Overall, an ICD, CRT, or CRT-D was implanted significantly less
frequently in the Eastern countries, while a higher rate of implant-
ation was observed in Western and Southern countries.

Clinical events at 1 year

Figure 2 reports the Kaplan –Meier curves for all-cause mortality
(Figure 2A), 1-year hospitalization for HF (Figure 2B), and the
combined measure of all-cause mortality and HF hospitalizations
(Figure 2C) in ambulatory chronic HF and in hospitalized acute
HF. The causes of death and rehospitalization for hospitalized
acute and ambulatory chronic patients are reported in Table 3.
The cumulative total mortality rate at 1-year follow-up was
17.4% in patients with acute HF, while all-cause mortality at Figure 2 Kaplan– Meier curves for all-cause death (A), admis-
1 year for ambulatory patients was 7.2%. sion to hospital for heart failure (HF) (B), and all-cause death
or admission to hospital for HF (C), divided into hospitalized
Patients acutely hospitalized for heart failure patients with acute HF (continuous line) and ambulatory patients
In the hospitalized population, cardiovascular deaths accounted for with chronic HF (dotted line).
66.4% of total deaths, non-cardiovascular deaths for 9.7%, while an
unknown cause was reported in 23.9% of the cases. All-cause
deaths in patients with HF and reduced EF (HF-REF) were at
18.6% at 1 year, while in those with HF-PEF they were 13.4%
(P ¼ 0.009). observation of the patients’ characteristics, patients hospitalized
Patients were readmitted at least once for any cause during the in Eastern countries showed a significantly lower mortality rate.
1-year follow-up in 43.9% of the cases; 36.5% were readmitted for The highest rates of mortality and hospitalizations for HF were
cardiovascular causes and 14.6% for non-cardiovascular causes, observed in the Southern European countries.
while hospitalizations due to HF accounted for 56.4% of the At multivariable analysis (Table 4A), older age, high creatinine,
total hospitalizations (Figure 2B, Table 3). low sodium, lower systolic blood pressure, use of inotropes, low
Table 3 also reports the rate of deaths or hospitalizations at EF, a third heart sound at entry, symptoms of cerebral hypoperfu-
1 year stratified by geographical areas. As expected from the sion, pulmonary and/or peripheral congestion, a history of kidney
A.P. Maggioni et al. 813

Table 3 One-year outcome

Total Northern Eastern Western Southern P-value

...............................................................................................................................................................................
Hospitalized patients (n 5 1892)a n ¼ 1892 n ¼ 140 n ¼ 991 n ¼ 218 n ¼ 543
All-cause death, % 17.4 19.3 13.0 18.4 24.7 ,0.0001
CV death, % 66.4 66.7 71.3 45.0 67.9 0.03
Non-CV death, % 9.7 11.1 4.7 17.5 11.9
Unknown, % 23.9 22.2 24.0 37.5 20.2
All-cause hospitalization, % 43.9 50.0 37.9 53.6 49.7 ,0.0001
HF hospitalization, % 24.8 30.0 20.2 19.6 33.9 ,0.0001
All-cause death or HF hospitalization, % 35.8 43.6 29.1 33.9 46.8 ,0.0001
Ambulatory patients (n 5 3226) n ¼ 3226 n ¼ 501 n ¼ 363 n ¼ 337 n ¼ 2025
All-cause death, % 7.2 9.0 5.0 6.2 7.4 0.13
CV death, % 54.5 46.7 66.7 52.4 55.7 0.59
Non-CV death, % 16.3 13.3 11.1 14.3 18.1
Unknown, % 29.2 40.0 22.2 33.3 26.2
All-cause hospitalization, % 31.9 38.1 33.1 37.7 29.2 ,0.0001
HF hospitalization, % 13.3 13.6 16.0 17.2 12.1 0.03
All-cause death or HF hospitalization, % 17.6 19.4 19.0 21.1 16.4 0.09

CV, cardiovascular; HF, heart failure.

a
A total of 1821 patients were discharged alive.

dysfunction, or a prior HF hospitalization were independently
associated with a higher mortality rate at 1 year. Using as reference
group the Southern geographical area, no significant difference was
observed in terms of 1-year mortality with respect to Western and
Northern areas, while patients admitted to hospital in Eastern
countries showed a significantly lower rate of all-cause death.
Ambulatory patients with chronic heart failure
The all-cause mortality rate at 1 year of chronic stable HF patients
was 7.2% (Figure 2A, Table 3). Patients in NYHA class III –IV showed
a much higher mortality than those in class I– II (13.5% vs. 4.8%,
P , 0.0001). All-cause mortality rates in patients with HF-REF and
of those with HF-PEF were 7.3% and 5.9%, respectively (P ¼ 0.17).
Of the 233 patients with chronic HF who died at 1 year, 54.5%
of deaths were due to cardiovascular causes, 16.3% to non-
cardiovascular causes, and in 29.2% of cases the cause of death
remained unknown. Among the cardiac causes of death, sudden
death occurred in 40.2% of the cases.
The 1-year admission rate was 31.9%: 24.0% due to cardiovascu-
lar causes and 11.4% to non-cardiovascular causes. Of all admis-
sions, 41.7% were due to HF. Again, the mortality rate of
patients followed in Eastern countries appeared to be lower than
that of patients observed in the other European areas. With
respect to hospitalizations due to HF, the highest rate was
observed in the Western countries.
At multivariable analysis (Table 4B), no significant differences were
observed in terms of 1-year all-cause death across the different Euro-
pean regions. Older age, advanced NYHA class, diabetes, chronic
kidney disease, peripheral artery diseases, low sodium level, low
EF, the presence of atrial fibrillation/flutter, pulmonary or peripheral
congestion, and S3 gallop were independently associated with a
higher 1-year all-cause mortality. Higher systolic blood pressure
and to be prescribed ACE inhibitos/ARBs and beta-blockers were
independently associated with a more favourable outcome.
Discussion
The main results of this survey include the clinical findings of
two cohorts of patients, one of chronic stable HF outpatients
and one of hospitalized HF patients. All patients of the two
cohorts were enrolled in the same hospitals by the same inves-
tigators. Both cohorts have been followed up for a year with a
rate of loss to follow-up of 1% in chronic patients and , 5% in
acute patients. This represents an acceptable performance for
an observational study and allows reliable conclusions to be
drawn on clinical evolution, therapy, and patient outcomes.
One-year outcomes
While survival of patients with chronic HF seems to improve
slowly over time in agreement with other data from the litera-
ture,15,16 both in-hospital and 1-year outcomes of patients admit-
ted for acute HF are still very high. This finding can be explained
by the fact that in-hospital therapeutic approaches to these
patients have remained practically unchanged during the last
decades. In contrast, several trials have been conducted in patients
with chronic HF, allowing the inclusion of effective treatments
in the recommendations of current international guidelines,17,18
widely adopted in clinical practice. This is probably the most
important reason for the observed improvement in outcomes.
As expected, the all-cause mortality rate in patients with HF-REF
was lower than that observed in those with HF-REF, but the differ-
ence was statistically significant only in patients hospitalized for
acute HF.
814 Acute and chronic heart failure outcomes

Table 4 Independent predictors of all-cause 1-year mortality

Variable HR (CI 95%) P-value

...............................................................................................................................................................................
(A) Acute heart failurea
Eastern vs. Southern 0.68 (0.53–0.88) 0.003
Northern vs. Southern 1.18 (0.76–1.82) 0.463
Western vs. Southern 1.02 (0.70–1.47) 0.928
Age (per year) 1.03 (1.02–1.04) ,0.0001
Systolic blood pressure (per mmHg) 0.995 (0.991– 0.999) 0.028
Chronic kidney dysfunction 1.48 (1.13–1.95) 0.004
Prior HF hospitalization 1.31 (1.03–1.67) 0.030
Inotropic support 2.00 (1.51–2.65) ,0.0001
Pulmonary/peripheral congestion 2.73 (1.71–4.35) ,0.0001
Confused/somnolent 1.51 (1.11–2.05) 0.009
S3 gallop 1.37 (1.05–1.80) 0.021
EF ,40 vs. ≥40% 1.66 (1.14–2.44) 0.009
Creatinine .1.5 vs. ≤1.5 mg/dL 1.43 (1.10–1.87) 0.007
Sodium ,136 vs. ≥136 mmol/L 1.84 (1.45–2.34) ,0.0001
(B) Chronic heart failureb
Eastern vs. Southern 0.95 (0.55–1.63) 0.844
Northern vs. Southern 1.28 (0.86–1.92) 0.224
Western vs. Southern 0.84 (0.52–1.37) 0.486
Age (per year) 1.04 (1.03–1.05) ,0.0001
NYHA III– IV vs. I–II 1.46 (1.09–1.95) 0.011
Systolic blood pressure (per mmHg) 0.98 (0.97–0.99) ,0.0001
Diabetes 1.59 (1.17–2.17) 0.003
Peripheral vascular disease 1.43 (1.02–2.01) 0.037
Chronic kidney dysfunction 1.48 (1.10–1.99) 0.009
Prescribed ACE inhibitors/ARBs 0.68 (0.49–0.95) 0.022
Prescribed beta-blockers 0.50 (0.36–0.69) ,0.0001
Sodium ,136 vs. ≥136 mmol/L 1.49 (1.03–2.15) 0.034
EF ,40 vs. ≥40% 1.51 (1.10–2.08) 0.010
AF/flutter 1.46 (1.10–1.93) 0.009
Pulmonary/peripheral congestion 1.65 (1.23–2.20) 0.001
S3 gallop 1.70 (1.12–2.61) 0.014

CI, confidence interval; HF, heart failure; HR, hazard ratio.

a
The following variables were inserted in the Cox model (backward selection): geographical area (included in each model), age, gender, systolic blood pressure, chronic heart
disease aetiology, body mass index ,30 kg/m2, diabetes, chronic kidney dysfunction, prior heart failure hospitalization, pulmonary/peripheral congestion at entry, S3 gallop at
entry, confused/somnolent at entry, peripheral hypoperfusion, inotropic support, clinical profiles at hospital entry, haemoglobin at entry ,12 g/dL, creatinine at entry .1.5 mg/
dL, sodium at entry ,136 mmol/L, blood urea nitrogen at entry .50 mg/dL, glycaemia at entry .126 mg/dL, potassium at entry .5.0 mEq/L, QRS at entry ≥120 ms, EF ,40% at
entry, AF (at ECG or history).
b
The following variables were inserted in the Cox model (backward selection): geographical area (included in each model), age, gender, NYHA class, systolic blood pressure, heart
rate, chronic heart disease aetiology, body mass index ,30 kg/m2, diabetes, COPD, peripheral vascular disease, chronic kidney dysfunction, prior heart failure hospitalization,
prior pacemaker, pulmonary/peripheral congestion, S3 gallop, ACE inhibitors/ARBs, beta-blockers, antialdosterone antagonists, haemoglobin ,12 g/dL, creatinine .1.5 mg/dL,
sodium ,136 mmol/L, blood urea nitrogen .50 mg/dL, glycaemia .126 mg/dL, potassium .5.0 mEq/L, QRS ≥120 ms, AF/flutter (at ECG or history), EF ,40%.

The independent determinants of all-cause mortality observed in
this study were in line with those described in previous studies con-
ducted in either hospitalized acute or ambulatory chronic HF.4 – 13 In
hospitalized patients, age, renal function, EF, and systolic blood pres-
sure are confirmed to be relevant prognostic markers, as well as the
presence of pulmonary or peripheral congestion. This suggests the
need to discharge patients only when signs of congestion are com-
pletely resolved and, when this is not possible, specifically to
monitor and intensively care for those patients who are at high
risk of subsequent events.
In chronic ambulatory patients, in addition to the independent
prognostic variables observed in acute HF patients, co-morbidities
such as diabetes, peripheral artery disease, or the presence of AF
seem to play a further negative role.
Differences across regions
Studies evaluating the differences across European regions in patient
characteristics, clinical management, use of resources, and their
association with outcome of patients hospitalized for acute HF are
scarce. An ancillary analysis of the EVEREST trial showed major
A.P. Maggioni et al.
differences across continents in HF severity, aetiology, and treat-
ment among patients hospitalized for acute HF, despite the
context of pre-defined selection criteria of a randomized clinical
trial.19
Similarly to the findings of the EVEREST trial,19 hospitalized
patients enrolled in Eastern European countries seem to have
the lowest risk profile, being younger, with high systolic blood
pressure, and treated more frequently with ACE inibitors/ARBs
and beta-blockers. The differences in HF severity and treatment
could explain the differences in outcome.
The more favourable profile of patients included in the survey in
Eastern countries is also confirmed for ambulatory patients, while
no major differences were observed in terms of use of medical
therapy. However, despite the fact that HF guidelines are similar in
all European regions, there were important differences in device
use across regions, with a significantly lower rate of implantation of
devices (ICD and/or CRT) in Eastern countries. The possible
reasons for this variation have been analysed in previous studies,
and may depend on multiple factors ranging from patient character-
istics to the reimbursement structure of the particular country.10,20
In any case, even if the lowest mortality rate was observed in the
Eastern European population, after adjustment for major covari-
ates, this difference was not confirmed, stressing the importance
on these variables on outcome.
Limitations
Some important limitations of our survey must be acknowledged.
First, criteria for HF diagnosis were discussed during the investiga-
tor meetings, and the Guidelines of reference21 were commented
on and diffused to all investigators. However, the diagnoses were
made by the investigators according to their clinical judgement
and not validated centrally. Secondly, even though we tried to
balance the methodological need for consecutiveness of enrolment
with the practical feasibility by increasing the workload for centres
by limiting recruitment to 1 day per week for 8 months, we cannot
prove the consecutiveness of patient enrolment. Further, a log
of out- and inpatients admitted to the enrolling hospitals was
not available. Thirdly, representativeness is often recognized as a
limitation in observational studies. To limit this issue, the centres
were selected in proportion to the size of the population of the
participating countries, taking into account the different techno-
logical levels of the cardiology centres invited to participate.
Fourthly, the patients were all enrolled in Cardiology wards and
clinics, and they did not include those presenting at the Emergency
Department, and/ or admitted to other hospital facilities. Accord-
ingly, the population reported herein does not represent the uni-
verse of HF patients. Fifthly, the ascertainment of cause of death
was not adjudicated by a formal committee.
Conclusions
The ESC-HF Pilot Survey tried to overcome some of the limita-
tions of previous HF surveys by creating a more representative
setting of centres and countries. In this sense, this study was
very useful for improving the quality of the data set, which has
been refined, allowing the implementation of a pan-European
815
long-term registry that is now ongoing with the inclusion of
nearly 14 000 patients by 30 European countries.
Despite the relatively small size of the survey, some relevant
clinical conclusions can be drawn. Patients hospitalized for acute
HF still have an unacceptably high mortality rate, probably due
to the fact that no effective treatments have been developed and
implemented in practice over the last decades. In contrast, morbid-
ity and mortality were much lower in chronic HF patients, which is
potentially related to the widespread adoption of life-saving
treatments.
Major differences in severity and treatment of patients with
acute or chronic HF exist among European regions, resulting in
varied 1-year outcomes. These variations may be due to different
local medical practice as well to differences in healthcare systems,
and should be taken into account when planning global trials in
patients with HF.
Acknowledgements
The authors would like to thank Donata Lucci and Cécile Laroche
for the statistical analysis, and Barbara Bartolomei Mecatti and
Emanuela Fiorucci for editorial and study assistance.
Funding
The Survey was funded by the ESC. No ad hoc support from industry
was used for this survey. Each participating National Cardiology
Society was granted 10 000 euros for their organizational needs
regarding implementation of the national network. At present the fol-
lowing companies are supporting the EURObservational Research pro-
gramme: Boehringer Ingelheim International, Menarini International,
Sanofi-Aventis Group, Laboratoires Servier; Amgen; Boston Scientific
International.
Conflict of interest: none declared.
Appendix 1. Participating Centres
and Investigators
Executive Committe
Aldo Maggioni (Chairman), Italy; Ulf Dahlström, Sweden; Gerasimos
Filippatos, Greece; Luigi Tavazzi, Italy; Faiez Zannad, France.
Steering Committee (National
Coordinators)
Austria, Friedrich Fruhwald; Denmark, Olav Wendelboe
Nielsen; France, Damien Logeart; Germany, Mathias Rauchhaus;
Greece, John Parissis; Italy, Marco Metra; The Netherlands,
Adriaan Voors; Norway, Lars Gullestad; Poland, Jaroslaw
Drozdz; Romania, Ovidiu Chioncel; Spain, Marisa Crespo
Leiro; Sweden, Ulf Dahlström and Hans Persson.
Oversight Committee
Angeles Alonso, Roberto Ferrari, Michel Komajda, Luigi Tavazzi,
David Wood.
816
EURObservational Research
Programme Team
Malika Manini (Head of Department), Charles Taylor (Data
Monitor), Cécile Laroche (Data Monitor), Emanuela Fiorucci
(Assistant).
Statistical analysis (ANMCO
Research Center, Florence, Italy)
Donata Lucci, Lucio Gonzini.
Participating Centres,
Investigators, and Data Collection
Officers
Austria Braunau: J. Auer; Feldbach: A. Oberrauner; Graz:
F. Fruhwald, M. Schumacher; Linz: C. Ebner; Tulln: A. Hallas.
Denmark Aalborg: G. Espersen; Copenhagen: F. Gustafsson,
N. Mattsson, O. Wendelboe Nielsen; Svendborg: K. Egstrup;
Vejle: S. Aagaard, T. Gohr, K. Huld, A. Sejr Knudsen; Viborg:
J. Refsgaard. France Bobigny: J. Charniot; Briis Sous Forges:
A. Juillard; Cherbourg: P. Pon-Gabrielsen; Paris: F. Douna,
G. Jondeau, D. Logeart; Pontoise: P. Jourdain; Saint Lo: L. Michel.
Germany Bad Nauheim: C. Hamm, S. Lehinant, A. Rieth; Berlin:
O. Goeing, H-P. Schultheiss, J. Von-Schlippenbach; Bützow:
R. Knollmann, C. Neubüser’ Heidelberg: H.A. Katus, T. Taeger,
C. Zugck; Hohenfelde: H. Fink, J. Schulz; Kitzingen: S. Held,
W. Karmann; Limburg: J. Kreuzer, K. Nitsche, K. Winter; Ribnitz-
Damgarten: A. Fahnrich; Rostock: K. Bruederlein, M. Rauchhaus,
C.H. Turan; Sinsheim: J. Berentelg; Stralsund: T. Ittel, C. Rubens;
Wuerzburg: M. Hanke, S. Stoerk. Greece Athens:
C. Chrysohoou, E. Kaldara, A. Karavidas, R. Margari, V. Matzaraki,
J. Nanas, J.T. Parissis, I. Pozios, P. Psarogiannakopoulos,
V. Pyrgakis, C. Stefanadis, J. Terrovitis, A. Trikas, S. Xydonas; Her-
aklion: A. Patrianakos; Heraklion Crete: P. Vardas; Volos:
A. Douras, J. Nastas, K. Ntertsas, T. Tsaknakis. Italy Albano
Laziale: P. Midi, G. Pajes; Ascoli Piceno: L. Moretti, M. Partemi;
Bologna: F. Barberini, A. Branzi, I. Gallelli, F. Grigioni, T. Ionico,
F. Pasquale; Brescia: L. Dei Cas, F. Delmagro, M. Metra,
E. Tanghetti, A. Vaccari; Cagliari: G. Mercuro; Citta Di Castello:
G.M. Arcuri; L. Marinacci, D. Severini; Cortona: F. Cosmi;
Cotignola: S. Bosi, L. Tavazzi; Cremona: G. Di Tano, S. Pirelli;
Ferrara: R. Ferrari, A. Fucili; Firenze: C. Minneci, G.M. Santoro;
Foggia: M. Correale, M. Di Biase; Gubbio: M. Buccolieri,
S. Mandorla, S. Martinelli; Legnago: M. Barbiero; Lumezzane:
A. Giordano, E. Zanelli; Milano: P. Agostoni, C. Fiorentini,
E. Salvioni; Modena: C. Leuzzi, M.G. Modena, L. Reggianini; Pavia:
F. Cobelli, C. Opasich; Poggibonsi: P. Baldini, M. Romei; Reggio Ca-
labria: G. Pulitano, A. Ruggeri; Rimini: F. Bologna, G. Piovaccari;
Roma: B. Brasolin, F. Fedele; Trieste: M. Merlo, G. Sinagra; Udine:
M.C. Albanese, D. Miani; The Netherlands Almelo: G. Linssen,
E. Rodijk; Amsterdam: Y. Pinto, P. Van Donk; Breda:
P. Dunselman; Deventer: D. Lok; Groningen: F. Brouwers, R.M.
De Jong. Norway Alesund: R. Boen, T. Hole, L. Rasmussen;
Acute and chronic heart failure outcomes
Drammen: E.M. Christiansen, E. Gjertsen, J. Lyng; Lillehammer:
M. German, G. Hogalmen; Oslo: L. Gullestad, R. Skardal; Rud:
T. Apelland, M. Figenboum Borgen, E. Forfang; Stavanger:
T. Baak, K. Dickstein, I. Eide Olsen. Poland Belchatow:
D. Stachurski; Biala: Z. Juszczyk, S. Stankala; Bydgoszcz:
W. Gilewski, W. Sinkiewicz; Chelmza: P. Kasztelowicz; Czesto-
chowa: J. Gabryel, P. Kardaszewicz, M. Lazorko-Piega; Gdansk:
J. Bellwon, K. Mosakowska, A. Rynkiewicz; Gostynin-Kruk:
S. Olczyk, M. Pagorek; Kalisz: R. Bartlinski, G. Borej,
J. Tarchalski; Kielce: R. Bartkowiak, B. Sosnowska-Pasiarska,
B. Wozakowska-Kaplon; Kluczbork: A. Krzeminski; Krakow:
K. Bury, A. Grzegorzko, E. Mirek-Bryniarska, J. Nessler,
M. Zabojszcz; Lodz: M. Broncel, J. Drozdz, A. Poliwczak,
A. Retwinski, K. Wojtczak Soska; Poznan: S. Grajek,
E. Straburzynska-Migaj; Rzeszow: J. Kuzniar, T. Rzeszuto; Sieradz:
G. Bednarczyk, P. Ruszkowski; Sochaczew: E. Piasecka-Krysiak,
J. Zambrzycki; Walbrzych: T. Nowak, R. Szelemej; Warszawa:
P. Balsam, A. Folga, A. Kaplon-Cieslicka, S. Kowalewski,
A. Mamcarz, M. Marchel, G. Opolski, M. Welnicki; Wroclaw:
E. Jankowska, P. Ponikowski; Zabrze: J. Nowak,
E. Nowalany-Kozielska, P. Rozentryt, M. Zembala; Zamosc:
A. Kleinrok, G. Prokop-Lewicka; Zielona Góra: B. Kudlinska,
Romania Brasov: M. Radoi; Bucharest: C. Macarie, D. Vinereanu;
Cluj-Napoca: R. Capalneanu; Craiova: A. Giuca, D.D. Ionescu;
Galati: E. Nechita; Iasi: M. Datcu; Slobozia: C. Istrate; Targoviste:
M. Vladoianu; Timisoara: R. Christodorescu. Spain Antequera:
R. Lopez Salguero; Aviles: V.M. Rodriguez Blanco; Barcelona:
M.A. Castel Lavilla, J. Comin-Colet, D. Silva Cantillo; Cartagena:
J. Ortega Bernal; Cordoba: J.M. Arizon del Prado; Cuenca:
A. Melero Pita; Gandia: J. Aguero; La Coruna: M. Crespo-Leiro;
Madrid: J.F. Delgado Jimenez; Marbella: F. Torres Calvo; Monforte:
R. Izquierdo Gonzalez; Oviedo: B. Dı́az Molina; Palma de Mallorca:
D. Cremer Luengos; Pozoblanco: C. Navarro Lostal; Valencia:
L. Almenar Bonet, P. Garcia Gonzalez, F. Ridocci Soriano; Villarreal:
M.J. Bosch Campos. Sweden Jonkoping: P. Karlstrom, I. Nyrinder;
Kristianstad: B. Olsson, T. Pettersson; Lindesberg: A. Stenberg; Lin-
koping: U. Dahlström; Umea: K. Lindmark; Varberg: B. Asserlund.
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