Poor Outcomes In Heart Failure Research Articles

Cardiac Cachexia: Perspectives for Prevention and Treatment.

Cachexia is a prevalent pathological condition associated with chronic heart failure. Its occurrence predicts increased morbidity and mortality independent of important clinical variables such as age, ventricular function, or heart failure functional class. The clinical consequences of cachexia are dependent on both weight loss and systemic inflammation, which accompany cachexia development. Skeletal muscle wasting is an important component of cachexia; it often precedes cachexia development and predicts poor outcome in heart failure. Cachexia clinically affects several organs and systems. It is a multifactorial condition where underlying pathophysiological mechanisms are not completely understood making it difficult to develop specific prevention and treatment therapies. Preventive strategies have largely focused on muscle mass preservation. Different treatment options have been described, mostly in small clinical studies or experimental settings. These include nutritional support, neurohormonal blockade, reducing intestinal bacterial translocation, anemia and iron deficiency treatment, appetite stimulants, immunomodulatory agents, anabolic hormones, and physical exercise regimens. Currently, nonpharmacological therapy such as nutritional support and physical exercise are considered central to cachexia prevention and treatment.

Subclinical Hypothyroidism is a Useful Predictor of Adverse Events in Heart Failure Patients with Reduced Left Ventricular Ejection Fraction

Thyroid dysfunction has an adverse effect on cardiac function and relates to poor prognosis of patients with heart failure (HF), but data of hypothyroidism as a predictor of adverse events are scarce. In this study, we evaluated the predictive value of subclinical hypothyroidism for poor outcome in HF. Continuous 71 ambulatory patients with HF with reduced LVEF who had never received thyroid hormone replacement therapy were enrolled. We assessed their baseline thyroid-stimulating hormone (TSH) and classified them into euthyroid (TSH: 0.35 to 5.50 uU/ml), hypothyroid (>5.50 uU/ml), or hyperthyroid (<0.35 uU/ml). We defined cardiovascular death or hospitalization for HF as study endpoints and compared outcomes among 3 thyroid states. Furthermore, we evaluated the prognostic value of TSH for poor outcome, using multivariate Cox proportional-hazards model. Sixty-one patients (85.9%) had euthyroidism, 8 patients (11.3%) hypothyroidism, and 2 patients (2.8%) hyperthyroidism. Kaplan-Meier event-free survival analysis revealed that the patients with hypothyroidism showed worse event-free survival compared to those with euthyroidism (p=0.013). Multivariate analysis demonstrated that TSH was a significantly independent predictor of adverse events after adjustments for age, gender, LVEF, and BNP. (HR: 1.216; 95% CI: 1.029 to 1.438; p=0.022). More than 10% of HF patients with reduced LVEF had subclinical hypothyroidism which demonstrated poor prognosis. High TSH level was a useful predictor of adverse events.

Exercise oscillatory ventilation in heart failure and in pulmonary arterial hypertension

BackgroundPatients with pulmonary arterial hypertension (PAH) and with heart failure (HF) have increased ventilatory responses to exercise in proportion to disease severity. Exercise-associated oscillatory ventilation (EOV) predicts poor outcome in HF. Whether EOV occurs in PAH is unknown. MethodsWe analyzed the initial cardiopulmonary exercise tests (CPETs) and right heart catheterization data of 109 patients with PAH and in 107 patients with HF consecutively referred to our center. ResultsThe PAH patients were aged 54±16years and their NYHA functional class was 2.8±0.5. The HF patients were aged 53±13years and NYHA 2.4±0.6. Hemodynamic data were obtained in only 36 of them. The patients with PAH compared to those with HF had a lower peak VO2 (13±5 vs 17±5mL/kg/min, p<0.001) and a higher ventilatory equivalent for CO2 (VE/VCO2) slope (55±21 vs 34±7, p<0.001). Mean pulmonary artery pressure was higher (50±10 vs 29±11mmHg) and wedge pressure lower (10±3 vs 19±5mmHg) in PAH patients, but cardiac output was not different (4.0±1.3 vs 4.2±1.2L/min). EOV was present in 22 patients (21%) with HF and in no patient with PAH. ConclusionsPatients with PAH compared to HF with slightly better functional class have a lower aerobic exercise capacity and higher ventilatory responses, but no EOV. An increase in pulmonary artery wedge pressure rather than a low cardiac output may be necessary condition of EOV in HF.

Addressing the conundrum of multimorbidity in heart failure: Do we need a more strategic approach to improve health outcomes?

There is clear evidence across the globe that the clinical complexity of patients presenting to hospital with the syndrome of heart failure is increasing - not only in terms of the presence of concurrent disease states, but with additional socio-demographic risk factors that complicate treatment. Management strategies that treat heart failure as the main determinant of health outcomes ignores the multiple and complex issues that will inevitably erode the efficacy and efficiency of current heart failure management programmes. This complex problem (or conundrum) requires a different way of thinking around the complex interactions that underpin poor outcomes in heart failure. In this context, we present the COordinated NUrse-led inteNsified Disease management for continuity of caRe for mUltiMorbidity in Heart Failure (CONUNDRUM-HF) matrix that may well inform future research and models of care to achieve better health outcomes in this rapidly increasing patient population.

Association between left ventricular global longitudinal strain and natriuretic peptides in outpatients with chronic systolic heart failure.

BackgroundBoth impaired left ventricular (LV) global longitudinal strain (GLS) and increased plasma concentrations of natriuretic peptides(NP) are associated with a poor outcome in heart failure (HF). Increased levels of NP reflect increased wall stress of the LV. However, little is known about the relationship between LV GLS and NP. This aim of this study was to evaluate the relationship between the echocardiographic measure LV GLS and plasma levels of NP.MethodsWe prospectively included 149 patients with verified systolic HF at the baseline visit in an outpatient HF clinic. LV GLS was assessed by two dimension speckle tracking and plasma concentrations of N-terminal-pro-brain-natriuretic-peptide (NT-proBNP) and pro-atrial-natriuretic-peptide (proANP) were analysed.ResultsThe patients had a median age of 70 years, 28.2 % were females, 26.5 % were in functional class III-IV, median left ventricular ejection fraction (LVEF) was 33 % and median LV GLS was −11 %. LV GLS was associated with increased plasma concentrations of NT-proBNP and proANP in multivariate logistic regression (NT-proBNP: Odds RatioGLS: 7.25, 95 %-CI: 2.48-21.1, P < 0.001 and proANP: Odds RatioGLS: 3.26, 95-%-CI: 1.28-8.30, P = 0.013) and linear regression (NT-proBNP: βGLS: 1.19, 95 %-CI: 0.62-1.76, P < 0.001 and proANP: βGLS: 0.42, 95-%-CI: 0.11-0.72, P = 0.007) models after adjustment for traditional confounders (age, gender, body-mass-index, atrial fibrillation, renal function) and left atrial volume index.ConclusionImpaired LV GLS is associated with increased plasma concentrations of NP and our data suggest that left ventricular myocardial mechanics estimated by LV GLS reflects myocardial wall stress in chronic systolic HF.

Low literacy self-care management patient education for a multi-lingual heart failure population: Results of a pilot study

PurposeThe purpose of this pilot study was to test the impact of language-free, low literacy self-care management patient education materials in an ethnically diverse multilingual heart failure (HF) population. MethodsA one group pre-test–post-test design measured changes in self-care, knowledge and health-related quality of life (HRQL) after a 1month intervention using language-free, low literacy self-care management patient education materials and delivered by a health educator. ResultsThe ethnically diverse sample (n=21) was predominately male (72%), 48% Black, 42% Hispanic, and 28% marginal/inadequate literacy. There were significant improvements in self-care and knowledge but not HRQL. ConclusionsLanguage-free, low literacy self-care patient education may facilitate improved self-care and knowledge in diverse populations who are at risk for poor HF outcomes.

Iron deficiency: Prevalence and relation to cardiovascular biomarkers in heart failure outpatients

BackgroundBoth iron deficiency (ID) and cardiovascular biomarkers are associated with a poor outcome in heart failure (HF). The relationship between different cardiovascular biomarkers and ID is unknown, and the true prevalence of ID in an outpatient HF clinic is probably overlooked. ObjectivesTo identify the prevalence of ID in a HF clinic and evaluate whether ID is associated with increased plasma concentrations of different cardiovascular biomarkers that carry a poor prognosis. MethodsWe prospectively included 149 patients with systolic HF referred to an outpatients HF clinic. ID was defined as ferritin<100μg/L or ferritin 100–300μg/L and Tranferin-saturation<0.20. Five different cardiovascular biomarkers were analyzed on frozen plasma. ResultsThe patients had a median age of 70 (Interquartile range: 64–75) years, 25% were females, 29% were in functional class III–IV and LVEF was 32 (27–39) %. The prevalence of ID was 45% (95%-confidence interval (CI): 37–53%). In multivariate analyses, ID was not associated with plasma concentrations of troponin I, NT-proBNP, MR-proANP, chromogranin A or copeptin (P>0.05 for all) but with plasma concentrations of hs-CRP (odds ratio: 2.03, 95%-CI: 1.02–4.02, P=0.043). ConclusionID is frequent in an outpatient HF clinic. ID is not associated with cardiovascular biomarkers after adjustment for traditional confounders. Inflammation, but not neurohormonal activation is associated with ID in systolic HF. Further studies are needed to understand iron metabolism in elderly HF patients

(516) - Modulation of LV Loading and Arterial Pulsatility Affects PET/CT Coronary Flow Reserve in Continuous Flow LVAD Patients

Coronary flow reserve (CFR) is associated with poor outcomes in heart failure (HF). The effect of changes in LV loading and arterial pulsatility (via modulation of pump speed) on CFR in continuous flow LVAD (CF-LVAD) has not been previously studied.

Nitric oxide dysregulation in patients with heart failure: the association of depressive symptoms with L-arginine, asymmetric dimethylarginine, symmetric dimethylarginine, and isoprostane.

Nitric oxide (NO) regulation plays a critical role in cardiovascular diseases including heart failure (HF). Markers of NO dysregulation have been found in individuals with depression without cardiovascular disease. Because depression is associated with poor HF outcomes, the present study tested the hypothesis that depression is associated with a dysregulated NO pathway in patients with HF. Serum levels of NO regulation (L-arginine, asymmetric dimethylarginine [ADMA], and symmetric dimethylarginine [SDMA]) and oxidative stress (isoprostane 8-epi prostaglandin F2α) were measured in 104 patients with HF (mean [standard deviation] age = 65.7 [8.4] years, 28% women) at baseline and 12 months. Depressive symptoms were measured using the Beck Depression Inventory. The associations between depressive symptoms with markers of NO regulation were examined with mixed-model analysis, adjusted for age, sex, time of assessment, left ventricular ejection fraction, creatinine, and hypertension. Depressive symptoms were correlated with a lower L-arginine/ADMA ratio (r = -0.22, p = .003) and higher SDMA levels (r = 0.28, p < .001). Associations were similar for somatic depressive symptoms and cognitive-affective symptoms (L-arginine/ADMA ratio: r = -0.20 [p = .009] versus r = -0.19 [p = .013]; ADMA: r = 0.16 [p = .043] versus r = 0.10 [p = .20]; SDMA: r = 0.27 [p < .001] versus r = 0.22 [p = .005], respectively). No associations were found between depressive symptoms and isoprostane. The association between depression and the L-arginine/ADMA ratio remained significant in multivariate adjusted models. Depressive symptoms were associated with markers of NO dysregulation, particularly the L-arginine/ADMA ratio and SDMA, in patients with HF. The lower L-arginine/ADMA ratio indicates less available NO, suggesting that NO-related endothelial dysfunction may play a role in the adverse risk of HF progression associated with depression.

Abstract 13770: DWS as an Index of Myocardial Stiffness and a Predictor of Heart Failure Outcome in Patients with Chronic Beta-blockade Therapy

Background: Diastolic dysfunction determines symptoms and prognosis in patients with left ventricular (LV) dysfunction. Diastolic wall strain (DWS) is associated with poor outcomes in heart failure with preserved ejection fraction. However, the utility of DWS is still unknown in heart failure with reduced ejection fraction (HFrEF). Our aim is to determine whether DWS is predictive of the outcome in HFrEF. Methods: We studied 54 HFrEF patients (LVEF&lt;50%) and followed DWS as an index of myocardial stiffness for 6 months after the induction of beta blockade (Bisoprolol 2.5-10 mg / day). DWS was determined in the LV M-mode echocardiogram using the following equation: DWS = {(LV posterior wall thickness at end-systole - LV posterior wall thickness at end-diastole) / LV posterior wall thickness at end-systole}. We followed for 7years after the induction of beta-blockade. Results: DWS increased after the induction of beta-blockade (0.32±0.11 vs 0.25±0.12,p&lt;0.05). DcT, EF and E’ also increased after the induction of beta-blockade. HR at rest and log BNP decreased following beta blockade. Patients with DWS ≤ median (0.25) before the induction of beta-blockade had higher rate of HF hospitalization than those with DWS &gt;median during 7 years (Log-rank p =0.025). DcT, EF, E’, HR at rest and log BNP before the induction of beta blockade were not significant predictors of HF outcome (Log-rank p=0.263, 0.504, 0.0796, 0.289 and 0.877) respectively. Conclusions: Induction of beta-blockade provided an improvement in DWS. DWS might be useful as an index of myocardial stiffness to predict the outcomes in HFrEF patients with chronic beta-blockade therapy.

Efficacy and safety of ivabradine in patients with chronic systolic heart failure according to blood pressure level in SHIFT.

Low systolic blood pressure (SBP) is associated with poor outcomes in heart failure and complicates management. In a post hoc analysis, we investigated the efficacy and safety of ivabradine in the SHIFT population divided by tertiles of baseline SBP. The analysis comprised 2110 patients with SBP <115 mmHg, 1968 with 115≤ SBP <130 mmHg, and 2427 with SBP ≥130 mmHg. Patients with low SBP were younger, had lower ejection fraction, and were less likely to be at target beta-blocker dose than patients in the other SBP groups. Ivabradine was associated with a similar relative risk reduction of the composite outcome in the three SBP groups [SBP <115 mmHg, hazard ratio (HR) = 0.84, 95% confidence interval (CI) 0.72-0.98; 115≤ SBP <130 mmHg, HR = 0.86, 95% CI 0.72 to 1.03; SBP ≥130 mmHg, HR = 0.77, 95% CI 0.66 to 0.92; P interaction = 0.68]. Similar results were found for cardiovascular mortality (P interaction = 0.91), hospitalization because of heart failure (P interaction = 0.79), all-cause mortality (P interaction = 0.90), and heart failure mortality (P interaction = 0.18). There was no evidence for a difference in safety profile according to SBP group. The efficacy and safety of ivabradine is independent of SBP. This may have implications for the management of HF patients with low SBP and elevated heart rate.

Renal impairment, worsening renal function, and outcome in patients with heart failure: an updated meta-analysis

Chronic kidney disease (CKD) and worsening renal function (WRF) have been associated with poor outcome in heart failure (HF). Articles were identified by literature search of MEDLINE (from inception to 1 July 2012) and Cochrane. We included studies on HF patients and mortality risk with CKD and/or WRF. In a secondary analysis, we selected studies investigating predictors of WRF. We retrieved 57 studies (1,076,104 patients) that investigated CKD and 28 studies (49,890 patients) that investigated WRF. The prevalence of CKD was 32% and associated with all-cause mortality: odds ratio (OR) 2.34, 95% confidence interval (CI) 2.20-2.50, P < 0.001). Worsening renal function was present in 23% and associated with unfavourable outcome (OR 1.81, 95% CI 1.55-2.12, P < 0.001). In multivariate analysis, moderate renal impairment: hazard ratio (HR) 1.59, 95% CI 1.49-1.69, P < 0.001, severe renal impairment, HR 2.17, 95% CI 1.95-2.40, P < 0.001, and WRF, HR 1.95, 95% CI 1.45-2.62, P < 0.001 were all independent predictors of mortality. Across studies, baseline CKD, history of hypertension and diabetes, age, and diuretic use were significant predictors for the occurrence of WRF. Across all subgroups of patients with HF, CKD, and WRF are prevalent and associated with a strongly increased mortality risk, especially CKD. Specific conditions may predict the occurrence of WRF and thereby poor prognosis.

Changes in Renal Function in Congestive Heart Failure

Both cardiovascular and renal diseases are common and frequently coexist in the same patient. Indeed, renal dysfunction has been shown to be a more powerful independent predictor of poor outcomes in heart failure (HF) than left ventricular ejection fraction or functional class. Furthermore, acute kidney injury is a frequent therapeutic concern in heart failure. Consequently, there has been much interest in developing new renoprotective treatments and novel biomarkers to monitor renal function. Additionally, given the crucial cardiorenal interaction and interdependence, the concept of a cardiorenal syndrome with five different subtypes has been advanced to better categorize patients and facilitate research.

Does pre-albumin predict in-hospital mortality in heart failure?

Malnutrition, inflammation and the so called wasting syndrome predict poor outcome in heart failure (HF) [1]. Albumin and total cholesterol have been used as markers of malnutrition and wasting syndrome in HF [2]. Lower serum cholesterol, but mainly hypoalbuminemia were reported to associate with hospital death in acute HF [3,4].

The immunological axis in heart failure: importance of the leukocyte differential

The important role of the immune system and inflammation in the pathophysiology of heart failure (HF) is becoming increasingly appreciated. We have reviewed the prognostic significance of under-recognized aspects of the leukocyte differential in HF, including lymphocytes, monocytes, eosinophils and mast cells. Studies to date evaluating lymphocyte counts in both chronic and hospitalized HF patients have consistently shown worse prognosis associated with low lymphocyte counts, despite widely heterogeneous study designs. Limited data suggest elevations in monocyte-derived cytokines and serum monocyte count may be predictive of poor outcomes in HF. Further data are required to better define the relationship between eosinophils, mast cells and HF. Leukocyte differentials are widely available, simple, inexpensive and appear to have independent prognostic significance, beyond traditional risk factors. Enhanced sympathetic activation and increased circulating cytokine levels (particularly tumor necrosis factor) have been implicated in the variability of leukocyte subpopulations. To date, immune-modulators targeting these mediators have been largely unsuccessful in improving cardiovascular outcomes in HF. Given the potential role of the immunological axis in HF, there may be an unmet need for novel therapeutic agents that can safely and effectively ameliorate these leukocyte derangements and perhaps improve the unacceptably high event rate in this population. Variations in leukocyte differentials may identify a high-risk subset of patients that may benefit from tailored immune therapies.

Diastolic stiffness as assessed by diastolic wall strain is associated with adverse remodelling and poor outcomes in heart failure with preserved ejection fraction

The pathophysiology of heart failure with preserved ejection fraction (HFpEF) is complex but increased left ventricular (LV) diastolic stiffness plays a key role. A load-independent, non-invasive, direct measure of diastolic stiffness is lacking. The diastolic wall strain (DWS) index is based on the linear elastic theory, which predicts that impaired diastolic wall thinning reflects resistance to deformation in diastole and thus, increased diastolic myocardial stiffness. The objectives of this community-based study were to determine the distribution of this novel index in consecutive HFpEF patients and healthy controls, define the relationship between DWS and cardiac structure and function and determine whether increased diastolic stiffness as assessed by DWS is predictive of the outcome in HFpEF. Consecutive HFpEF patients (n = 327, EF ≥ 50%) and controls (n = 528) from the same community were studied. Diastolic wall strain was lower in HFpEF (0.33 ± 0.08) than in controls (0.40 ± 0.07, P < 0.001). Within HFpEF, those with DWS ≤ median (0.33) had higher LV mass index, relative wall thickness, E/e', Doppler-estimated LV end-diastolic pressure to LV end-diastolic volume ratio, left atrial volume index, and brain natriuretic peptide (BNP) levels than those with DWS > median. Heart failure with preserved ejection fraction patients with DWS ≤ median had higher rate of death or HF hospitalization than those with DWS > median (P = 0.003) even after the adjustment for age, gender, log BNP, LV geometry, or log E/e' (P < 0.01). These data suggest that DWS, a simple index, is useful in assessing diastolic stiffness and that more advanced diastolic stiffness is associated with worse outcomes in HFpEF.

Prospective Evaluation of Elastic Restraint to Lessen the Effects of Heart Failure (PEERLESS-HF) Trial

BackgroundLeft ventricular (LV) remodeling predicts poor outcomes in heart failure (HF) patients. The HeartNet® cardiac restraint device (Paracor Medical Inc., Sunnyvale, CA) may reduce LV remodeling and improve functional capacity, quality of life, and outcomes in HF patients. To evaluate the safety and efficacy of the HeartNet Ventricular Support System in HF patients receiving optimal medical therapy. Methods and ResultsProspective, randomized, controlled, multicenter trial in patients with symptomatic HF and LV ejection fraction ≤35% on optimal medical and device therapy. The primary efficacy end points were changes in peak VO2, 6-minute walk (6MW) distance, and Minnesota Living with Heart Failure (MLWHF) quality of life score at 6 months. The primary safety end point was all-cause mortality at 12 months. Because the planned adaptive interim analysis of the first 122 subjects with a completed 6-month follow-up indicated futility to reach the peak VO2 end point, trial enrollment was suspended. Hence, the results on the 96 treatment and 114 control subjects are reported. Groups were similar at baseline. At 6 months, responder frequency for a prespecified improvement was similar between groups for peak VO2 (P = .502) and MLWHF score (P = .184) but borderline higher for improvement in 6MW distance in the treatment compared with the control group (33 [38%] vs. 25 [25%]; P = .044). At 6 months, the treatment group had a significantly greater improvement in Kansas City Cardiomyopathy Questionnaire (KCCQ) (P < .001) and decrease in LV mass (P = .032), LV end-diastolic diameter (P = .015), LV end-systolic diameter (P = .032), and LV end-diastolic volume (P = .031) as compared with controls. At 12 months, all-cause mortality and responder rates were similar in the 2 groups. Success rate for the HeartNet implantation was 99%. ConclusionEnrollment in the trial was stopped because an interim analysis showed futility of reaching the peak VO2 end point. However, because of the device safety and favorable signals for LV remodeling and quality of life, further investigation of this device is warranted.

Pharmacologic Strategies to Target Oxidative Stress in Heart Failure

Reactive oxygen species (ROS), which are involved in normal physiological functions at low concentrations, can have deleterious effects when produced in excess. Over time, ROS may result in a pathological state of imbalance known as oxidative stress. Oxidative stress has long been implicated in many diseases, and is consistently associated with poor outcomes in heart failure. Most therapies that are currently being used may provide some reduction in oxidative stress, but there is no consensus on the clinical outcomes of various antioxidants. Currently, there are no antioxidant therapies that are being used routinely to specifically target oxidative stress in patients with heart failure. This article reviews the current understanding of ROS generation, and the potential for novel pharmacologic strategies to target oxidative stress in heart failure.

Progressive Rise in Red Cell Distribution Width Is Associated With Disease Progression in Ambulatory Patients With Chronic Heart Failure

BackgroundSingle red cell distribution width (RDW) assessment is a consistent prognostic marker of poor outcomes in heart failure as well as in other patient cohorts. The objective of this study was to determine the prognostic value of sequential RDW assessment in ambulatory patients with chronic heart failure. Methods and ResultsWe reviewed 6,159 consecutive ambulatory patients with chronic heart failure between 2001-2006 and examined changes in RDW values from baseline to 1-year follow-up. Clinical, demographic, laboratory, and ICD-9 coding data were extracted from electronic health records, and all-cause mortality was followed over a mean follow-up of 4.4 ± 2.4 years. In this study cohort, median baseline RDW was 14.9%. RDW >16% at baseline (18.5% of cohort) was associated with a higher mortality rates than RDW ≤16%. For each +1% increment of baseline RDW, the risk ratio for all-cause mortality was 1.17 (95% confidence interval [CI] 1.15–1.19; P < .0001). At 12-month follow-up (n = 1,601), a large majority of subjects (68% in first tertile, 56% in second tertile of baseline RDW) showed rising RDW and correspondingly higher risk for all-cause mortality (risk ratio for +1% increase in changes in RDW was 1.08 (95% CI 1.03–1.13; P = .001). This effect was independent of anemia status or other baseline cardiac or renal indices, and particularly strong in those with lower baseline RDW. ConclusionsIn our ambulatory cohort of patients with chronic heart failure, baseline and serial increases in RDW were associated with poor long-term outcomes independently from standard cardiac, hematologic, and renal indices.

Predicting Poor Outcomes in Heart Failure

Health plans must prioritize disease management efforts to reduce hospitalization and mortality rates in heart failure patients. We developed a risk model to predict the 5-year risk of mortality or hospitalization for heart failure among patients at a large health maintenance organization. We identified 4696 patients who had an echocardiogram and a heart failure diagnosis from 1999 to 2004.We observed a 56% five-year risk of hospitalization for heart failure or death (95% confidence interval, 54% to 58%). The hazard ratios for echocardiogram data contributed statistically significantly to the model, but echocardiogram findings did not improve our ability to predict risk accurately once we had accounted for demographic characteristics and clinical findings. A more complex model demonstrated a modest capacity to accurately predict risk. Our risk model discriminated the highest- and lowest-risk patients with limited success-the observed risk was 3 times higher in the highest risk quintile, compared with the lowest-risk quintile. Using data available from electronic health records, we developed a series of risk-prediction models for poor outcomes in patients with heart failure. We found that a relatively simple model is as effective as a more complex model, but that all the models predict with only modest accuracy. Until better prediction variables are available for heart failure patients, our prediction model may be valuable for prioritizing centralized disease management program efforts by stratifying patients according to their absolute risk of poor outcomes.