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The syndrome of heart failure has reached worldwide epidemic proportions. Five million Americans currently have heart failure, with 550,000 new cases diagnosed annually [1]. The prevalence of heart failure is predicted to double to 10 million cases by 2037. Heart failure primarily is a syndrome of the elderly and is uncommon below 50 years of age. Heart failure accounts for 20% of all hospitalizations over 65 years and is the single largest expense for the Center for Medicare Services (CMS) in the USA. Approximately 1 million patients are hospitalized each year with cardiac decompensation, and heart failure accounts for approximately 280,000 deaths annually. Five-year mortality approaches 50% for patients with mild-to-moderate heart failure, whereas half of those with severe heart failure are deceased within 2 years [1].
Hospitalizations due to acutely decompensated heart failure (ADHF) have increased steadily for the last three decades in both men and women [1]. These admissions have increased due to a number of factors (Box 1). Heart failure accounted for an estimated US$25.8 billion in expenses in 2004 in the USA [1]. 60% of heart failure costs are related to in-patient care. Most hospitals sustain financial losses with each heart failure admission because fixed costs exceed reimbursement rates [2]. Contrary to common perceptions, the primary determinant of hospital costs is length of stay, not pharmacy, laboratory and radiology costs [3]. Initiatives that shorten the length of stay may result in savings for hospitals and for patients with cardiac decompensation (Box 2). The mean hospital length of stay for heart failure is currently 4.3 days, and in-hospital mortality averages 4% [4]. Approximately 50% of patients with heart failure are readmitted within 6 months, the highest readmission rate of any discharge (DRG) diagnosis [5]. Furthermore, their 1-year mortality rate ranges from 20-45% [1,6,7]. Thus, current management practices for ADHF are less than ideal.
The Acute Decompensated Heart Failure National Registry (ADHERE) registry has provided valuable information about the demographics, treatment, and outcomes of patients admitted to the hospital with ADHF [4]. Data have been collected from more than 150,000 patients in over 285 academic and community-based hospitals across the USA. Registry patients who were hospitalized with ADHF were elderly (average 75 years old) and had a wide range of comorbid conditions...