Acute heart failure (HF) leads to more than 1 million hospitalizations in the United States each year, and the 1-year mortality rate after these events ranges between 20% and 30%. “Some of these patients will experience worsening HF during their hospitalization, showing signs or symptoms that require therapy to be escalated,” says Adam D. DeVore, MD. Although worsening HF has been used as an endpoint in many clinical trials, few data are available that look at the prevalence of worsening in-hospital HF and its associated outcomes.

In a study published in the Journal of the American Heart Association, Dr. DeVore and colleagues used inpatient data from the Acute Decompensated Heart Failure National Registry to examine the prevalence and outcomes of patients with worsening HF, which was defined as requiring escalation of therapy at least 12 hours after patients present to the hospital. “Our study was unique in that it provided ‘real world’ data on these patients,” says Dr. DeVore. Patients with worsening HF were compared with those who had an uncomplicated hospital course and those who had a complicated presentation.

Assessing Outcomes

“Our study showed that 11% of patients with acute HF developed in-hospital worsening HF,” says Dr. DeVore. Those with worsening HF in the hospital had the highest rates of mortality, all-cause readmission, and Medicare payments at 30 days and 1 year after being hospitalized. These patients also had worse post-discharge outcomes and higher costs when compared with patients who had uncomplicated hospital courses and with those who had complicated presentations.


When compared with an uncomplicated hospital course, worsening in-hospital HF was associated with more than a two-fold greater mortality risk at 30 days as well as a 24% higher risk of all-cause readmission at 30 days. It was also associated with 35% higher post-discharge Medicare payments at 30 days, and 22 fewer days alive and out of the hospital when assessed at 1 year. When compared with complicated presentations, worsening in-hospital HF had a 29% greater mortality risk at 30 days, an 11% higher risk of all-cause readmission at 30 days, 11% higher post-discharge Medicare payments at 30 days, and 11 fewer days alive and out of the hospital at 1 year.

Important Implications

The findings have important implications for patients hospitalized with acute HF. Prevention of AF that worsens in the hospital may be an important endpoint in future trials and should be considered in the design of such studies. “Early recognition of acute HF that worsens during hospitalization may improve outcomes and reduce the use of healthcare resources,” Dr. DeVore says. “Clinicians should consider the impact of these events on patients’ prognosis both in the hospital and after discharge.”