Lower Risk Of Heart Failure Hospitalization Research Articles

Abstract 4138553: Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction: A Meta-analysis of Randomized Controlled Trials

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) were initially developed to treat type 2 diabetes mellitus, but they have also shown benefits in mitigating cardiovascular risk. Given the increasing evidence of their efficacy in diverse disease states and their proposed mechanisms of action, it is plausible that SGLT2i could improve outcomes in patients with acute myocardial infarction (AMI) if administered early after presentation. However, the efficacy and safety of these therapies when used early in the course of acute coronary heart disease remain largely unexplored. Objective: The aim of this current study was to assess the benefit of early initiation of SGLT2i after AMI. Methods: We searched the Cochrane Central Registry of Controlled Trials, PubMed, Embase, Web of Science, and clinicalTrials.gov databases for all randomized controlled trials (RCTs) published up to May 2024 comparing SGLT2 inhibitors to placebo. The primary clinical endpoints included overall mortality, cardiovascular (CV) death, heart failure (HF) hospitalization, and adverse effects. Data were analyzed using a random-effects model to account for potential heterogeneity among the included studies. Significant heterogeneity was defined as an I-squared statistic ≥ 50%; a fixed-effects model was employed if heterogeneity was not significant. The odds ratio (OR) with a 95% confidence interval (CI) was calculated for each endpoint. Results: Four RCTs were included in the analysis, comprising 11,108 patients (SGLT2i, n = 5,561; placebo, n = 5,547) who enrolled with a mean age of 63±9 years and 77% males. SGLT2i were associated with a 28% reduction in risk of HF hospitalization (OR: 0.72 [95% CI, 0.59-0.88]; p = 0.001; I 2 = 0%). However, there was no significant reduction in overall mortality (OR: 1.01 [95% CI, 0.83-1.23]; p = 0.93; I 2 = 27%), CV mortality (OR: 1.04 [95% CI, 0.83-1.30]; p = 0.74; I 2 = 0%), and serious adverse effects (OR: 1.06 [95% CI, 0.87-1.28]; p = 0.59; I 2 = 62%). Conclusion: In patients with AMI, early initiation of SGLT2i was associated with a lower risk of HF hospitalization without increasing the incidence of serious adverse effects when compared to placebo. However, no significant difference was observed in overall mortality and CV deaths.

Temporal trends in infection-related hospitalizations among patients with heart failure: A Danish nationwide study from 1997 to 2017

BackgroundDespite improved survival, hospitalization is still common among patients with heart failure (HF). ObjectiveThis study aimed to examine temporal trends in infection-related hospitalization among HF patients and compare it to temporal trends in the risk of HF hospitalization and death. MethodsUsing Danish nationwide registers, we included all patients aged 18-100 years, with HF diagnosed between 1st January 1997 and 31st December 2017, resulting in a total population of 147.737 patients. The outcomes of interest were primarily infection-related hospitalization and HF hospitalization and secondarily all-cause mortality. The Aalen Johansen's estimator was used to estimate five-year absolute risks for the primary outcomes. Additionally, cox analysis was used for adjusted analyses. ResultsThe population had a median age of 74 [64, 82] years and 57.6 % were males. Patients with HF had a higher risk of infection over time 16.4 % (95% CI 16.0–16.8) in 1997–2001 vs. 24.5% (95% CI 24.0–24.9) in 2012–2017. In contrast, they had a lower risk of HF hospitalization 26.5% (95% CI 26.1–27.0) in 1997–2001 vs. 23.2% (95% CI 22.8–23.7) in 2012–2017. The risk of infection stratified by infection type showed similar trends for all infection types and marked the risk of pneumonia infection as the most significant in all subintervals. ConclusionIn the period from 1997 to 2017, we observed patients with HF had an increased risk of infection-related hospitalization, driven by pneumonia infections. In contrast, the risk of HF hospitalization decreased over time.

Urate-lowering therapy in patients with hyperuricemia and heart failure: A retrospective cohort study using the UK Clinical Practice Research Datalink.

Elevated serum uric acid (sUA) is associated with heart failure (HF). Urate-lowering therapy (ULT) in HF is associated with lower risk of HF hospitalization (hHF) and mortality. Data on patients with HF and gout or hyperuricemia in the Clinical Practice Research Datalink database linked to the Hospital Episode Statistics and the Office for National Statistics in the United Kingdom were analyzed. Risks of hHF and all-cause mortality or cardiovascular-related mortality by ULT exposure (ULT initiated within ≤6 months of gout or hyperuricemia diagnosis) were analyzed in a propensity score-matched cohort using adjusted Cox proportional hazards regression models. Of 2174 propensity score-matched pairs, patients were predominantly male, aged >70 years, with mean ± standard deviation sUA 9.3 ± 1.8 (ULT-exposed) and 9.4 ± 1.9 mg/dL (ULT-unexposed). At 5 years, ULT-exposed patients had a 43% lower risk of hHF or all-cause mortality (adjusted hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.51-0.65) and a 19% lower risk of hHF or cardiovascular-related mortality (adjusted HR: 0.81; 95% CI: 0.71-0.92) versus no ULT exposure. ULT was associated with reduced risk of adverse clinical outcomes in patients with HF and gout or hyperuricemia over 5 years.

Catheter Ablation for Atrial Fibrillation in Patients with Left Ventricular Ejection Fraction ≤ 45%: A Meta-Analysis of Randomized Controlled Trials.

Atrial fibrillation (AF) and heart failure (HF) frequently coexist, resulting in adverse outcomes. However, controversies remain regarding the efficacy of catheter ablation (CA) in AF patients with severe left ventricular dysfunction. The purpose of this study was to perform a meta-analysis of prospective randomized controlled trials to evaluate the efficacy of CA versus medical therapy (MT) in AF patients with left ventricular ejection fraction (LVEF) ≤45%. We searched the literature for studies that compared CA to MT in AF patients with LVEF ≤45%. A meta-analysis of 7 clinical trials was performed, including 1163 patients with AF and HF. Subgroup analysis was performed based on baseline LVEF. All tests were 2-sided; only the p-value <0.05 was considered statistically significant. We found that CA was associated with lower all-cause mortality (risk ratio: 0.52, 95% CI: 0.37 to 0.72; p<0.01) and greater improvements in LVEF (mean difference: 4.80%, 95% CI: 2.29% to 7.31%; p<0.01) compared to MT. Patients in the CA group had a lower risk of HF hospitalization and AF recurrence and a significantly better quality of life than those in the MT group. The results of subgroup analysis indicated that patients with milder left ventricular dysfunction improved LVEF after AF ablation (mean difference: 6.53%, 95% CI: 6.18% to 6.88%; p<0.01) compared to patients with more severe disease (mean difference: 2.02%, 95% CI: 0.87% to 3.16%; p<0.01). Our meta-analysis demonstrated that CA was associated with significant improvements in outcomes of AF patients with LVEF ≤45%. Additionally, AF patients with milder left ventricular dysfunction could benefit more from CA.

Significance of effective cardiac resynchronization therapy pacing for clinical responses: An analysis based on the effective cardiac resynchronization therapy algorithm

High percent ventricular pacing maximizes cardiac resynchronization therapy (CRT) response. An effective CRT algorithm classifies each left ventricular (LV) pace as effective or ineffective on the basis of the detection of QS or QS-r morphology on the electrogram; however, the relationship between percent effective CRT pacing (%e-CRT) and responses is unclear. We aimed to clarify the association between %e-CRT and clinical outcomes. Of the 136 consecutive CRT patients, 49 using the adaptive and effective CRT algorithm with percent ventricular pacing > 90% were evaluated. The primary and secondary outcomes were heart failure (HF) hospitalization and prevalence of CRT responders, defined as patients with an improvement in LV ejection fraction of ≥10% or a reduction in LV end-systolic volume of ≥15% after CRT device implantation, respectively. We divided the patients into the effective group (n = 25) and the less effective group (n = 24) by the median value of %e-CRT (97.4%). During the median follow-up period of 507 days (interquartile range 335-730 days), the effective group had a significantly lower risk of HF hospitalization than did the less effective group as revealed by Kaplan-Meier analysis (log-rank, P = .016). Univariate analysis revealed %e-CRT ≥ 97.4% (hazard ratio 0.12; 95% confidence interval 0.01-0.95; P = .045) as a predictor of HF hospitalization. The effective group had a higher prevalence of CRT responders than did the less effective group (23 [92%] vs 9 [38%]; P < .001). Univariate analysis revealed that %e-CRT ≥ 97.4% (odds ratio 19.20; 95% confidence interval 3.63-101.00; P < .001) was a predictor of CRT response. High %e-CRT is associated with high CRT responder prevalence and low HF hospitalization risk.

Use of and association between heart failure pharmacological treatments and outcomes in obese versus non-obese patients with heart failure with reduced ejection fraction: data from the Swedish Heart Failure Registry.

To investigate the use of guideline-directed medical therapies (GDMT) and associated outcomes in obese (body mass index ≥30 kg/m2 ) versus non-obese patients with heart failure (HF) with reduced ejection fraction (HFrEF). Patients with HFrEF from the Swedish HF Registry were included. Of 16 116 patients, 24% were obese. In obese versus non-obese patients, use of treatments was 91% versus 86% for renin-angiotensin system inhibitors (RASi)/angiotensin receptor-neprilysin inhibitors (ARNi), 94% versus 91% for beta-blockers, 53% versus 43% for mineralocorticoid receptor antagonists. Obesity was shown to be independently associated with more likely use of each treatment, triple combination therapy, and the achievement of target dose by multivariable logistic regressions. Multivariable Cox regressions showed use of RASi/ARNi and beta-blockers being independently associated with lower risk of all-cause/cardiovascular death regardless of obesity, although, when considering competing risks, a lower risk of cardiovascular death with RASi/ARNi in obese versus non-obese patients was observed. RASi/ARNi were associated with lower risk of HF hospitalization in obese but not in non-obese patients, whereas beta-blockers were not associated with the risk of HF hospitalization regardless of obesity. At the competing risk analysis, RASi/ARNi use was associated with higher risk of HF hospitalization regardless of obesity. Obese patients were more likely to receive optimal treatments after adjustment for factors affecting tolerability, suggesting that perceived beyond actual tolerance issues limit GDMT implementation. RASi/ARNi and beta-blockers were associated with lower mortality regardless of obesity, with a greater association between RASi/ARNi and lower cardiovascular death in obese versus non-obese patients when considering competing risk.

Abstract 13240: The Relationship Between History of Valve Surgery and Heart Failure Event in Japanese Atrial Fibrillation Patients: The Fushimi Af Registry

Background: We previously reported that valvular heart disease (VHD) was associated with an increased risk of hospitalization for heart failure (HF) in Japanese atrial fibrillation (AF) patients. However, the association of history of surgery for VHD with HF hospitalization remains unknown. Method: The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, which is a typical urban district of Japan. We started to enroll patients from March 2011, and follow-up data were available for 4,489 patients by the end of July 2021. In the entire cohort, 747 patients had VHD. We divided them to surgery group (n=182) and non-surgery group (n=565). We compared clinical characteristics and incidence rates of HF hospitalization between two groups. Result: Patients who received valve surgery were younger (72.0 years vs. 78.0 years, p&amp;lt;0.001), had lower systolic blood pressure (118 mmHg vs. 123 mmHg, p=0.02) and pulse rate (75.5 bpm vs. 79.1 bpm, p=0.003), more often paroxysmal type (46.7% vs. 31.0%, p&amp;lt;0.001), less likely to have hypertension (51.1% vs. 66.2%, p&amp;lt;0.001) and had lower CHADS2 score (2.09 vs. 2.55, p&amp;lt;0.001) than non-surgery group. Body weight, sex, prior HF, chronic kidney disease and prescription data were comparable between two groups. During the median follow-up of 1,679 days, the incidence rate of HF hospitalization was lower in surgery group than non-surgery group (2.58% vs. 4.43% per person-year, respectively, log rank p=0.001). On multivariate Cox regression analysis, history of surgery was not significantly associated with a lower risk of HF hospitalization (adjusted hazard ratio 0.76; 95% confidence interval 0.52-1.12, p=0.16). Conclusion: The incidence rate of HF hospitalization was lower in patients with valve surgery than non-surgery group. However, history of valve surgery was not independently associated with a lower risk of HF hospitalization in Japanese AF patients.

Non-cardiology vs. cardiology care of patients with heart failure and reduced ejection fraction is associated with lower use of guideline-based care and higher mortality: Observations from The Swedish Heart Failure Registry

BackgroundPatients with heart failure (HF) are often cared for by non-cardiologists. The implications are unknown. MethodsIn a nationwide HF cohort with reduced ejection fraction (HFrEF), we compared demographics, clinical characteristics, guideline-based therapy use and outcomes in non-cardiology vs. cardiology in-patient and out-patient care. ResultsBetween 2000 and 2016, 36,076 patients with HFrEF were enrolled in the Swedish HF registry (19,337 [54%] in-patients overall), with 44% of in-patients and 45% of out-patients managed in non-cardiology settings. Predictors of treatment in non-cardiology were age > 75 years (adjusted odds ratio for non-cardiology 1.20; 95% confidence interval 1.14–1.27), lower education level (0.71; 0.66–0.76 for university vs. compulsory), valve disease (1.24; 1.18–1.31) and systolic blood pressure (SBP) >120 mmHg (1.05; 1.00–1.10). Non-cardiology care was significantly associated with lower use of beta-blockers (0.80; 0.74–0.86) and devices (intracardiac defibrillator [ICD] and/or cardiac resynchronization therapy [CRT]: 0.63; 0.56–0.71), and less frequent specialist follow-up (0.61; 0.57–0.65). Over 1-year follow-up the risk of all-cause mortality (adjusted hazard ratio 1.09; 1.03–1.15) was higher but the risk of first HF (re-) hospitalization was lower (0.93; 0.89–0.97) in non-cardiology vs. cardiology care. ConclusionsIn HFrEF, non-cardiology care was independently associated with older ageand lower education. After covariate adjustment, non-cardiology care was associated with lower use of beta-blockers and devices, higher mortality, and lower risk of HF hospitalization. Access to cardiology care may not be equitable and this may have implications for use of guideline-based care and outcomes.

Efficacy and safety of dapagliflozin according to aetiology in heart failure with reduced ejection fraction: insights from the DAPA-HF trial.

We examined the efficacy and safety of dapagliflozin, compared with placebo, according to aetiology in patients with heart failure (HF) with reduced ejection fraction (HFrEF) enrolled in the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF). Aetiology was investigator-reported and categorized as ischaemic or non-ischaemic. The primary outcome was the composite of an episode of worsening HF or cardiovascular death. A total of 4744 patients were randomized in DAPA-HF, of whom 2674 (56.4%) patients had an ischaemic aetiology. Participants with an ischaemic aetiology had a higher risk of cardiovascular mortality [hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.13-1.63], but lower risk of HF hospitalization (HR 0.83, 95% CI 0.70-0.98) than non-ischaemic patients. Compared with placebo, dapagliflozin reduced the risk of worsening HF or cardiovascular death to a similar extent in both patients with ischaemic and non-ischaemic aetiology (HR 0.77, 95% CI 0.65-0.92, and HR 0.71, 95% CI 0.58-0.87, respectively; P for interaction=0.55). Consistent benefits were observed for the components of the primary outcome and all-cause mortality. Dapagliflozin, as compared with placebo, increased the proportion of patients with an improvement of Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ-TSS) of ≥5 points (P for interaction=0.32) and decreased the proportion with a deterioration in KCCQ-TSS of ≥5 points (P for interaction=0.76), irrespective of aetiology. Study drug discontinuation and serious adverse events were similar according to treatment groups, irrespective of aetiology. Dapagliflozin reduced the risk of worsening HF and death, and improved symptoms, similarly in patients with ischaemic and non-ischaemic aetiology. In addition, dapagliflozin was safe and well-tolerated, irrespective of aetiology.

Non‐insulin antihyperglycaemic drugs and heart failure: an overview of current evidence from randomized controlled trials

Type 2 diabetes mellitus (T2DM) is highly prevalent in the general population and especially in patients with heart failure (HF). It is not only a risk factor for incident HF, but is also associated with worse outcomes in prevalent HF. Therefore, antihyperglycaemic management in patients at risk of or with established HF is of importance to reduce morbidity/mortality. Following revision of the drug approval process in 2008 by the Food and Drug Administration and European Medicines Agency, several cardiovascular outcome trials on antihyperglycaemic drugs have recently investigated HF endpoints. Signals of harm in terms of increased risk of HF have been identified for thiazolidinediones and the dipeptidyl peptidase 4 inhibitor saxagliptin, and therefore, these drugs are not currently recommended in HF. Sulfonylureas also have an unfavourable safety profile and should be avoided in patients at increased risk of/with HF. Observational studies have assessed the use of metformin in patients with HF, showing potential safety and potential survival/morbidity benefits. Overall use of glucagon‐like peptide 1 receptor agonists has not been linked with any clear benefit in terms of HF outcomes. Sodium–glucose cotransporter protein 2 inhibitors (SGLT2i) have consistently shown to reduce risk of HF‐related outcomes in T2DM with and without HF and are thus currently recommended to lower risk of HF hospitalization in T2DM. Recent findings from the DAPA‐HF trial support the use of dapagliflozin in patients with HF with reduced ejection fraction and, should ongoing trials with empagliflozin, sotagliflozin, and canagliflozin prove efficacy, will pave the way for SGLT2i as HF treatment regardless of T2DM.

P5650Improvement in ejection fraction predicts heart failure after catheter ablation for atrial fibrillation in patients with left ventricular systolic dysfunction: from the KPAF registry

Abstract Introduction The presence of atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF) is associated with increased risks of mortality and hospitalization for heart failure (HF). Although prior studies reported that catheter ablation (CA) for AF in low LVEF patients reduced risks of all-cause mortality and HF hospitalization, the predictors of worsening HF after ablation has not been adequately evaluated. Purpose The purpose of this study was to investigate the impact of improvement in LVEF after AF ablation on the incidence of subsequent HF hospitalization in patients with low LVEF. Methods The Kansai Plus Atrial Fibrillation (KPAF) Registry is a multicenter registry enrolling 5,013 consecutive patients undergoing first-time ablation for AF. The current study population consisted of 1,031 patients with reduced LVEF of &lt;60%. We divided the study population into 3 groups according to LVEF at follow-up; 678 patients (65.8%) with improved LVEF (≥5 U change in LVEF), 288 patients (27.9%) with unchanged LVEF (−5 U ≤ change in LVEF &lt;5 U) and 65 patients (6.3%) with worsened LVEF (&lt;−5 U change in LVEF). Results During the median follow-up of 1067 [879–1226] days, patients improved LVEF had lower rate of HF hospitalization, compared with those with unchanged and worsened LVEF (2.1%, 8.0%, and 21.5%, respectively, P&lt;0.0001). Recurrent atrial tachyarrhythmias were documented in 43.5%, 47.2% and 67.7%, respectively (P=0.0008). Figure 1 Conclusion Among patients with reduced LVEF undergoing AF ablation, patients with subsequently improved LVEF in association with maintained sinus rhythm had markedly lower risk of HF hospitalization during follow-up as compared with those with unchanged or worsened LVEF.

Use of Analytics to Identify Patients with Sub-Optimal Cardiac Resynchronization Therapy Pacing

Introduction Heart failure (HF) hospitalizations are of growing concern for patients and payers. Cardiac resynchronization therapy patients that achieve high CRT pacing (>90%) are at lower risk of HF hospitalization. There has been no way to identify patients with suboptimal CRT pacing outside of routine office or remote follow up. Analytic software has been developed to identify programming optimization opportunities at a clinic level. Hypothesis Cardiac device analytic software can identify opportunities for programming optimization and enable improvements in CRT pacing percentage. Methods Cardiac device analytic software (Medtronic PaceartTM Analytics) was used to identify CRT patients with suboptimal CRT pacing at a single center. Patients actively followed within the clinic were included. Patients with CRT pacing programmed off, LV leads off due to diaphragmatic stimulation, or who declined further procedures or more aggressive medical therapy were not included. Reduction in HF related healthcare utilization was modeled based on expected reduction in the risk of HF hospitalizations with increased CRT pacing percentage. Cost savings were estimated using national claims payment data. Results A total of 88 out of 642 patients were identified with suboptimal CRT pacing through the analytic tool. There were 42 patients not eligible for improvement for reasons outlined above; 46 patients were considered eligible for intervention. The mean (standard error) baseline CRT pacing was 71.6% (5.5%). With intervention, 21 patients (45.6%) improved CRT pacing to 94.1% (0.6%). 11 patients improved with control of atrial fibrillation, 9 with treatment of PVC's, and 1 with device reprogramming. This improvement of 22.5% was modeled to prevent 7 HF hospitalizations in 1 year, equating to $117,268 in potential savings to the healthcare system from a payer perspective. Conclusions Analytics data can be used to successfully identify patients that have suboptimal CRT pacing and may lead to cost savings through reducing unnecessary HF hospitalizations

Novel concept to guide systolic heart failure medication by repeated biomarker testing\u2014results from TIME-CHF in context of predictive, preventive, and personalized medicine

BackgroundIt is uncertain whether repeated measurements of a multi-target biomarker panel may help to personalize medical heart failure (HF) therapy to improve outcome in chronic HF.MethodsThis analysis included 499 patients from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF), aged ≥ 60 years, LVEF ≤ 45%, and NYHA ≥ II, who had repeated clinical visits within 19 months follow-up. The interaction between repeated measurements of biomarkers and treatment effects of loop diuretics, spironolactone, β-blockers, and renin-angiotensin system (RAS) inhibitors on risk of HF hospitalization or death was investigated in a hypothesis-generating analysis. Generalized estimating equation (GEE) models were used to account for the correlation between recurrences of events in a patient.ResultsOne hundred patients (20%) had just one event (HF hospitalization or death) and 87 (17.4%) had at least two events. Loop diuretic up-titration had a beneficial effect for patients with high interleukin-6 (IL6) or high high-sensitivity C-reactive protein (hsCRP) (interaction, P = 0.013 and P = 0.001), whereas the opposite was the case with low hsCRP (interaction, P = 0.013). Higher dosage of loop diuretics was associated with poor outcome in patients with high blood urea nitrogen (BUN) or prealbumin (interaction, P = 0.006 and P = 0.001), but not in those with low levels of these biomarkers. Spironolactone up-titration was associated with lower risk of HF hospitalization or death in patients with high cystatin C (CysC) (interaction, P = 0.021). β-Blockers up-titration might have a beneficial effect in patients with low soluble fms-like tyrosine kinase-1 (sFlt) (interaction, P = 0.021). No treatment biomarker interactions were found for RAS inhibition.ConclusionThe data of this post hoc analysis suggest that decision-making using repeated biomarker measurements may be very promising in bringing treatment of heart failure to a new level in the context of predictive, preventive, and personalized medicine. Clearly, prospective testing is needed before this novel concept can be adopted.Clinical trial registrationisrctn.org, identifier: ISRCTN43596477

Influenza Vaccination Reduces Hospitalization for Heart Failure in Elderly Patients with Chronic Kidney Disease: A Population-Based Cohort Study.

Elderly patients with chronic kidney disease (CKD) are at a higher risk of hospitalization for cardiovascular diseases (CVD). Previous studies have reported the beneficial effects of the influenza vaccine in patients with CVD. However, the effects of influenza vaccination on the reduction of hospitalizations for heart failure (HF) in elderly patients with CKD remain unclear. This cohort study comprised elderly patients (≥ 55 years of age) with a recorded diagnosis of CKD (n = 4406) between January 1, 1999 and December 31, 2008. Each patient was followed-up until the end of 2008. The hazard ratio (HR) and 95% confidence interval (CI) for the association between the influenza vaccination and the first HF hospitalization were analyzed. In addition, the patients were categorized into four groups based on their vaccination status (unvaccinated and total number of vaccinations: 1, 2-3, and ≥ 4). We found that elderly patients with CKD receiving influenza vaccination exhibited a lower risk of HF hospitalization (adjusted HR, 0.31; 95% CI, 0.26-0.39, p < 0.001). The protective effects of influenza vaccination remained consistent regardless of the age group (55-64, 65-74, ≥ 75), sex, and influenza seasonality. When the patients were stratified according to the total number of vaccinations, the adjusted HRs for HF hospitalization were 0.60 (0.47-0.77), 0.30 (0.23-0.41), and 0.10 (0.06-0.16) for patients who received 1, 2-3, and ≥ 4 vaccinations during the follow-up period, respectively. The results revealed that elderly patients with CKD receiving annual influenza vaccination are at a lower risk of HF hospitalization.