Optimising Heart Failure Therapies in the Acute Setting

Safety Indicators in Patients Receiving High-intensity Care After Hospital Admission for Acute Heart Failure: The STRONG-HF Trial

BACKGROUND

Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) demonstrated the safety and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) with high-intensity care (HIC) compared with usual care in patients hospitalized for acute heart failure (HF). In the HIC group, the following safety indicators were used to guide up-titration: estimated glomerular filtration rate of <30 mL/min/1.73 m2, serum potassium of >5.0 mmol/L, systolic blood pressure (SBP) of <95 mmHg, heart rate of <55 bpm, and N-terminal pro-B-type natriuretic peptide concentration of >10% higher than predischarge values.

METHODS AND RESULTS

We examined the impact of protocol-specified safety indicators on achieved dose of GDMT and clinical outcomes. Three hundred thirteen of the 542 patients in the HIC arm (57.7%) met ≥1 safety indicator at any follow-up visit 1-6 weeks after discharge. As compared with those without, patients meeting ≥1 safety indicator had more severe HF symptoms, lower SBP, and higher heart rate at baseline and achieved a lower average percentage of GDMT optimal doses (mean difference vs the HIC arm patients not reaching any safety indicator, -11.0% [95% confidence interval [CI] -13.6 to -8.4%], P < .001). The primary end point of 180-day all-cause death or HF readmission occurred in 15.0% of patients with any safety indicator vs 14.2% of those without (adjusted hazard ratio 0.84, 95% CI 0.48-1.46, P = .540). None of each of the safety indicators, considered alone, was significantly associated with the primary end point, but an SBP of <95 mm Hg was associated with a trend toward increased 180-day all-cause mortality (adjusted hazard ratio 2.68, 95% CI 0.94-7.64, P = .065) and estimated glomerular filtration rate decreased to <30 mL/min/1.73 m2 with more HF readmissions (adjusted hazard ratio 3.60, 95% CI 1.22-10.60, P = .0203). The occurrence of a safety indicator was associated with a smaller 90-day improvement in the EURO-QoL 5-Dimension visual analog scale (adjusted mean difference -3.32 points, 95% CI -5.97 to -0.66, P = .015).

CONCLUSIONS

Among patients with acute HF enrolled in STRONG-HF in the HIC arm, the occurrence of any safety indicator was associated with the administration of slightly lower GDMT doses and less improvement in quality of life, but with no significant increase in the primary outcome of 180-day HF readmission or death when appropriately addressed according to the study protocol.

New insights in acute heart failure

Acute heart failure (AHF) is a clinical complex disease and a worldwide issue due to its inconsistent diagnosis and poor prognosis. The cornerstone of pathophysiology of AHF is systemic venous congestion, which is led by the underlying structural and functional cardiac condition. Systemic venous congestion is a major target for AHF management because it causes symptoms and organs dysfunction, and is associated with poor prognosis. The mainstay of decongestive therapy is diuresis with intravenous loop diuretics combined with other diuretics including thiazides when necessary, and non-invasive ventilation. The presence of unresolved congestion at discharge can lead heart failure related rehospitalization, and careful follow-up is required especially during "vulnerable phase", several months after discharge. The updated recommendation for management of AHF has been provided by latest guidelines from European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America. Several large studies have currently demonstrated the benefits of guideline-directed oral medical therapies, and trials are ongoing on medication such as selective sodium-glucose transport proteins 2 inhibitors and protocols for congestive therapy. This review aimed to summarize the latest insights in AHF, based primarily on the most recent guidelines and large randomized controlled trials.

Clinical role of intrarenal venous flow patterns in decompensated heart failure with worsening renal function

Introduction

The clinical implication of intrarenal venous flow patterns in decompensated heart failure with worsening renal function is unknown. We aimed to study the relationship between intrarenal venous flow patterns, inferior vena cava volume status, caval index, clinical degree of congestion and the renal outcome in patients with decompensated heart failure and worsening renal function. Secondary objectives were to study the combined endpoint of readmission and mortality rate within 30 days (after the last scan) among intrarenal venous flow patterns and the effect of congestion status on the renal outcome.

Methods

Twenty-three patients admitted for decompensated heart failure (ejection fraction ⩽40%) with worsening renal function (absolute increase in serum creatinine of 26.5 µmol/L or ⩾1.5-fold increment from baseline) were enrolled in this study. A total of 64 scans were performed. Patients were visited on day 0, 2, 4 and 7 (or earlier if discharged). Patients were called 30 days after discharge to evaluate readmission or mortality. Intrarenal venous flow patterns were ranked from continuous, interrupted, biphasic, to monophasic. Clinical congestion was scored from 0 to 7.

Results

Intrarenal venous flow patterns had statistically significant positive correlations with inferior vena cava volume status (Spearman's ρ, 0.51; p < 0.01) and congestion score (ρ, 0.65; p < 0.01) and a significant negative correlation with caval index (ρ, -0.53; p < 0.01). Intrarenal venous flow patterns were not significant in predicting estimated glomerular filtration rate improvement or the combined endpoint. Reduced congestion significantly predicted an estimated glomerular filtration rate improvement on the following scan day (p = 0.04, odds ratio = 4.3, 95% confidence interval = 1.1-17.2).

Conclusion

Although intrarenal venous flow patterns correlate with other congestive parameters, clinical congestion status rather than intrarenal venous flow patterns predicted the renal outcome.

Assessing Correlation Between Thoracic Impedance and Remotely Monitored Pulmonary Artery Pressure in Chronic Systolic Heart Failure

Background

Heart failure (HF) readmission continues to be a major health problem. Monitoring pulmonary artery pressure (PAP) and thoracic impedance (TI) are the two modalities utilized for early identification of decompensation in HF patients. We aimed to assess the correlation between these two modalities in patients who simultaneously had both the devices.

Methods

Patients with history of New York Heart Association class III systolic HF with a pre-implanted intracardiac defibrillator (ICD) capable of monitoring TI and pre-implanted CardioMEMs™ remote HF monitoring device were included. Hemodynamic data including TI and PAPs were measured at baseline and then weekly. Weekly percentage change was then calculated as: Weekly percentage change = (week 2 - week1)/week 1 × 100. Variability between the methods was expressed by Bland-Altman analysis. Significance was determined as a P-value < 0.05.

Results

Nine patients met the inclusion criteria. There was no significant correlation between the assessed weekly percentage changes in pulmonary artery diastolic pressure (PAdP) and TI measurements (r = -0.180, P = 0.065). Using Bland-Altman analytic methods, both methods had no significant difference in agreement (0.011±0.094%, P = 0.215). With the linear regression model applied for Bland-Altman analysis, the two methods appeared to have proportional bias without agreement (unstandardized beta-coefficient of 1.91, t 22.9, P ≤ 0.001).

Conclusion

Our study demonstrated that variations exist between measurement of PAdP and TI; however, there is no significant correlation between weekly variations between them.

Efficacy and Safety of Shenfu Injection on Acute Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

The adjunctive efficacy and safety of Shenfu Injection (SFI) for acute heart failure (AHF) still remains ambiguous even though previous studies made initial conclusions.

OBJECTIVE

To comprehensively evaluate the adjunctive efficacy and safety of SFI in the treatment of AHF.

STUDY DESIGN

This was a meta-analysis and systematic review.

METHODS

8 databases were searched for qualified randomized controlled trials (RCTs) from May 1990 to May 2022. The primary results included total clinical effective rate (TCER) and left ventricular ejection fraction (LVEF). The secondary results included left ventricular end diastolic dimension (LVEDD), heart rate (HR), N-terminal pro-B-type natriuretic peptide (NT-proBNP), brain natriuretic peptide (BNP) and adverse events (AE). The quality evaluation, meta-analysis, sensitivity analysis, subgroup analysis and publication bias were conducted by RevMan5.3 software. Meta-regression analysis was conducted using Stata software 15.0, and trial sequential analyses (TSA) was performed by TSA program. Finally, the GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) system was applied for evaluating the quality of evidence.

RESULTS

61 RCTs containing 5505 AHF patients were included. The meta results demonstrated SFI combined with conventional western treatment (CWT) for AHF was superior to CWT alone in improving the TCER (RR = 1.21; 95% CI (1.18, 1.24); p < 0.001), improving LVEF (SMD = 0.85; 95% CI (0.77,0.92); p < 0.001) and reducing HR (SMD = -0.67; 95% CI (0.80, -0.54) p < 0.001). It had a lower AE rate in the SFI+CWT group (27/753, 3.59%) than the CWT group (68/739, 9.20%) (RR = 0.40; 95% CI (0.26, 0.61); p < 0.001). The outcomes' evidentiary quality of TCER, HR, LVEF and AE were assessed as moderate.

CONCLUSION

Adjunctive use of SFI was safer to improve TCER and heart function of AHF, but the results should be interpreted with cautious for clinical practice until high quality-designed RCTs were require for further confirmation due to poor quality of part of the included studies.

Long COVID: post-acute sequelae of COVID-19 with a cardiovascular focus

Emerging as a new epidemic, long COVID or post-acute sequelae of coronavirus disease 2019 (COVID-19), a condition characterized by the persistence of COVID-19 symptoms beyond 3 months, is anticipated to substantially alter the lives of millions of people globally. Cardiopulmonary symptoms including chest pain, shortness of breath, fatigue, and autonomic manifestations such as postural orthostatic tachycardia are common and associated with significant disability, heightened anxiety, and public awareness. A range of cardiovascular (CV) abnormalities has been reported among patients beyond the acute phase and include myocardial inflammation, myocardial infarction, right ventricular dysfunction, and arrhythmias. Pathophysiological mechanisms for delayed complications are still poorly understood, with a dissociation seen between ongoing symptoms and objective measures of cardiopulmonary health. COVID-19 is anticipated to alter the long-term trajectory of many chronic cardiac diseases which are abundant in those at risk of severe disease. In this review, we discuss the definition of long COVID and its epidemiology, with an emphasis on cardiopulmonary symptoms. We further review the pathophysiological mechanisms underlying acute and chronic CV injury, the range of post-acute CV sequelae, and impact of COVID-19 on multiorgan health. We propose a possible model for referral of post-COVID-19 patients to cardiac services and discuss future directions including research priorities and clinical trials that are currently underway to evaluate the efficacy of treatment strategies for long COVID and associated CV sequelae.

Pulmonary Embolism and Heart Failure: A Reappraisal

Acute heart failure and acute pulmonary embolism share many features, including epidemiological aspects, clinical presentation, risk factors and pathobiological mechanisms. As such, it is not surprising that diagnosis and management of these common conditions might be challenging for the treating physician, in particular when both are concomitantly present. While helpful guidelines have been elaborated for both acute heart failure and pulmonary embolism, not many studies have been published on the coexistence of these diseases. With a special focus on diagnostic tools and therapeutic options, the authors review the available literature and, when evidence is lacking, present their own approach to the management of dyspnoeic patients with acute heart failure and pulmonary embolism.

Nurse-led ambulatory care supported by non-invasive haemodynamic assessment after acute heart failure decompensation

Heart failure (HF) is characterized by frequent decompensation and an unpredictable trajectory. To prevent early hospital readmission, coordinated discharge planning and individual therapeutic approach are recommended.

Aims

We aimed to assess the effect of 1 month of ambulatory care, led by nurses and supported by non‐invasive haemodynamic assessment, on the functional status, well‐being, and haemodynamic status of patients post‐acute HF decompensation.

Methods and results

This study had a multicentre, prospective, and observational design and included patients with at least one hospitalization due to acute HF decompensation within 6 months prior to enrolment. The 1 month ambulatory care included three visits led by a nurse when the haemodynamic state of each patient was assessed non‐invasively by impedance cardiography, including thoracic fluid content assessment. The pharmacotherapy was modified basing on haemodynamic assessment. Sixty eight of 73 recruited patients (median age = 67 years; median left ventricular ejection fraction = 30%) finished 1 month follow‐up. A significant improvement was observed in both the patients' functional status as defined by New York Heart Association class (P = 0.013) and sense of well‐being as evaluated by a visual analogue score (P = 0.002). The detailed patients' assessment on subsequent visits resulted in changes of pharmacotherapy in a significant percentage of patients (Visit 2 = 39% and Visit 3 = 44%).

Conclusions

The proposed model of nurse‐led ambulatory care for patients after acute HF decompensation, with consequent assessment of the haemodynamic profile, resulted in: (i) improvement in the functional status, (ii) improvement in the well‐being, and (iii) high rate of pharmacotherapy modifications.

Assessing congestion in acute heart failure using cardiac and lung ultrasound - a review

Introduction: Acute heart failure (AHF) is one of the leading causes of hospital admissions and is characterized by systemic and pulmonary congestion, which often precedes the overt clinical signs and symptoms. Echocardiography in the management of chronic HF is well described; however, there are less evidence regarding echocardiography and lung ultrasound (LUS) in the acute setting.Areas covered: We have summarized current evidence regarding the use of echocardiography and LUS for assessing congestion in patients with AHF. We discuss the value and reliability of handheld/pocketsize ultrasound devices in AHF.Expert opinion: Echocardiography is an essential tool for the diagnostic work up in patients with AHF. No individual parameter reliably detects congestion, thus the physician must integrate several measurements from the right and left heart. Novel methods and advances in cardiac imaging and clinical chemistry make it possible to detect congestion at an early stage. LUS is particularly helpful in assessing congestion, and it has demonstrated diagnostic, therapeutic, and prognostic value in AHF. LUS is relatively easy to learn and allows for quick assessment of the presence of pulmonary congestion and pleural effusion. We recommend integration of LUS for routine management of patients with AHF.

Acute heart failure – The ‘real’ Malaysian experience: An observational study from a single non-cardiac centre

Background:

Cardiovascular care in Malaysia adopts a ‘spoke-and-hub’ model, leaving the majority of acute heart failure (AHF) care to non-cardiac centres. Granular data on AHF care are essential and yet remain scarce.

Objectives:

This study aimed to illustrate the baseline characteristics, management and outcome of AHF patients.

Methods:

A retrospective, cross-sectional study was conducted on 1307 AHF patients admitted between 1 January 2012 and 31 December 2016.

Results:

The younger and Malay-predominant population reflects the distribution of ischaemic heart disease in Malaysia, highlighting the need to tackle metabolic risks factors. The majority are precipitated by ischaemia (61.8%). Common co-morbidities include hypertension (70.9%), coronary artery disease (57.8%) and diabetes (62.2%). The majority were of New York Heart Association Class II (31.9%) and Class III (25.6%). A total of 14.5% required inotropes and vasopressors, 12.9% required intravenous nitrates and 8.6% required dialysis. A further 4.9% of patients required intubation and mechanical ventilation, and 25.9% required non-invasive ventilation. Readmission and mortality were extremely high in our population. Short inpatient stays, restricting optimisation of medication, and gaps in the provision of coronary intervention and stress testing are possible contributing factors. When compared to global and regional registries, disparities were noted specifically surrounding mortality rate and optimum use of guideline-directed medical therapy.

Conclusion:

Although smaller and single centred, our study provides a unique insight into a pure Malaysian-only cohort from a hospital with no cardiology services in-house, which is more reflective of the majority of hospitals in Malaysia, unlike previous studies and registries.

Chrysophanol Protects Against Acute Heart Failure by Inhibiting JNK1/2 Pathway in Rats

BACKGROUND Acute heart failure (AHF) usually requires urgent therapy. Myocardial damage, oxidative stress, and inflammation are major components in the pathology of AHF. This study was designed to investigate the effects of chrysophanol on AHF. MATERIAL AND METHODS Sprague-Dawley rats were injected with isoprenaline hydrochloride to construct AHF rat models. AHF rats were treated with normal saline (negative control), chrysophanol, the combination of chrysophanol and SP600125, or benazepril (positive control) using sham rats as blank controls. Echocardiography, histological staining, and enzyme activity analysis were performed to assess the heart functions and myocardial damage. Effects on apoptosis, oxidative stress (OS), and inflammation were evaluated by biochemical analysis, TUNEL staining, and ELISA. RESULTS Chrysophanol improved the parameters of cardiac functions and alleviated the myocardial damage accompanied by the reduction of creatine kinase and lactate dehydrogenase activity. Meanwhile, chrysophanol inhibited the myocardial apoptosis along with the upregulation of Bcl-2 and downregulation of Bax and cleaved caspase-3. AHF-induced abnormal changes of OS parameters (MDA, GPx, CAT, SOD) and inflammatory markers (IL-6, IL-1ß, TNF-alpha, IFN-γ) were alleviated by chrysophanol. Benazepril treatment showed similar results with chrysophanol, while the addition of SP600125 enhanced the chrysophanol-mediated protection effects in AHF rats. Western blot analysis demonstrated that chrysophanol inhibited the phosphorylation of JNK1/2 and its upstream/downstream factors. CONCLUSIONS Chrysophanol improved cardiac functions and protected against myocardial damage, apoptosis, OS, and inflammation by inhibiting activation of the JNK1/2 pathway in AHF rat models. These finding indicate that chrysophanol may be a promising approach for treatment of AHF.

Acute heart failure

Acute heart failure (AHF) is a syndrome defined as the new onset (de novo heart failure (HF)) or worsening (acutely decompensated heart failure (ADHF)) of symptoms and signs of HF, mostly related to systemic congestion. In the presence of an underlying structural or functional cardiac dysfunction (whether chronic in ADHF or undiagnosed in de novo HF), one or more precipitating factors can induce AHF, although sometimes de novo HF can result directly from the onset of a new cardiac dysfunction, most frequently an acute coronary syndrome. Despite leading to similar clinical presentations, the underlying cardiac disease and precipitating factors may vary greatly and, therefore, the pathophysiology of AHF is highly heterogeneous. Left ventricular diastolic or systolic dysfunction results in increased preload and afterload, which in turn lead to pulmonary congestion. Fluid retention and redistribution result in systemic congestion, eventually causing organ dysfunction due to hypoperfusion. Current treatment of AHF is mostly symptomatic, centred on decongestive drugs, at best tailored according to the initial haemodynamic status with little regard to the underlying pathophysiological particularities. As a consequence, AHF is still associated with high mortality and hospital readmission rates. There is an unmet need for increased individualization of in-hospital management, including treatments targeting the causative factors, and continuation of treatment after hospital discharge to improve long-term outcomes.

Association of Arterial Hypertension with Hepatobiliary Pathology: The Occurrence of Comorbidity and Features of Metabolic Processes

Comorbidity of hypertension and hepatobiliary pathology has negative medical and social consequences, including an increase in the indicators of hospital admissions, disability and mortality.

OBJECTIVE

The aim was to study the occurrence of hypertension combined with hepatobiliary diseases depending on social status, gender and age in 2003-2017 and their influence on indicators of metabolic processes in patients with a therapeutic profile.

METHODS

A cross-sectional study using the inpatients' medical record database of the clinic of Federal Research Centre for Basic and Translational Medicine (Novosibirsk, Russia), which collects demographics, diagnoses (using ICD-10 codes), procedures and examinations of all inpatients from 2003-2017 was conducted. The incidence of comorbidity of hypertension and hepatobiliary pathology depending on age, gender and social status, based on the analysis of 13496 medical records was examined. A comparative analysis of biochemical parameters characterizing the main types of metabolism (lipid, protein, carbohydrate and purine) was carried out in 3 groups of patients: with hypertension; with hepatobiliary pathology, and with a combined pathology.

RESULTS

During the years 2003-2005, there was the greatest frequency of this comorbidity in workers, in women, in the age group 60 years and older. In 2009-2017, the highest incidence was observed in the male administrative staff. In patients with this comorbidity, more pronounced changes in carbohydrate, protein, lipid and purine metabolism were found in comparison with groups of patients with isolated diseases.

CONCLUSION

The results highlight the need to improve the system of prevention and treatment of comorbidity taking into account sex, age, occupation and features of metabolism.

Producing an effective care plan in advanced heart failure

An effective discharge plan is associated with better outcomes in advanced heart failure (HF) patients. Furthermore, a patient-centred care planning can improve patients' satisfaction, quality of life, and enhance self-care. Telemedicine may allow optimized monitoring of advanced HF patients. Nevertheless, its implementation into clinical practice across European countries is still limited. This document reflects the key points discussed concerning effective management plans in advanced HF by a panel of experts during a Heart Failure Association meeting on physiological monitoring of the complex multimorbid HF patient.

Renal function, electrolytes, and congestion monitoring in heart failure

Congestion, renal function, and electrolyte imbalance (particularly potassium) are common problems in the management of the complex multi-morbid patient with heart failure (HF). Poor control of these fundamental clinical features is associated with adverse outcomes. Close monitoring of serum potassium and renal function is recommended by most current guidelines during the management of an episode of acute decompensated HF, yet the recommendations remain poorly implemented. Physicians are advised to treat a state of euvolaemia after an admission with decompensated HF and residual congestion is a marker of worse outcome, yet control of congestion is poorly assessed and managed in real-world practice. This document reflects the key points discussed by a panel of experts during a Heart Failure Association meeting on physiological monitoring of the complex multi-morbid HF patient, and here, we present to aspects related to renal function, electrolyte, and congestion monitoring.

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study

OBJECTIVE

To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation.

METHODS

Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units.

RESULTS

We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6-10 days, 1287 (15.0%) 11-15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk.

CONCLUSIONS

Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments.

Safety, Tolerability and efficacy of Rapid Optimization, helped by NT-proBNP and GDF-15, of Heart Failure therapies (STRONG-HF): rationale and design for a multicentre, randomized, parallel-group study

AIMS

Patients admitted for acute heart failure (HF) are at high risk of readmission and death, especially in the 90 days following discharge. We aimed to assess the safety and efficacy of early optimization of oral HF therapy with beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) or angiotensin receptor-neprilysin inhibitors (ARNi), and mineralocorticoid receptor antagonists (MRA) on 90-day clinical outcomes in patients admitted for acute HF.

METHODS

In a multicentre, randomized, open-label, parallel-group study, a total of 900 patients will be randomized in a 1:1 ratio to either 'usual care' or 'high-intensity care'. Patients enrolled in the usual care arm will be discharged and managed according to usual clinical practice at the site. In the high-intensity care arm, doses of oral HF medications - including a BB, ACEi or ARB, and MRA - will be up-titrated to 50% of recommended doses before discharge and to 100% of recommended doses within 2 weeks of discharge. Up-titration will be delayed if the patients develop worsening symptoms and signs of congestion, hyperkalaemia, hypotension, bradycardia, worsening of renal function or significant increase in N-terminal pro-B-type natriuretic peptide between visits. The primary endpoint is 90-day all-cause mortality or HF readmission.

CONCLUSIONS

STRONG-HF is the first study to assess whether rapid up-titration of evidence-based guideline-recommended therapies with close follow-up in a large cohort of patients discharged from an acute HF admission is safe and can affect adverse outcomes during the first 90 days after discharge.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03412201.