Sex- and age-related differences in the management and outcomes of chronic heart failure: an analysis of patients from the ESC HFA EORP Heart Failure Long-Term Registry

Aims: This study aimed to assess age- and sex-related differences in management and 1-year risk for all-cause mortality and hospitalization in chronic heart failure (HF) patients. Methods and results: Of 16 354 patients included in the European Society of Cardiology Heart Failure Long-Term Registry, 9428 chronic HF patients were analysed [median age: 66 years; 28.5% women; mean left ventricular ejection fraction (LVEF) 37%]. Rates of use of guideline-directed medical therapy (GDMT) were high (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists: 85.7%, 88.7% and 58.8%, respectively). Crude GDMT utilization rates were lower in women than in men (all differences: P\ua0 64 0.001), and GDMT use became lower with ageing in both sexes, at baseline and at 1-year follow-up. Sex was not an independent predictor of GDMT prescription; however, age >75 years was a significant predictor of GDMT underutilization. Rates of all-cause mortality were lower in women than in men (7.1% vs. 8.7%; P\ua0=\ua00.015), as were rates of all-cause hospitalization (21.9% vs. 27.3%; P\ua075 years. Conclusions: There was a decline in GDMT use with advanced age in both sexes. Sex was not an independent predictor of GDMT or adverse outcomes. However, age >75 years independently predicted lower GDMT use and higher all-cause mortality in patients with LVEF 6445%

EURObservational Research Programme: Regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot)

AimsThe 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.MethodsThe 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.ConclusionThe 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

EURObservational Research Programme: Regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot)

AimsThe 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.MethodsThe 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.ConclusionThe 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. © 2013 The Author

Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC-EORP Heart Failure Long-Term Registry

Aims: Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes. Methods and results: We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25–80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363–419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12–2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96–1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33–1.07; P = 0.083) and cardiovascular mortality (HR 0.62,. 95% CI 0.38–1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01–1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09–0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29–0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37–0.87; P = 0.008) were independently associated with successful decrease. Conclusion: Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease. © 2020 European Society of Cardiolog

Acute heart failure congestion and perfusion status – impact of the clinical classification on in-hospital and long-term outcomes; insights from the ESC-EORP-HFA Heart Failure Long-Term Registry

none614siAims: Classification of acute heart failure (AHF) patients into four clinical profiles defined by evidence of congestion and perfusion is advocated by the 2016 European Society of Cardiology (ESC)guidelines. Based on the ESC-EORP-HFA Heart Failure Long-Term Registry, we compared differences in baseline characteristics, in-hospital management and outcomes among congestion/perfusion profiles using this classification. Methods and results: We included 7865 AHF patients classified at admission as: ‘dry-warm’ (9.9%), ‘wet-warm’ (69.9%), ‘wet-cold’ (19.8%) and ‘dry-cold’ (0.4%). These groups differed significantly in terms of baseline characteristics, in-hospital management and outcomes. In-hospital mortality was 2.0% in ‘dry-warm’, 3.8% in ‘wet-warm’, 9.1% in ‘dry-cold’ and 12.1% in ‘wet-cold’ patients. Based on clinical classification at admission, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.78 (1.43–2.21) and ‘wet-cold’ vs. ‘wet-warm’ 1.33 (1.19–1.48). For profiles resulting from discharge classification, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.46 (1.31–1.63) and ‘wet-cold’ vs. ‘wet-warm’ 2.20 (1.89–2.56). Among patients discharged alive, 30.9% had residual congestion, and these patients had higher 1-year mortality compared to patients discharged without congestion (28.0 vs. 18.5%). Tricuspid regurgitation, diabetes, anaemia and high New York Heart Association class were independently associated with higher risk of congestion at discharge, while beta-blockers at admission, de novo heart failure, or any cardiovascular procedure during hospitalization were associated with lower risk of residual congestion. Conclusion: Classification based on congestion/perfusion status provides clinically relevant information at hospital admission and discharge. A better understanding of the clinical course of the two entities could play an important role towards the implementation of targeted strategies that may improve outcomes.noneChioncel O.; Mebazaa A.; Maggioni A.P.; Harjola V.-P.; Rosano G.; Laroche C.; Piepoli M.F.; Crespo-Leiro M.G.; Lainscak M.; Ponikowski P.; Filippatos G.; Ruschitzka F.; Seferovic P.; Coats A.J.S.; Lund L.H.; Auer J.; Ablasser K.; Fruhwald F.; Dolze T.; Brandner K.; Gstrein S.; Poelzl G.; Moertl D.; Reiter S.; Podczeck-Schweighofer A.; Muslibegovic A.; Vasilj M.; Fazlibegovic E.; Cesko M.; Zelenika D.; Palic B.; Pravdic D.; Cuk D.; Vitlianova K.; Katova T.; Velikov T.; Kurteva T.; Gatzov P.; Kamenova D.; Antova M.; Sirakova V.; Krejci J.; Mikolaskova M.; Spinar J.; Krupicka J.; Malek F.; Hegarova M.; Lazarova M.; Monhart Z.; Hassanein M.; Sobhy M.; El Messiry F.; El Shazly A.H.; Elrakshy Y.; Youssef A.; Moneim A.A.; Noamany M.; Reda A.; Dayem T.K.A.; Farag N.; Halawa S.I.; Hamid M.A.; Said K.; Saleh A.; Ebeid H.; Hanna R.; 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Cerdena I.L.; Baldomero I.F.H.; Padron A.L.; Rosillo S.O.; Gonzalez-Gallarza R.D.; Montanes O.S.; Manjavacas A.M.I.; Conde A.C.; Araujo A.; Soria T.; Garcia-Pavia P.; Gomez-Bueno M.; Cobo-Marcos M.; Alonso-Pulpon L.; Cubero J.S.; Sayago I.; Gonzalez-Segovia A.; Briceno A.; Subias P.E.; Hernandez M.V.; Cano M.J.R.; Sanchez M.A.G.; Jimenez J.F.D.; Garrido-Lestache E.B.; Pinilla J.M.G.; de la Villa B.G.; Sahuquillo A.; Marques R.B.; Calvo F.T.; Perez-Martinez M.T.; Gracia-Rodenas M.R.; Garrido-Bravo I.P.; Pastor-Perez F.; Pascual-Figal D.A.; Molina B.D.; Orus J.; Gonzalo F.E.; Bertomeu V.; Valero R.; Martinez-Abellan R.; Quiles J.; Rodrigez-Ortega J.A.; Mateo I.; ElAmrani A.; Fernandez-Vivancos C.; Valero D.B.; Almenar-Bonet L.; Sanchez-Lazaro I.J.; Marques-Sule E.; Facila-Rubio L.; Perez-Silvestre J.; Garcia-Gonzalez P.; Ridocci-Soriano F.; Garcia-Escriva D.; Pellicer-Cabo A.; de la Fuente Galan L.; Diaz J.L.; Platero A.R.; Arias J.C.; Blasco-Peiro T.; Julve M.S.; Sanchez-Insa E.; Aured-Guallar C.; Portoles-Ocampo A.; Melin M.; Hagglund E.; Stenberg A.; Lindahl I.-M.; Asserlund B.; Olsson L.; Dahlstrom U.; Afzelius M.; Karlstrom P.; Tengvall L.; Wiklund P.-A.; Olsson B.; Kalayci S.; Temizhan A.; Cavusoglu Y.; Gencer E.; Yilmaz M.B.; Gunes H.Chioncel, O.; Mebazaa, A.; Maggioni, A. P.; Harjola, V. -P.; Rosano, G.; Laroche, C.; Piepoli, M. F.; Crespo-Leiro, M. G.; Lainscak, M.; Ponikowski, P.; Filippatos, G.; Ruschitzka, F.; Seferovic, P.; Coats, A. J. S.; Lund, L. H.; Auer, J.; Ablasser, K.; Fruhwald, F.; Dolze, T.; Brandner, K.; Gstrein, S.; Poelzl, G.; Moertl, D.; Reiter, S.; Podczeck-Schweighofer, A.; Muslibegovic, A.; Vasilj, M.; Fazlibegovic, E.; Cesko, M.; Zelenika, D.; Palic, B.; Pravdic, D.; Cuk, D.; Vitlianova, K.; Katova, T.; Velikov, T.; Kurteva, T.; Gatzov, P.; Kamenova, D.; Antova, M.; Sirakova, V.; Krejci, J.; Mikolaskova, M.; Spinar, J.; Krupicka, J.; Malek, F.; Hegarova, M.; Lazarova, M.; Monhart, Z.; Hassanein, M.; Sobhy, M.; El Messiry, F.; El Shazly, A. H.; Elrakshy, Y.; Youssef, A.; Moneim, A. A.; Noamany, M.; Reda, A.; Dayem, T. K. A.; Farag, N.; Halawa, S. I.; Hamid, M. A.; Said, K.; Saleh, A.; Ebeid, H.; Hanna, R.; Aziz, R.; Louis, O.; Enen, M. A.; Ibrahim, B. S.; Nasr, G.; Elbahry, A.; Sobhy, H.; Ashmawy, M.; Gouda, M.; Aboleineen, W.; Bernard, Y.; Luporsi, P.; Meneveau, N.; Pillot, M.; Morel, M.; Seronde, M. -F.; Schiele, F.; Briand, F.; Delahaye, F.; Damy, T.; Eicher, J. -C.; de Groote, P.; Fertin, M.; Lamblin, N.; Isnard, R.; Lefol, C.; Thevenin, S.; Hagege, A.; Jondeau, G.; Logeart, D.; Le Marcis, V.; Ly, J. -F.; Coisne, D.; Lequeux, B.; Le Moal, V.; Mascle, S.; Lotton, P.; Behar, N.; Donal, E.; Thebault, C.; Ridard, C.; Reynaud, A.; Basquin, A.; Bauer, F.; Codjia, R.; Galinier, M.; Tourikis, P.; Stavroula, M.; Tousoulis, D.; Stefanadis, C.; Chrysohoou, C.; Kotrogiannis, I.; Matzaraki, V.; Dimitroula, T.; Karavidas, A.; Tsitsinakis, G.; Kapelios, C.; Nanas, J.; Kampouri, H.; Nana, E.; Kaldara, E.; Eugenidou, A.; Vardas, P.; Saloustros, I.; Patrianakos, A.; Tsaknakis, T.; Evangelou, S.; Nikoloulis, N.; Tziourganou, H.; Tsaroucha, A.; Papadopoulou, A.; Douras, A.; Polgar, L.; Merkely, B.; Kosztin, A.; Nyolczas, N.; Nagy, A. C.; Halmosi, R.; Elber, J.; Alony, I.; Shotan, A.; Fuhrmann, A. V.; Amir, O.; Romano, S.; Marcon, S.; Penco, M.; Di Mauro, M.; Lemme, E.; Carubelli, V.; Rovetta, R.; Metra, M.; Bulgari, M.; Quinzani, F.; Lombardi, C.; Bosi, S.; Schiavina, G.; Squeri, A.; Barbieri, A.; Di Tano, G.; Pirelli, S.; Ferrari, R.; Fucili, A.; Passero, T.; Musio, S.; Di Biase, M.; Correale, M.; Salvemini, G.; Brognoli, S.; Zanelli, E.; Giordano, A.; Agostoni, P.; Italiano, G.; Salvioni, E.; Copelli, S.; Modena, M. G.; Reggianini, L.; Valenti, C.; Olaru, A.; Bandino, S.; Deidda, M.; Mercuro, G.; Dessalvi, C. C.; Marino, P. N.; Di Ruocco, M. V.; Sartori, C.; Piccinino, C.; Parrinello, G.; Licata, G.; Torres, D.; Giambanco, S.; Busalacchi, S.; Arrotti, S.; Novo, S.; Inciardi, R. M.; Pieri, P.; Chirco, P. R.; Galifi, M. A.; Teresi, G.; Buccheri, D.; Minacapelli, A.; Veniani, M.; Frisinghelli, A.; Priori, S. G.; Cattaneo, S.; Opasich, C.; Gualco, A.; Pagliaro, M.; Mancone, M.; Fedele, F.; Cinque, A.; Vellini, M.; Scarfo, I.; Romeo, F.; Ferraiuolo, F.; Sergi, D.; Anselmi, M.; Melandri, F.; Leci, E.; Iori, E.; Bovolo, V.; Pidello, S.; Frea, S.; Bergerone, S.; Botta, M.; Canavosio, F. G.; Gaita, F.; Merlo, M.; Cinquetti, M.; Sinagra, G.; Ramani, F.; Fabris, E.; Stolfo, D.; Artico, J.; Miani, D.; Fresco, C.; Daneluzzi, C.; Proclemer, A.; Cicoira, M.; Zanolla, L.; Marchese, G.; Torelli, F.; Vassanelli, C.; Voronina, N.; Erglis, A.; Tamakauskas, V.; Smalinskas, V.; Karaliute, R.; Petraskiene, I.; Kazakauskaite, E.; Rumbinaite, E.; Kavoliuniene, A.; Vysniauskas, V.; Brazyte-Ramanauskiene, R.; Petraskiene, D.; Stankala, S.; Switala, P.; Juszczyk, Z.; Sinkiewicz, W.; Gilewski, W.; Pietrzak, J.; Orzel, T.; Kasztelowicz, P.; Kardaszewicz, P.; Lazorko-Piega, M.; Gabryel, J.; Mosakowska, K.; Bellwon, J.; Rynkiewicz, A.; Raczak, G.; Lewicka, E.; Dabrowska-Kugacka, A.; Bartkowiak, R.; Sosnowska-Pasiarska, B.; Wozakowska-Kaplon, B.; Krzeminski, A.; Zabojszcz, M.; Mirek-Bryniarska, E.; Grzegorzko, A.; Bury, K.; Nessler, J.; Zalewski, J.; Furman, A.; Broncel, M.; Poliwczak, A.; Bala, A.; Zycinski, P.; Rudzinska, M.; Jankowski, L.; Kasprzak, J. D.; Michalak, L.; Soska, K. W.; Drozdz, J.; Huziuk, I.; Retwinski, A.; Flis, P.; Weglarz, J.; Bodys, A.; Grajek, S.; Kaluzna-Oleksy, M.; Straburzynska-Migaj, E.; Dankowski, R.; Szymanowska, K.; Grabia, J.; Szyszka, A.; Nowicka, A.; Samcik, M.; Wolniewicz, L.; Baczynska, K.; Komorowska, K.; Poprawa, I.; Komorowska, E.; Sajnaga, D.; Zolbach, A.; Dudzik-Plocica, A.; Abdulkarim, A. -F.; Lauko-Rachocka, A.; Kaminski, L.; Kostka, A.; Cichy, A.; Ruszkowski, P.; Splawski, M.; Fitas, G.; Szymczyk, A.; Serwicka, A.; Fiega, A.; Zysko, D.; Krysiak, W.; Szabowski, S.; Skorek, E.; Pruszczyk, P.; Bienias, P.; Ciurzynski, M.; Welnicki, M.; Mamcarz, A.; Folga, A.; Zielinski, T.; Rywik, T.; Leszek, P.; Sobieszczanska-Malek, M.; Piotrowska, M.; Kozar-Kaminska, K.; Komuda, K.; Wisniewska, J.; Tarnowska, A.; Balsam, P.; Marchel, M.; Opolski, G.; Kaplon-Cieslicka, A.; Gil, R. 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Unravelling the interplay between hyperkalaemia, renin\u2013angiotensin\u2013aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC-HFA-EORP Heart Failure Long-Term Registry

Aims: We assessed the interplay between hyperkalaemia (HK) and renin\u2013angiotensin\u2013aldosterone system inhibitor (RAASi) use, dose and discontinuation, and their association with all-cause or cardiovascular death in patients with chronic heart failure (HF). We hypothesized that HK-associated increased death may be related to RAASi withdrawal. Methods and results: The ESC-HFA-EORP Heart Failure Long-Term Registry was used. Among 9222 outpatients (HF with reduced ejection fraction: 60.6%, HF with mid-range ejection fraction: 22.9%, HF with preserved ejection fraction: 16.5%) from 31 countries, 16.6% had HK ( 655.0 mmol/L) at baseline. Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) was used in 88.3%, a mineralocorticoid receptor antagonist (MRA) in 58.7%, or a combination in 53.2%; of these, at 6550% of target dose in ACEi: 61.8%; ARB: 64.7%; and MRA: 90.3%. At a median follow-up of 12.2 months, there were 789 deaths (8.6%). Both hypokalaemia and HK were independently. associated with higher mortality, and ACEi/ARB prescription at baseline with lower mortality. MRA prescription was not retained in the model. In multivariable analyses, HK at baseline was independently associated with MRA non-prescription at baseline and subsequent discontinuation. When considering subsequent discontinuation of RAASi (instead of baseline use), HK was no longer found associated with all-cause deaths. Importantly, all RAASi (ACEi, ARB, or MRA) discontinuations were strongly associated with mortality. Conclusions: In HF, hyper- and hypokalaemia were associated with mortality. However, when adjusting for RAASi discontinuation, HK was no longer associated with mortality, suggesting that HK may be a risk marker for RAASi discontinuation rather than a risk factor for worse outcomes

Acute heart failure congestion and perfusion status – impact of the clinical classification on in-hospital and long-term outcomes; insights from the ESC-EORP-HFA Heart Failure Long-Term Registry

Aims: Classification of acute heart failure (AHF) patients into four clinical profiles defined by evidence of congestion and perfusion is advocated by the 2016 European Society of Cardiology (ESC)guidelines. Based on the ESC-EORP-HFA Heart Failure Long-Term Registry, we compared differences in baseline characteristics, in-hospital management and outcomes among congestion/perfusion profiles using this classification. Methods and results: We included 7865 AHF patients classified at admission as: ‘dry-warm’ (9.9%), ‘wet-warm’ (69.9%), ‘wet-cold’ (19.8%) and ‘dry-cold’ (0.4%). These groups differed significantly in terms of baseline characteristics, in-hospital management and outcomes. In-hospital mortality was 2.0% in ‘dry-warm’, 3.8% in ‘wet-warm’, 9.1% in ‘dry-cold’ and 12.1% in ‘wet-cold’ patients. Based on clinical classification at admission, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.78 (1.43–2.21) and ‘wet-cold’ vs. ‘wet-warm’ 1.33 (1.19–1.48). For profiles resulting from discharge classification, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.46 (1.31–1.63) and ‘wet-cold’ vs. ‘wet-warm’ 2.20 (1.89–2.56). Among patients discharged alive, 30.9% had residual congestion, and these patients had higher 1-year mortality compared to patients discharged without congestion (28.0 vs. 18.5%). Tricuspid regurgitation, diabetes, anaemia and high New York Heart Association class were independently associated with higher risk of congestion at discharge, while beta-blockers at admission, de novo heart failure, or any cardiovascular procedure during hospitalization were associated with lower risk of residual congestion. Conclusion: Classification based on congestion/perfusion status provides clinically relevant information at hospital admission and discharge. A better understanding of the clinical course of the two entities could play an important role towards the implementation of targeted strategies that may improve outcomes. © 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiolog

Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12 440 patients of the ESC Heart Failure Long-Term Registry.

AIMS: To evaluate how recommendations of European guidelines regarding pharmacological and non-pharmacological treatments for heart failure (HF) are adopted in clinical practice. METHODS AND RESULTS: The ESC-HF Long-Term Registry is a prospective, observational study conducted in 211 Cardiology Centres of 21 European and Mediterranean countries, members of the European Society of Cardiology (ESC). From May 2011 to April 2013, a total of 12 440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. Intravenous treatments for acute HF were heterogeneously administered, irrespective of guideline recommendations. In chronic HF, with reduced EF, renin-angiotensin system (RAS) blockers, beta-blockers, and mineralocorticoid antagonists (MRAs) were used in 92.2, 92.7, and 67.0% of patients, respectively. When reasons for non-adherence were considered, the real rate of undertreatment accounted for 3.2, 2.3, and 5.4% of the cases, respectively. About 30% of patients received the target dosage of these drugs, but a documented reason for not achieving the target dosage was reported in almost two-thirds of them. The more relevant reasons for non-implantation of a device, when clinically indicated, were related to doctor uncertainties on the indication, patient refusal, or logistical/cost issues. CONCLUSION: This pan-European registry shows that, while in patients with acute HF, a large heterogeneity of treatments exists, drug treatment of chronic HF can be considered largely adherent to recommendations of current guidelines, when the reasons for non-adherence are taken into account. Observations regarding the real possibility to adhere fully to current guidelines in daily clinical practice should be seriously considered when clinical practice guidelines have to be written