ESC report

European Heart Journal (2006) 27, 27252736

doi:10.1093/eurheartj/ehl193

EuroHeart Failure Survey II (EHFS II): a survey on

hospitalized acute heart failure patients:
description of population
Markku S. Nieminen1*, Dirk Brutsaert2, Kenneth Dickstein3, Helmut Drexler4, Ferenc Follath5,
Veli-Pekka Harjola1, Matthias Hochadel6, Michel Komajda7, Johan Lassus1,
Jose Luis Lopez-Sendon8, Piotr Ponikowski9, and Luigi Tavazzi10 on behalf of the EuroHeart Survey
Investigators
1

Received 30 March 2006; revised 21 June 2006; accepted 27 July 2006; online publish-ahead-of-print 25 September 2006

See page 2619 for the editorial comment on this article (doi:10.1093/eurheartj/ehl332)

KEYWORDS
Acute heart failure;
EuroHeart Survey;
Echocardiography;
Demographics;
Treatment

Aims The objective of the EuroHeart Failure Survey II (EHFS II) was to assess patient characteristics,
aetiology, treatment, and outcome of acute heart failure (AHF) in Europe in relation to the guidelines
on the diagnosis and treatment of AHF published by the European Society of Cardiology.
Methods and results Patients hospitalized for AHF were recruited by 133 centres in 30 European countries.
Three thousand ve hundred and eighty patients were entered into the database by the end of August
2005. Mean age was 70 years, and 61% of patients were male. New-onset AHF (de novo AHF) was diagnosed
in 37%, of which 42% was due to acute coronary syndromes (ACS). Clinical classication according to the
guidelines divided AHF patients into (i) decompensated HF (65%), (ii) pulmonary oedema (16%), (iii) HF and
hypertension (11%), (iv) cardiogenic shock (4%), and (v) right HF (3%). Coronary heart disease, hypertension, and atrial brillation were the most common underlying conditions. Arrhythmias, valvular dysfunction, and ACS were each present as precipitating factor in one-third of cases. Preserved left ventricular
ejection fraction (
45%) was observed in 34%. Valvular disorders were common, especially mitral regurgitation (MR) which was reported on echocardiography in 80% of patients. Median length of stay was 9
days, and in-hospital mortality 6.7%. At discharge, 80% of patients were on angiotensin-converting
enzyme-inhibitors or angiotensin receptor blockers, whereas 61% were taking beta-blocker medication.
Conclusion Decompensated HF is the most common clinical presentation of AHF patients. More than
one-third of AHF patients do not have a previous history of HF, and new-onset HF is often caused by
ACS. Preserved systolic function is found in a substantial proportion of the patients. The prevalence of
valvular dysfunction is strikingly high and contributes to the clinical presentation. The EHFS II on AHF
veried that the use of evidence-based HF medication was well adopted to clinical practice.

Introduction
Heart failure (HF) is one of the most important causes of
morbidity and mortality in the industrialized world.1 The
prevalence of symptomatic HF is estimated to range from
0.4 to 2.0% in general European population.2 The incidence
increases rapidly with age, and in Europe, the mean age
of HF population is 74 years.36 Although the number of
deaths due to HF has risen generally with the ageing of

* Corresponding author. Tel: 358 9 47172200; fax: 358 9 47174015.

E-mail address: markku.nieminen@hus.

populations, there seems to be a trend towards improvement in survival, more clearly among men.710
Characteristics, clinical presentation, treatment, and
outcomes of HF patients in the acute decompensated
phase have not been adequately described, in part
because a clear denition of acute HF (AHF) has been
lacking. The EuroHeart Failure Survey I (EHFS I) with
11 327 patients described the demographics of acutely hospitalized HF patients as well as those in hospital with possible HF.11,12 The ADHERE registry has data on over 100 000
hospitalizations for AHF from the USA.13 In-hospital mortality was 4 and 7%, in ADHERE and EHFS I, respectively.

& The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Division of Cardiology, Department of Medicine, Helsinki University Central Hospital, Haartmaninkatu 4, PO Box 340, 00029
HUS, Finland; 2 Department of Cardiology, A.Z Middelheim Hospital, University of Antwerp, Belgium; 3 Cardiology Division,
Stavanger University Hospital, Norway; 4 Abt. Kardiologie u. Angiolgie, Zentrum Innere Medizin, Med. Hochschule Hannover
r
(MHH), Germany; 5 Department of Internal Medicine, University Hospital Zurich, Switzerland; 6 Stiftung Institut fu
Herzinfarktforschung, Ludwigshafen, Germany; 7 Cardiology Department, CHU Pitie Salpetriere, Paris, France; and
8
Department of CardiologyPlanta 1, Hospital Universitario La Paz, Madrid, Spain; 9 Department of Cardiology, Military
Hospital, Wroclaw, Poland; 10 Divisione di Cardiologia, Policlinico san Matteo, I.R.C.C.S, Pavia, Italy

2726

M.S. Nieminen et al.

The primary objective of EuroHeart Failure Survey II (EHFS

II) was to assess characteristics and management of AHF
patients across Europe in relation to the guidelines on the
diagnosis and treatment of AHF published by the European
Society of Cardiology (ESC).14 Specic issues addressed in
this second EuroHeart Failure Survey were to evaluate: (i)
aetiology and precipitating factors of AHF in Europe in
general, (ii) patient characteristics for acute new-onset of
HF (de novo AHF) and for acute decompensated chronic HF
(ADCHF), and (iii) for clinical groups classied according to
ESC AHF guidelines.14 Furthermore, diagnostic processes
and therapies including devices were evaluated. Length of
stay (LOS) and in-hospital mortality were registered.

Clinical history, symptoms and signs, and medication (admission

as well as discharge) were recorded. The pre-hospital medical
history including previous HF, coronary heart disease (CHD), hypertension, renal failure (dened as any of the following: patients
serum creatinine recurrently .177 mmol/L (.2.0 mg/dL) at
present or in the past or patient on dialysis or with a renal transplant), atrial brillation, diabetes, and precipitating factors, such
as arrhythmias, acute coronary syndromes (ACS), and valvular disorders, were entered into the CRF. The medical management of
HF before and during hospitalization was registered. The most
recent echocardiography data were collected. Diastolic dysfunction
was classied by the investigator as mild, moderate, or severe
according to the generally accepted echocardiographic criteria.15

Methods

The data are presented as absolute numbers and percentages and

medians with interquartile range (IQR). For age and ejection fraction (EF), means and standard deviations are given. Subgroups
were compared by x2 test with respect to dichotomous variables,
by Cochran-Armitage test with respect to ordinal categorical variables and by MannWhitney U test with respect to continuous variables. Changes in the prescription rates of drugs between admission
and discharge were assessed by McNemars test. A signicance level
of 0.05 was assumed and all P-values are the results of two-tailed
tests. The statistical computations were performed using SAS,
version 9.1 (Cary, NC, USA).

Results
The EHFS II collected data from 3580 patients of which 3.5%
were collected from Northern Europe, 20.4% from Western
Europe, 34.4% from Central Europe, and 42.4% from
Mediterranean Europe.

Inclusion criteria
EHFS II recruited patients admitted to hospital (emergency area,
internal medicine/cardiology wards, CCU, or ICU) with dyspnoea
and verication of HF (new-onset AHF or ADCHF) based on (i) symptoms (dyspnoea) and signs (i.e. rales, hypotension, hypoperfusion,
right ventricular HF) of HF and (ii) lung congestion on chest X-ray.

Classication of included patients

The patients were classied by the attending physician according to
the guidelines on AHF by the ESC.14 The class of high output HF was
not recorded by the EHFS II. ADCHF was dened as worsening of HF
in patients with a previous diagnosis or hospitalization for HF and
new-onset AHF (de novo AHF) as AHF in patients with no prior
history of HF. The severity and pattern of the AHF patients were
assessed and classied as follows.
(i) Decompensated HF: dyspnoea or tachycardia and pulmonary
congestion or interstitial oedema veried by chest X-ray
(ii) Pulmonary oedema: HF accompanied by alveolar oedema in
the chest X-ray or with O2 saturation ,90% (without supplemental oxygen)
(iii) Cardiogenic shock: AHF accompanied by low blood pressure
(SBP , 90 mmHg) and oliguria (,0.5 mL/kg/h for at least
6 h) or low cardiac index (,2.2 L/min/m2).
(iv) HF and hypertension: high blood pressure (.180/100 mmHg)
accompanied by symptoms of HF (dyspnoea and tachycardia)
and radiological ndings of pulmonary congestion or oedema
and with preserved left ventricular (LV) function at index hospitalization or before.
(v) Right HF: HF due to right-sided pathophysiology with
increased jugular venous pressure and liver size and usually
accompanied by peripheral oedema as unique or concomitant
to left HF.

Baseline characteristics of de novo AHF vs. ADCHF

patients
The baseline characteristics according to previous history of
HF of patients enrolled in EHFS II are shown in Table 1. AHF
patients were elderly, mean age 69.9 (SD 12.5) years and
61% male. Males were younger, 67.8 (12.4) years, compared
with the females 73.1 (12.0) years (P , 0.01). Figure 1
shows the age distribution by decade and gender. In all,
there were marked differences in baseline characteristics
between the CHF patients (63%) who were hospitalized
due to worsening HF (ADCHF) and the new-onset AHF (de
novo AHF) patients (37%), (Table 1).
Although there were only minor differences in age and
gender distribution between ADCHF and de novo AHF
patients, concomitant diseases were signicantly more
common in patients with ADCHF (Table 1). CHD and hypertension were the most frequent underlying diseases and
often co-existent. Dilated cardiomyopathy was present in
25% cases of ADCHF patients. Atrial brillation or utter
was extremely prevalent (47%) in ADCHF patients
(Table 1). The majority (73%) of ADCHF patients was
admitted with decompensated HF. Although decompensated
HF was the most common presentation in de novo AHF as
well, pulmonary oedema (26%) and cardiogenic shock (7%)
were signicantly more prevalent than that in ADCHF
patients (Figure 2).

Precipitating factors for AHF hospitalization

The cause of hospitalization for HF differed in de novo AHF
and ADCHF groups. ACS was the major precipitating factor

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

The patients were screened at the emergency area, including

cardiac care unit (CCU) and intensive care unit (ICU), as well as on
ward facilities (internal medicine and cardiology) of the 133 participating hospitals [university hospitals (47%), community or district
hospitals (49%), and private clinics (4%)] in 30 European countries.
The centres were invited by the ESC EuroHeart network. The participating centres were voluntary and a minimum of 20 patients per
centre was expected to be collected. The patient recruitment for
this registry and data collection were performed from 21 October
2004 until 31 August 2005. Data collection ofcers of the participating centres had access to the electronic case report form (CRF)
through login on the EuroHeart Survey website for online data
entry. The statistical analyses were carried out in agreement with
the Helsinki study centre, Finland, and EuroHeart Survey organization in the Biostatistical centre in Ludwigshafen, Germany.

Statistical analysis

EHFS II: a survey on hospitalized AHF patients

2727

Table 1 Underlying diseases and precipitating factors of EHFS II AHF patients

Characteristics

Total

ADCHF

De novo AHF

P-value

Number (%)
Age, mean (SD)
Male (%)

3580
69.9 (12.5)
61.3

2251 (62.9%)
69.5 (12.1)
63.7

1329 (37.1%)
70.5 (13.1)
57.3

,0.01
,0.001

53.6
62.5
32.8
38.7
13.3
34.4
16.8
14.7
19.3
9.1
19.3

62.0
64.3
34.4
46.5
14.7
43.8
20.2
16.8
21.5
12.0
25.1

39.4
59.4
30.0
25.4
11.0
18.5
11.0
11.3
15.7
4.3
9.5

,0.001
,0.01
,0.01
,0.001
,0.01
,0.001
,0.001
,0.001
,0.001
,0.001
,0.001

Precipitating factors (on admission)

ACS (%)
STEMI
Non-STEMI
Unstable angina
Arrhythmia (%)
Valvular cause (%)
Infection (%)
Non-compliance with therapy (%)

30.2
11.1
10.0
9.1
32.4
26.8
17.6
22.2

23.1
6.0
7.1
9.9
32.5
30.3
19.2
31.8

42.2
19.7
14.8
7.7
32.2
20.8
15.0
6.9

,0.001
,0.001
,0.001
,0.05
NS
,0.001
,0.01
,0.001

P-value for difference between ADCHF and de novo AHF. TIA, transient ischaemic attack. Renal failure dened as any of
the following: patients serum creatinine recurrently .177 mmol/L (.2.0 mg/dL) at present or in the past or patient on
dialysis or with renal transplant; anaemia as reported.

Figure 1

Age distribution by gender in EHFS II.

in patients with de novo AHF, present in 42% of cases, in

which the ACS mostly was due to myocardial infarction
(MI). Arrhythmia was equally prevalent as precipitating
factor in AHF patients, regardless of previous history of HF.
Valvular disorders, infections, and non-compliance to medication were more common in ADCHF (Table 1).

16.2 and 11.4% of patients, respectively. Cardiogenic shock

was seen in 3.9% and RV HF in only 3.2% at presentation.
Differences between clinical classes are summarized in
Table 2.
In decompensated HF, over two-thirds had a history of HF
(ADCHF). Valvular disease and atrial brillation or utter
were common as underlying diseases. Important precipitating factors were arrhythmias (33%) and valvular causes
(30%). Non-compliance to HF medication was also assessed
to cause decompensation of HF in almost 25% in this group.
Pulmonary oedema and cardiogenic shock were mostly
precipitated by an acute coronary event (49 and 72%,
respectively), often with subsequent MI. ST-elevation MI
(STEMI) was the cause of ACS in 55% of cases with cardiogenic shock, which is a signicantly higher proportion than
in any other clinical class. In contrast, non-STEMI was most
often present in the pulmonary oedema group, in which
hypertension was very prevalent as underlying disease
(70%), and diabetes was also more frequent (Table 2).
Almost all (95%) patients presenting with hypertensive HF
had a previous history of hypertension, other underlying diseases being similar to other groups in frequency.
In the right HF class, atrial brillation and valvular diseases were prevalent as both precipitating factors and
underlying conditions, whereas only 38% had a history of
CHD.

Patient characteristics by clinical class

Decompensated HF was the most common clinical presentation, accounting for about two-thirds of cases (Figure 2).
Pulmonary oedema and hypertensive HF were present in

Clinical and echocardiographic ndings

Overall, the median blood pressure was 135/80 mmHg, IQR
110160/7090 mmHg. In hypertensive HF, blood pressure

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Underlying diseases (%)

CHD
Hypertension
Diabetes mellitus
Atrial brillation/utter
Previous stroke or TIA
Valvular disease
Renal failure
Anaemia
Chronic obstructive pulmonary disease
Pacemaker implanted
Dilated cardiomyopathy

2728

M.S. Nieminen et al.

was 170/100 mmHg (IQR 145200/80110 mmHg), whereas

in cardiogenic shock, it was 90/59 mmHg (IQR 75109/
4368 mmHg). Heart rates were elevated (median 95 bpm,
IQR 77114 bpm), especially in pulmonary oedema and cardiogenic shock in which the median heart rate measured on
admission ECG was 100 bpm. Median respiratory rates were

20 breaths/min in all classes and in pulmonary oedema
as high as 28 breaths/min.
Echocardiography results were available in the majority of
patients enrolled in EHFS II, and of these, 89% (2733/3062)
had reported LVEF. Overall mean LVEF was 38%, but de
novo AHF patients had slightly higher mean LVEF (42 vs.
36%; P , 0.0001) compared with ADCHF patients (Table 3).
Especially severely depressed LV function (LVEF , 30%) was
more common in the ADCHF group (34.6 vs. 21.3%;
P , 0.0001). In contrast, preserved LVEF
45% was
present in 34.3% of the whole study population (42.8% in
de novo AHF vs. 29.6% in ADCHF patients, P , 0.0001).
Left atrial diameter was enlarged to a median value of
47 mm.
Valvular disorders were common, as shown in Table 3. MR
was extremely frequent and reported in four out of ve
patients. Although usually mild, even moderate to severe
regurgitation was found in 43% in the study population
(Figure 3). MR was followed in prevalence by tricuspid
valve regurgitation(TR) and aortic valve regurgitation (AR).
Stenotic valve diseases were less common, aortic stenosis
(AS) of moderate to severe degree present in 9%, with no
difference between de novo AHF and ADCHF patients.
Looking at the differences between clinical classes, moderate to severe MR was present in nearly half of the patients

with decompensated HF and was very frequent in patients

with cardiogenic shock and pulmonary oedema as well, 41
and 38%, respectively (Table 3). In right HF, MR was less
common, whereas TR was found in 84% of cases in this
group and 2/3 of TR were assessed as moderate to severe.
Pulmonary oedema was associated with moderate to
severe AS in 12% of patients. In hypertensive HF, MR was
prevalent but mostly mild, whereas stenotic valve disease
was uncommon.

Procedures and treatment

Diagnostic investigations and procedures performed during
hospitalization are listed in Table 4. BNP and NT-proBNP
measurements were recorded in only 16% of study population and there was great variation in sampling rate by
centre (092% of patients recruited/centre). Transthoracic
or transesophageal echocardiography was performed in
90% of patients, of which 85% during the index hospitalization in a median time of 1 day from admission. The remaining echocardiography data were from the preceding year.
Pulmonary artery catheter was used for haemodynamic guidance in 5% overall, but in not more than 25% of patients in
the cardiogenic shock group.
In the acute phase, 93% received diuretic treatment,
mostly by intravenous (iv) bolus or continuous infusion
(Table 5). Nitrate or nitroprusside iv was used in as many
as 71% in the pulmonary oedema group. However, their use
in hypertensive HF and cardiogenic shock did not differ
from the study population overall. Beta-blockers were
given intravenously to 10%, mainly in patients with ACS or

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Figure 2 Distribution of patients by clinical classication of AHF. Inserted table shows the distribution separately in all patients and patients with de novo AHF,
as well as ADCHF. ***P , 0.0001 between de novo AHF and ADCHF.

EHFS II: a survey on hospitalized AHF patients

2729

Table 2 Baseline characteristics and precipitating factors by clinical classication of EHFS II patients
Characteristics

Total

Decomp. HF

Pulmonary
oedema

Cardiogenic
shock

Hypert. HF

Right HF

No. of patients (% of total)

Age (years), mean (SD)
Age, IQR
Male (%)
Body mass index (kg/m2)
New-onset AHF (%)
Hospitalization for HF within last
12 months (%)

3580
69.9 (12.5)
62.678.7
61.3
26.8
37.1
44.5

2340 (65.4)
69.7 (12.8)
62.378.7
62.1
26.5
29.7
48.0

581 (16.2)
71.2 (11.5)
64.679.7
59.4
26.9
59.6
33.7

139 (3.9)
67.3 (12.7)
59.577.2
67.6
26.4
64.7
29.3

407 (11.4)
69.8 (11.2)
61.978.4
60.4
28.0
37.3
45.1

113 (3.2)
69.6 (13.4)
63.079.5
50.4
26.6
39.8
46.4

53.6
62.5
32.8
38.7
13.3
34.4
16.8
14.7
19.3
9.1
19.3

54.0
56.0
30.9
41.3
12.4
37.5
16.6
15.0
19.2
10.6
21.8

54.9
70.1
39.4
28.1
15.7
26.2
15.8
15.7
19.3
5.9
11.4

52.5
54.0
34.3
24.6
11.8
18.0
18.1
14.4
18.1
10.8
10.2

53.8
94.6
34.5
37.7
16.0
31.7
18.7
11.3
18.0
4.9
20.2

38.1
52.2
29.2
58.4
13.3
43.8
17.7
16.8
27.4
8.8
15.9

Precipitating factors (on admission)

ACS (%)
STEMI
Non-STEMI
Unstable angina
Arrhythmia (%)
Atrial
Ventricular
Valvular cause (%)
Infection (%)
Non-compliance with therapy (%)

30.2
11.1
10.0
9.1
32.4
29.4
4.1
26.8
17.6
22.2

24.7
8.4
7.7
8.6
32.9
30.1
3.7
30.2
18.5
24.6

49.4
17.0
22.4
10.0
29.3
25.7
5.2
24.1
17.1
16.9

71.9
55.4
12.9
3.6
29.7
18.8
13.0
17.4
11.8
7.9

24.4
4.7
5.4
14.3
34.5
34.0
2.0
12.6
15.6
21.9

14.2
6.2
5.3
2.7
33.9
33.0
2.7
32.7
17.1
18.1

TIA, transient ischaemic attack. Renal failure dened as any of the following: patients serum creatinine recurrently .177 mmol/L (.2.0 mg/dL) at present
or in the past or patient on dialysis or with renal transplant; anaemia as reported.

atrial brillation. Amiodarone was used in 18% of cases.

Ventilatory support was given in 14% of all patients. The
need for endotracheal intubation and mechanical ventilation was high (37%) in cardiogenic shock patients
(Table 5). The most frequently used inotropes were dopamine (11%) and dobutamine (10%), and levosimendan was
given to 4%. The use of vasoactive medication, as well as
treatment with levosimendan and amiodarone, was highest
in cardiogenic shock patients, of whom not more than
one-third was treated with an intra-aortic balloon pump
(IABP). Angiography and percutaneous coronary intervention
(PCI) were more often performed in groups with high prevalence of ACS and/or CHD. Thrombolysis was performed in
20%, PCI in 38%, and coronary artery bypass graft (CABG)
in 4% of STEMI patients during the index hospitalization.
Revascularization procedures were less frequent in NSTEMI
patients.

Cardiovascular medication
Medications on admission and at discharge are listed in
Table 6. There was an increase in use of HF medication
during hospitalization. Overall, beta-blockers (43% on
admission increased to 61% at discharge), angiotensinconverting enzyme (ACE)-inhibitors (5571%), and

aldosterone
antagonists
(spironolactone/eplerenone,
2848%) were more often prescribed to patients at
discharge.
There was, as expected, a difference in medication on
admission between patients with and without a history of
HF (Table 6). At discharge, de novo AHF patients less frequently had diuretics, and an aldosterone antagonist was
used in only 36% of patients when compared with 54% in
ADCHF patients. ACE-inhibitors and angiotensin receptor
blockers were prescribed in similar proportions at discharge.
Beta-blockers were more frequently used in de novo AHF
patients (66 vs. 59% in ADCHF, P , 0.001).

In-hospital mortality and LOS

In-hospital mortality in EHFS II was 6.7%. De novo AHF
patients had a higher in-hospital mortality compared
with ADCHF patients (8.1 vs. 5.8%, P , 0.001) (Table 7 and
Figure 4). Among clinical groups, in-hospital mortality was
extremely high in cardiogenic shock patients (39.6%). In pulmonary oedema and right HF, prognosis was also worse than
average. The best survival was seen in hypertensive HF, as
almost all patients were discharged alive.
Median LOS in all patients was 9 days (IQR 614). Half of
the patients were treated in ICU or CCU, and their median

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Underlying diseases (%)

CHD
Hypertension
Diabetes mellitus
Atrial brillation/utter
Previous stroke or TIA
Valvular disease
Renal failure
Anaemia
Chronic obstructive pulmonary disease
Pacemaker implanted
Dilated cardiomyopathy

2730

M.S. Nieminen et al.

Table 3 Echocardiographic ndings by previous history of HF and by clinical class

Variable

All

ADCHF

De novo
AHF

Decomp HF

Pulm.
oedema

Cardiog.
shock

Hypert. HF Right HF

ECHO available (n)

3062
1928
1134
1991
525
121
328
97
60 (5367)
55 (4860)
59 (5266) 56 (5061) 55 (4861) 56 (5061) 50 (4357)
LVEDD (mm), median (IQR)*
58 (5165)
EF% mean (SD)*
38 (15)
36 (15)
42 (16)
37 (15)
40 (14)
33 (15)
44 (13)
48 (16)
LVEF , 30 (%)
29.9
34.6
21.3
34.6
23.1
48.1
12.0
10.1
LVEF 3044 (%)
35.8
35.8
35.9
35.7
38.4
27.9
37.3
26.6
LVEF
45 (%)
34.3
29.6
42.8
29.7
38.4
24.0
50.7
63.3
LA (mm), median (IQR)*
47 (4252)
48 (4354)
45 (4050)
48 (4254) 45 (4050) 43 (4047) 45 (4150) 47 (3952)
49.5
35.4
15.1

47.3
36.3
16.3

53.3
33.8
12.9

48.2
33.1
18.7

51.3
40.9
7.8

43.8
42.5
13.7

53.6
36.8
9.6

54.7
32.1
13.2

Mitral regurgitation (%)*

None
Mild
Moderate
Severe

20.2
36.6
31.2
12.1

15.7
35.1
34.6
14.6

27.9
39.1
25.3
7.7

18.4
34.3
33.3
14.0

23.4
38.8
30.8
7.0

19.5
39.8
28.3
12.4

22.4
43.0
24.9
9.7

33.0
45.7
13.8
7.4

Tricuspid regurgitation(%)*
None
Mild
Moderate
Severe

38.6
31.4
22.4
7.5

31.1
31.7
27.4
9.8

51.6
30.8
13.9
3.7

34.3
31.0
26.3
8.4

53.2
31.3
13.1
2.4

44.0
33.9
16.5
5.5

46.3
33.2
15.0
5.4

16.3
30.4
25.0
28.3

LVEDD, LV end-diastolic diameter; LA, left atrial (transversal) diameter.

*P , 0.0001 for difference between de novo AHF and ADCHF groups.
**P , 0.05.

stay in ICU/CCU was 3 days (IQR 25). Cardiogenic shock and

pulmonary oedema patients needed ICU/CCU treatment in a
higher proportion compared with other clinical classes. LOS
was similar regardless of previous history of HF, and even in
different clinical classes, the differences were surprisingly
small (Table 7). Taking into account only the patients discharged alive, LOS increased in the cardiogenic shock
group to 13 days (IQR 1019), whereas LOS in other clinical
groups did not change substantially; 9 days (IQR 614) for
decompensated HF, 10 days (IQR 615) for pulmonary
oedema, 8 days (IQR 612) for hypertensive HF, and 12
days (IQR 717) for right HF.

Discussion
EHFS II is specically targeted on AHF. In EHFS II, only
patients hospitalized due to AHF, either de novo AHF or
ADCHF, were included, and they were classied according
to the current ESC guidelines on AHF. This is the rst time
this classication was used systematically and describes
the frequency and background of various forms of AHF.
High output HF was not recorded as it is rare and a not wellrecognized patient group. There are very few other studies
or surveys which have analysed the aetiology and management of AHF. The largest registry ADHERE13 contains information from individual hospitalizations, and the registry is
collected retrospectively based on discharge diagnosis,
probably missing some acute new-onset HF patients,
especially patients with ACS may not be included in full. A
recent paper described AHF patients treated in cardiology
wards in Italy, which had more selected and severe patient

population (nearly half with pulmonary oedema) compared

with the present study.16
In EHFS II, the mean age was similar to previous surveys
and registries of AHF patients both in Europe and in the
USA.1618 Co-morbidities were abundant, CHD and hypertension being the most common and often co-existing. Nearly
40% of the patients in EHFS II did not have a previous
history of HF, in other words, had de novo AHF. In this
group, ACS was a major precipitating factor. A signicant
proportion of AHF patients had preserved LV function,
which is in concordance with previous reports11,13,19
stating again that up to 50% of HF patients have preserved
systolic function.

Precipitating factors
Arrhythmias, valvular dysfunction and ACS were each
present as precipitating factor in almost one-third of AHF
hospitalizations. Infections and non-compliance to medication superimposed on these factors, the latter predominantly in patients with a previous history of HF.
Arrhythmias were common in all groups and mostly of
atrial origin. Atrial brillation has previously been reported
in high frequency in AHF patients,13,19,20 and in EHFS II, it
played a signicant role, both as underlying condition and
precipitating factor. Nearly half of the ADCHF patients had
a history of atrial brillation which was also reected on
the use of anticoagulant therapy.

CHD and ACS in AHF

CHD is the most frequent cause of HF and also seen as concomitant disease in patients with ADCHF. EHFS II further

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Diastolic dysfunction (%)**

None or mild
Moderate
Severe

EHFS II: a survey on hospitalized AHF patients

2731

cardiogenic shock group where about one-third of all

arrhythmias were of ventricular origin. Despite higher
prevalence of chronic CHD, diabetes, and renal failure in
ADCHF patients, this higher clinical risk prole for coronary
events did not translate into higher frequency of ACS.

Valvular disorders

Figure 3 Graph of prevalence of valvular dysfunction in AHF patients. The

graph shows the prevalence of mild vs. moderate to severe valvular dysfunction in the study population overall (A) and separately in de novo AHF (B) and
ADCHF patients (C). AS, aortic valve stenosis; MS, mitral valve stenosis; MR,
mitral valve regurgitation.

demonstrates that ACS was the most important precipitating

factor in patients with de novo AHF. In cardiogenic shock and
pulmonary oedema, only 40% had a previous history of HF,
but more than half of the patients had an ACS as precipitating factor.
The relative distribution of ACS types is also interesting,
as non-STEMI was mostly found in the pulmonary oedema
group. In contrast, over half of the patients with cardiogenic
shock presented with concomitant STEMI. This is in line with
the previous reports that STEMI is the most common form of
ACS in cardiogenic shock,21 and underlines the importance
and need for invasive treatment. In EuroHeart ACS survey,
the proportion of ST-elevation ACS decreased with age.22
Furthermore, in their study, the prevalence of pulmonary
oedema was low (,5%) in younger age groups but up to
20% of the octogenarians. Indeed, pulmonary oedema
patients were older than cardiogenic shock patients in
EHFS II as well. Ischaemia leading to systolic or diastolic dysfunction may precipitate pulmonary oedema in the elderly,
whereas STEMI more often leads to output failure and
cardiogenic shock. Myocardial ischaemia may also provoke
ventricular arrhythmias, as observed particularly in the

Diversity of AHF patients

The differences observed between groups, de novo AHF and
ADCHF on one hand and clinical classes on the other hand,
have important implications. First, they emphasize the
diversity and heterogeneity of AHF patients. Identication
of more distinct entities helps us to direct our treatment
efforts more correctly, targeting underlying conditions and
precipitating factors. Secondly, they highlight the lack of
evidence for treatment of major subclasses of AHF, such as
patients with preserved LVEF. More precisely dened AHF
patient categories, as suggested in the ESC guidelines on
AHF, should be used as a base for systematic clinical
research to improve prognosis. Further investigations
testing the efcacy of different treatment regimens in predened classes are urgently needed.

Diagnostic procedures
Nearly all patients underwent ECG and chest X-ray.
Echocardiography was performed during the initial hospitalization in the majority of patients, especially in de novo AHF,
or fairly recent echocardiographic data were available for
patient evaluation. In-hospital echocardiography was done
in most cases within rst days of hospitalization. The rate
of echocardiography early during hospitalization is amazingly high and clearly higher than that in EHFS I11 and
shows excellent adherence to current HF guidelines.1,14

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Valvular dysfunction was reported as the precipitating factor

in almost one-third of patients with ADCHF. The prevalence
of valvular disorders reported in this survey is far higher
than in any previous HF study. History of haemodynamically
signicant or symptomatic valvular disease was present in
one-third of the patients, but on echocardiography more
than four out of ve had some degree of disturbance in valvular function. In ADCHF patients, regurgitant valvular disorders were signicantly more common than in de novo
AHF. However, the nding that 72% of de novo AHF and
84% of ADCHF patients had evidence of MR is most important, especially because the grade of MR was assessed as
moderate to severe in over 40% of cases. This is not necessarily due to primary valve disease, but may be caused by
degeneration of valvular and cardiac structures with both
cardiac remodelling and increasing age. Tricuspid regurgitation was common as well and reects haemodynamic conditions in AHF. The high prevalence of atrioventricular
valve dysfunction is possibly overestimated as it was
reported by echocardiography done early during the initial
hospitalization in a high percentage of patients. The frequency and severity of this valve dysfunction may diminish
as a result of therapy and unloading of the ventricle. AS
was most common in patients presenting with pulmonary
oedema and may contribute to the clinical presentation.
No echocardiography follow-up data were recorded in the
present study.

2732

M.S. Nieminen et al.

Table 4 Diagnostic investigations and procedures by clinical class

Procedure % performed

Total

Decomp. HF

Pulmonary
oedema

Cardiogenic
shock

Hypert. HF

Right HF

ECG
Chest X-ray
ECHOa
BNP/NT-proBNP
Angiographyb
CT scan
MRI
EP study
Holter ECG
Exercise test
Arterial Line
PAC

99.9
97.7
85.0
16.3
36.5
4.0
0.8
1.6
12.5
4.4
8.1
5.3

99.9
97.6
83.6
17.2
35.6
4.0
0.9
1.8
12.4
4.7
5.9
3.9

100
98.8
86.5
14.6
44.2
3.6
0.5
2.1
13.3
3.4
14.6
7.9

100
94.2
91.0
11.5
66.7
5.8
2.2
1.4
5.0
2.2
34.5
25.4

100
98.8
89.8
14.8
21.7
1.2
0.5
1.0
14.1
5.2
3.5
2.7

99.1
96.5
81.7
17.9
27.5
14.2
0.9
0.0
12.4
4.4
6.2
4.4

ECHO, echocardiography; MRI, magnetic resonance imaging; EP, electrophysiology; PAC, pulmonary artery catheter.
a
Performed during index hospitalization.
b
Performed during index hospitalization or within 1 year of admission.

Treatment % performed

Total

Decomp. HF

Pulmonary
oedema

Cardiogenic
shock

Hypert. HF

Right HF

Ventilatory supporta
Invasive mechanical ventilation
Diuretic
Oral
Iv bolus
Infusion
Beta-blocker
Opioids
Iv nitrate
Iv nitroprusside
Iv inotrope
Adrenaline
Dobutamine
Dopamine
Levosimendan
Noradrenaline
Amiodarone
Heparin (UFH)
LMWH
Blood transfusion
PCI
CABG
IABP
Pacemaker
ICD

13.9
5.1
92.9
8.6
72.1
12.3
10.1
19.4
37.8
0.9

8.1
2.3
94.6
10.3
71.7
12.6
10.4
13.5
30.4
0.5

31.5
11.0
97.6
3.6
81.9
12.1
8.3
38.3
70.6
2.1

56.1
36.7
77.5
0.0
58.7
18.8
9.4
49.3
36.5
2.2

7.4
1.7
82.8
8.7
68.6
5.5
11.1
18.2
39.7
1.2

14.2
4.4
88.5
8.0
58.4
22.1
10.6
10.7
8.6
0.0

1.8
10.2
11.3
3.9
2.6
17.5
18.7
41.0
5.9
8.4
1.8
2.2
2.7
1.2

1.2
8.6
8.5
4.4
1.2
16.8
17.8
38.3
5.2
6.4
1.6
1.2
2.4
1.4

2.6
13.3
15.8
3.8
4.5
18.8
18.8
54.6
7.9
10.2
3.1
1.4
3.8
0.9

15.8
44.6
65.5
7.9
24.5
32.1
45.7
37.0
10.1
40.6
4.3
30.9
5.0
2.9

0.0
2.0
2.2
0.2
0.7
14.8
15.9
37.8
3.5
7.0
0.5
0.5
1.7
0.5

1.8
14.2
12.4
0.9
2.7
16.8
15.2
43.8
12.4
7.1
0.9
0.0
3.5
0.0

UFH, unfractionated heparin; LMWH, low-molecular-weight heparin; ICD, implantable cardioverter/debrillator.

a
Ventilatory support continuous positive airway pressure/non-invasive positive pressure ventilation/invasive mechanical
ventilation (intubated).

Mean LVEF was reduced in all clinical categories except

hypertensive and right HF. However, preserved LVEF was
common in all clinical groups, comprising on average
one-third of the overall population. As data were recorded
in some patients solely before hospitalization, the proportion of patients with preserved LV function may be overestimated. In contrast, early in-hospital echocardiography

may overestimate the prevalence of valvular dysfunction

as discussed previously. Nevertheless, diastolic dysfunction
of at least moderate degree was present in half of the
studied subjects. This should be expected in an elderly
population with high prevalence of hypertension. Indeed,
abnormal relaxation of the left ventricle plays an important
role in precipitating AHF.

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Table 5 Acute cardiac care by clinical class

EHFS II: a survey on hospitalized AHF patients

2733

Table 6 Medication on admission and at discharge by history of HF

Prescription rates

Admission
All
n 3580

ADCHF
n 2251

De novo AHF
n 1329

All
n 3338

ADCHF
n 2118

De novo AHF
n 1220

71.2
28.1
55.0
9.3
63.1
43.2
86.0
27.7
17.8
4.4
26.6
12.9

83.2
37.9
63.3
9.6
71.6
46.5
94.1
31.8
16.1
4.9
34.4
16.3

50.5*
11.4*
40.8*
8.9
48.6*
37.6*
72.2*
20.6*
20.8
3.4
13.3*
7.2*

90.1**
47.5**
71.1**
10.4
80.2**
61.4**
98.6**
32.9**
14.6**
4.5
31.0**
17.6**

94.0**
54.3**
72.0**
10.4
81.1**
58.9**
98.9**
35.3
13.4**
5.4
36.5
20.6**

83.4*,**
35.7*,**
69.5**
10.6
78.8**
65.7*,**
98.0**
28.7*,**
16.7
3.0
21.4*,**
12.4*,**

42.9
7.9
24.0

44.6
7.2
29.3

40.0
8.9
14.8*

49.4**
13.4**
33.1**

46.4
9.8**
36.9**

54.6*,**
19.6*,**
26.6*,**

28.4
16.6
17.0
13.6

28.3
18.3
17.1
13.9

28.5
13.8
16.9
13.1

41.8**
20.9**
17.3
14.4

38.4**
22.8**
17.7
14.6

47*,**
17.7**
16.7
14.2

ARB, angiotensin receptor blocker.

*P , 0.0001 between ADCHF and de novo AHF.
**P , 0.0001 between admission and discharge.

Table 7 Outcomes and LOS in EHFS II

Variable

All

ADCHF

De novo
AHF

Decomp. HF

Pulm.
oedema

Cardiog.
shock

Hypert. HF

Right HF

In-hospital mortality (n)

LOS days, median (IQR)
% staying in ICU/CCU
ICU/CCU stay days, median (IQR)
Life-threatening arrhythmias (%)

239/3580
9 (614)
51.0
3 (25)
4.7

131/2250
9 (614)
46.3
3 (25)
3.9

108/1329
9 (515)
59.0
3 (25)
6.2

116/2340
9 (615)
44.4
3 (25)
3.6

53/581
10 (615)
76.0
3 (25)
7.2

55/139
10 (417)
92.7
4 (28)
24.5

6/407
8 (612)
41.3
3 (15)
1.7

9/113
11 (717)
43.6
3 (25)
2.7

Median LOS reported as for all patients (including in-hospital deaths). Median LOS in ICU/CCU for patients admitted to these units during index
hospitalization.

Management and mortality of hospitalized AHF

patients
In the management of AHF, ventilatory support and inotropic
therapy were needed in a large proportion of patients with
cardiogenic shock, in which IABP was used in not more
than one-third of the patients. It seems, though, that the
use of IABP in patients with cardiogenic shock has increased
during the past few years.21 The use of vasoactive medication in the cardiogenic shock group exceeded that of
other clinical classes taken all together. Invasive diagnostic
and therapeutic procedures were more common in patients
with cardiogenic shock or pulmonary oedema. Still, arterial
line was used only in one-third of the patients and
pulmonary artery catheter in one-fourth of the patients in
cardiogenic shock. Despite intensive treatment efforts,

in-hospital mortality in this category remained very high,

as has also been previously reported.16,21
With respect to medication, EHFS II provides important
information on the state of implementation of guidelines.
HF medication was rather well implemented at discharge
in EHFS II patients. Although it is difcult to assess contraindications as possible reasons for not prescribing HF medication, it is still possible to point out trends and evaluate
adherence to guidelines. An analysis from EHFS I recently
found that underutilization of evidence-based medication
is only in part explained by the differences between the
general HF population and patients enrolled in clinical
trials.23 In contrast, HF patients with preserved systolic
function are common, and treatment strategies in this
group are less well dened. The use of iv beta-blocking

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Cardiovascular medication
Diuretic
Spironolactone/eplerenone
ACE-inhibitors (ACE-I)
ARB
ACE-inhibitor or ARB
Beta-blocker (BB)
BB/ACE-I/ARB/diuretic
Oral nitrate
Calcium channel blocker
Other vasodilator
Digitalis compound
Antiarrhythmic drug
Antithrombotic agents
Aspirin
Clopidogrel
Vitamin K antagonist
Other medication
Lipid regulating drug
Other CV medication
Oral antihyperglycaemic therapy
Insulin

Discharge

2734

M.S. Nieminen et al.

In-hospital mortality in EHFS II by history of HF and clinical class.

agents in EHFS II was mainly in patients with ACS or atrial

brillation which is in line with the ESC guidelines.14
Diuretics were widely used as basic therapy as recommended, but the use of vasodilators seemed lower than
expected in AHF. In contrast, inotropes were rather frequently used. Medication data will be analysed further and
more detailed analyses will evaluate, for example,
whether the recommendations for the use of iv therapies
in the ESC guidelines on AHF were followed.
EHFS II shows that agents acting on the reninangiotensin
system (i.e. ACE-inhibitors, angiotensin receptor blockers,
and aldosterone antagonists) are more frequently used
than just a few years earlier, when the rst HF survey was
conducted.12 Furthermore, prescription of ACE-inhibitors
and angiotensin receptor blockers to ADCHF patients
increased during hospital stay so that four out of ve
patients were on either medication at the time of discharge.
In de novo AHF patients, treatment with these drugs was
implemented as well, and at discharge there was no difference in the use of these drugs compared with ADCHF
patients. Beta-blocker use has also increased during the
past few years. Still, less than half of the patients with previous history of HF were taking a beta-blocker on admission.
Beta-blocker medication was initiated in a signicant proportion during hospital stay both in ADCHF and in de novo
AHF, with a slightly higher prescription rate at discharge in
de novo AHF patients.
In-hospital mortality in EHFS II was similar to the European
surveys,12,16 and slightly higher than in reports from the
USA.13,17 LOS was on average 2 days shorter compared
with EHFS I, although differences in study populations preclude drawing any general conclusions about changes in outcomes and management of AHF patients. Interestingly, no
clear differences in LOS were seen between groups of clinical severity. When only patients discharged alive were considered, median LOS in cardiogenic shock increased by 3
days and had the longest in-hospital stay. Other groups
were not markedly affected. It is still noteworthy that in
both cases LOS in de novo AHF and ADCHF was similar. As
expected, patients with pulmonary oedema and cardiogenic

shock were admitted to ICU/CCU for treatment more often

than other clinical classes, but the LOS in these units was
on average short.

Limitations of the study

Surveys based on voluntary participation and recruitment of
patients have limitations that have to be acknowledged.
First, centres attending to the survey may be biased
toward bigger and more active hospitals. Secondly, patient
recruitment activity differs between countries and centres,
and proportions in the study population do not reect the
general population. The limited number of centres and the
fact that not all European countries took part in the survey
also restricts the possibility to generalize the results, and
the data are representative for the participating centres
only. Inclusion criteria aimed at identifying patients with
veried AHF, but the nal diagnosis was not conrmed centrally. The clinical classication was also assessed locally.
Some overlap in classications may occur, as reporting and
adherence to classication criteria are dependent on discretion of the participating investigators. Furthermore, no centralized reading of echocardiographic results was done.

Conclusions
EHFS II provides up-to-date information on demographics,
characteristics, and underlying conditions of AHF patients
as well as aetiology, investigation, and treatment practices
of AHF in Europe. It is the rst European survey to include
patients admitted primarily for AHF. Patients were classied
according to whether or not they had a previously known
diagnosis of HF. Furthermore, EHFS II allows comparison
between groups based on the clinical classication of the
ESC guidelines on the diagnosis and treatment of AHF.
Demographics and characteristics are well in line with previous reports and with results from the previous EuroHeart
Failure Survey.
ACS, valvular dysfunction, and arrhythmias were the most
common precipitating factors, with the dominance of each

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Figure 4

EHFS II: a survey on hospitalized AHF patients

of these factors being somewhat different depending on

patient class. The nding of valvular dysfunction in a large
majority of patients is remarkable. Adherence to treatment
guidelines and the use of HF medication have improved since
the rst survey on HF in Europe. Outcomes are similar to
other reports, the in-hospital mortality being nearly identical to the previous survey. The EHFS II provides comprehensive information for further in-detail analyses on AHF, and
follow-up data are currently being collected.

Acknowledgement
EuroHeart Failure Survey II was endorsed by the Heart Failure
Association of the European Society of Cardiology, former Working
Group of Heart Failure.
Conict of interest: none declared.

Heart Failure II Expert Committee: M. Nieminen (Survey Chairman)

and V.-P. Harjola (Research Fellow), Finland; D. Brutsaert, Belgium;
M. Komajda, France; H. Drexler, Germany; L. Tavazzi, Italy;
K. Dickstein, Norway; Piotr Ponikowski, Poland; Jose Luis LopezSendon, Spain; Ferenc Follath, Switzerland.
EuroHeart Survey Team (European Heart House, France): Malika
Manini (Operations Manager), Claire Bramley (Data Monitor),
Valerie Laforest (Data Monitor), Charles Taylor (Database
Administrator).
Statistical analysis centre (Ludwigshafen am Rhein, Germany):
M. Hochadel (Statistician).
National Coordinators: Austria, Kurt Huber; Belgium, Guy De
Backer; Bulgaria, Vera Sirakova; Czech Republic, Roman Cerbak;
Denmark, Per Thayssen; Egypt, Osama Abdel Aziz, Khalid Tammam;
Finland, Seppo Lehto; France, Franc
ois Delahaye; Georgia, Bondo
Kobulia; Germany, Uwe Zeymer; Greece, Dennis Cokkinos, Dimitrios
Krematisnos; Hungary, Kristof Karlocai; Ireland, Emer Shelley;
Israel, Shlomo Behar; Italy, Aldo Maggioni; Lithuania, Virginija
Grabauskiene; The Netherlands, Jaap Deckers; Norway, Inger
Asmussen; Poland, Janina Stepinska; Portugal, Lino Gonc
alves;
Russia, Vyacheslav Mareev; Serbia and Montenegro, Zonara
Vasilijevic; Slovakia, Igor Riecansky; Slovenia, Miran F. Kenda;
Spain, Jose
Luis Lopez-Sendon; Sweden, Annika Rosengren;
Switzerland, Peter Buser; Turkey, Tugrul Okay; Ukraine, Oleg
Sychov; UK, Peter Schoeld.
There was no national coordinator in participating countries
which are not mentioned in the above list.
EuroHeart Survey Board Committee: Anselm Gitt (Chairman),
Germany; L. Tavazzi, Italy; R. Seabra Gomes, Portugal; J. Marrugat
de la Iglesia, Spain; L. Wallentin, Sweden; P. Kearney, Ireland;
R. Boyle, UK; M.L. Simoons (Ad hoc Consultant), The Netherlands.
List of Industry Sponsors: Main Sponsors: Abbott Laboratories,
GlaxoSmithKline Services Unlimited; Roche Diagnostics GmbH;
Sano-Synthelabo Groupe.
List of Institutions: Czech Society of Cardiology, Fe
de
ration Fran
caise de Cardiologie; Hellenic Cardiological Society; Italian
Federation of Cardiology; Portuguese Society of Cardiology;
Spanish Society of Cardiology; The Netherlands Heart Foundation.
Participating Centres, Investigators, and Data Collection Ofcers
Armenia:
Liana
Tumasyan, Armen
Nargizyan, Arman
Astvatsatryan, Yerevan; Kristine Margaryan, Alina Ohanyan,
Yerevan. Austria: Kurt Huber, Gabriele Jakl, Vienna. Belgium: Dirk
Brutsaert, Carl Convens, Antwerpen. Bulgaria: Stefan Naydenov
Naydenov, Soa; Assen Rachev Goudev, Kalina Koleva, Soa;
Valentin Petrov, Asen Petrov, Shoumen; Snejana Tisheva, Virginia
Jordanova, Nadia Stancheva, Pleven; Vera Sirakova, Yavor

Peychev, Varna. Croatia: Duska Glavas, Split; Vjekoslava Raos,

Irena Ivanac, Zagreb. Czech Republic: Jiri Vitovec, Hana
Pavelcikova, Brno; J. Kautzner, Ivan Malek, Ruzena Jandova,
Prague; Petr Zajicek, Valasske Mezirici; Hana Rosolova, Hess
Zdenek, Pilsen; Jindrich Spinar, Milan Sepsi, Brno. Egypt: Khalid
Ahmed Al Khashab, Fayoum; Aly Saad, Zagazig; Heba Farouk,
Cairo. Estonia: Julia Reinmets, Toomas Marandi, Tallinn. Finland:
Seppo Lehto, Kirsti Savolainen, Kuopio; Markku Nieminen, VeliPekka Harjola, Mervi Pietila, Helsinki. France: Jean Marco,
Frederic Petit, Toulouse; Patrick Jourdain, Pontoise; Nicolas
Danchin, Sylvie Marinier, Paris; Francois Delahaye, Armelle
Delahaye, Lyon; Daniel Galley, Christine Beltra, Albi; Claude Gully,
La Roche sur Yon; Michel Komajda, Celine Fratini-Lefol, Paris; JeanPierre Bassand, Marie-France Seronde, Denis Pales Espinosa,
Besancon. Georgia: Konstantine Nodar Liluashvili, Tbilisi; Gulnara
Tabidze, Irina Jashi, Levan Tvildiani, Tbilisi. Germany: Ralph
Winkler, Ludwigshafen am Rhein; Thomas Rehm, Duisburg. Greece:
Antonios Dimopoulos, G. Athanassopoulos, G. Giamouzis, Natassa
Tsiavou, Athens; Athanasios Trikas, C. Stefanadis, Andreas
Synetos, Athens; Apostolos Karavidas, Ioannis Fotiadis, Andreas
Kaoukis, Dimitrios A. Korres, Athens; Ioannis Vogiatzis, Veria;
Alexandros Gotsis, Stella Ntourtsiou, Paraskevi Bozia, Komotini;
John Nanas, Stavros Drakos, Athens; Gerasimos Filippatos, Virginia
Markou, Athens; Dimitra Kontogianni, D. Babalis, Charalambos
Grassos, G. Goranitou, Athens; Alexandros Douras, Lambros
Papakosmas, Athanasios Koutroubas, Themistoklis Tsaknakis, Volos;
Petros Stravopodis, Antonios Kassimatis, Zakynthos; Efstathia
Prappa, John Kandylas, Manolis Paximadakis, Athens; Stavros
Kakouros, Margetis Panagiotis, Athens; John Parissis, Katerina
Fountoulaki, Dimitrios Farmakis, Athens; P.E. Vardas, Alexander
Patrianakos, Heraklion; Ioannis Skoularigis, Nicolaos Prattis,
Larisa; M. Zairis, Stefanos Foussas, Nikolaos Patsourakos, Pireus.
Hungary: Istvan Preda, Eva Csoti, Budapest; Andrea Badics,
Szekesfehervar. Israel: Menashe Epstein, Rehovot. Italy:
G. Rosano, Rome; Lorenza Robiglio, Antonio Pesola, Lido di
Camaiore; Franco Naccarrella, Giovannina Lepera, Stefano
Sdringola Maranga, Bologna; Francesco Gentile, Chiara Benchini,
Cinisello Balsamo; Annamaria Nicoletti, Emidio Feraco, Silvio
Vena, Cosenza; Pietro Agricola, Crema; Alberto De Bernardi, Maria
Teresa Spinnler, Moncalieri; Rita Mariotti, Pisa; Luigi Tavazzi, Carlo
Campana, Pavia; Luigi Tarantini, Belluno. Lithuania: Ausra
Kavoliuniene, Vaida Mizariene, Kaunas; Virginija Grabauskiene,
Ruta Jasaityte, Vilnius; Vitas Vysniauskas, D. Petraskiene,
Marijampole; Rasa Raugaliene, Kaunas. Moldova: Eleonora
Vataman, Victor Priscu, Kishinau. Poland: Michal Marchel,
Grzegorz Opolski, Warszawa; Piotr Ponikowski, Pawel Siwolowski,
Wroclaw; Wladyslaw Sinkiewicz, Piotr Sobanski, Bydgoszcz;
Zbigniew Gasior, Daniel Jakubowski, Katowice; Beata Malczewska,
Nowy Dwor Mazowiecki. Portugal: Ana Oliveira Soares, Rafael
Ferreira, Joao Ribeiro, Amadora; Marisa Trabulo, Carnaxide; Pedro
Costa Ferreira, Viseu; Aurora Andrade, Vila Nova de Gaia; Rui
Teixeira Almeida, Porto; Jose Silva Cardoso, Claudia Santos, Porto.
Romania: Cristian Podoleanu, Attila Frigy, Targu-Mures; Maria
Dorobantu,
Ana-Gabriela
Fruntelata,
Bucharest.
Russian
Federation: Mariya Sitnikova, Mariya Trukshina, St Petersburg.
Serbia and Montenegro: Masar Gashi, Prishtina UNMIK Kosova;
Zorana Vasiljevic, Ana Vojvodic, Belgrade; Milutin Miric, Natasa
Markovic, Goran Loncar, Belgrade; Jelica Milosavljevic, Snezana
Ivanovic, Jagodina; Zoran Stajic, Zorica Nikolic, Zdravko
Mijailovic, Belgrade. Slovenia: Mitja Lainscak, Murska Sobota;
Stojan Kariz, Simon Ralca, Katarina Thaler, Izola; Bojan Vrtovec,
Gregor Poglajen, Ljubljana. Spain: F. Fernandez Aviles, Manuel
Gomez Bueno, Pedro Mota Gomez, Valladolid; Jose Azpitarte
Almagro, Raquel del Valle Fernandez, Granada; Francisco Ridocci
Soriano, Mercedes Nadal, Victoria Jacas, Valencia; Eduardo de
Teresa, Manuel Jimenez-Navarro, Carlos Sanchez-Gonzalez,
Antonio Mun
oz-Garcia, Malaga; Enrique Galvo Basilio, Anna Diaz
Calvo, Barcelona; Jose Luis Lopez-Sendon, Jose Juan Gomez de
Diego, Madrid; Manuel Mendez, Nuria Munoz, Madrid; Norbero

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Appendix: organization of the survey

2735

2736

References
1. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M,
Tavazzi L, Smiseth O A, Gavazzi A, Haverich A, Hoes A, Jaarsma T,
Korewicki J, Levy S, Linde C, Lopez-Sendon J L, Nieminen M S,
Pierard L, Remme W J. Guidelines for the diagnosis and treatment of
chronic heart failure: executive summary (update 2005). The task force
for the diagnosis and treatment of chronic heart failure of the
European Society of Cardiology. Eur Heart J 2005;26:11151140.
2. Cowie MR, Mosterd A, Wood DA, Poole-Wilson PA, Sutton GC, Grobbee DE.
The epidemiology of heart failure. Eur Heart J 1997;18:208225.
3. Murdoch DR, Love MP, Robb SD, McDonagh TA, Davie AP, Ford I, Capewell
S, Morrison CE, McMurray JJ. Importance of heart failure as a cause of
death: changing contribution to overall mortality and coronary heart
disease mortality in Scotland 19791992. Eur Heart J 1998;19:18291835.
4. Cleland JG, Gemmell I, Khand A, Boddy A. Is the prognosis of heart failure
improving? Eur J Heart Fail 1999;1:229241.
5. Wilhelmsen L, Rosengren A, Eriksson H, Lappas G. Heart failure in
the general population of menmorbidity, risk factors and prognosis.
J Intern Med 2001;249:253261.
6. Cowie MR, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, Suresh V,
Sutton GC. Incidence and aetiology of heart failure; a population-based
study. Eur Heart J 1999;20:421428.
7. MacIntyre K, Capewell S, Stewart S, Chalmers JW, Boyd J, Finlayson A,
Redpath A, Pell JP, McMurray JJ. Evidence of improving prognosis in
heart failure: trends in case fatality in 66 547 patients hospitalized
between 1986 and 1995. Circulation 2000;102:11261131.
8. Barker WH, Mullooly JP, Getchell W. Changing incidence and survival for
heart failure in a well-dened older population, 19701974 and
19901994. Circulation 2006;113:799805.
9. Kearney MT, Marber M. Trends in incidence and prognosis of heart failure;
you always pass failure on the way to success. Eur Heart J 2004;
25:283284.
10. Schaufelberger M, Swedberg K, Koster M, Rosen M, Rosengren A. Decreasing one-year mortality and hospitalization rates for heart failure in
Sweden; data from the Swedish hospital discharge registry 1988 to
2000. Eur Heart J 2004;25:300307.

11. Cleland JG, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC,

Dietz R, Gavazzi A, Hobbs R, Korewicki J, Madeira HC, Moiseyev VS,
Preda I, van Gilst WH, Widimsky J, Freemantle N, Eastaugh J, Mason J.
The EuroHeart failure survey programmea survey on the quality of
care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 2003;24:442463.
12. Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, Cohen-Solal A,
Dietz R, Gavazzi A, Van Gilst WH, Hobbs R, Korewicki J, Madeira HC,
Moiseyev VS, Preda I, Widimsky J, Freemantle N, Eastaugh J, Mason J,
Study Group on Diagnosis of the Working Group on Heart Failure of
the European Society of Cardiology. The EuroHeart failure survey programmea survey on the quality of care among patients with heart
failure in Europe. Part 2: treatment. Eur Heart J 2003;24:464474.
13. Adams KF Jr, Fonarow GC, Emerman CL, LeJemtel TH, Costanzo MR,
Abraham WT, Berkowitz RL, Galvao M, Horton DP, ADHERE Scientic
Advisory Committee and Investigators. Characteristics and outcomes of
patients hospitalized for heart failure in the United States: rationale,
design, and preliminary observations from the rst 100,000 cases in the
acute decompensated heart failure national registry (ADHERE). Am
Heart J 2005;149:209216.
14. Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G,
Hasin Y, Lopez-Sendon J, Mebazaa A, Metra M, Rhodes A, Swedberg K,
Priori SG, Garcia MA, Blanc JJ, Budaj A, Cowie MR, Dean V, Deckers J,
Burgos EF, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth
OA, Dickstein K, Albuquerque A, Conthe P, Crespo-Leiro M, Ferrari R,
Follath F, Gavazzi A, Janssens U, Komajda M, Morais J, Moreno R,
Singer M, Singh S, Tendera M, Thygesen K. Executive summary of the
guidelines on the diagnosis and treatment of acute heart failure: the
task force on acute heart failure of the European Society of Cardiology.
Eur Heart J 2005;26:384416.
15. Sohn DW, Chai IH, Lee DJ, Kim HC, Kim HS, Oh BH, Lee MM, Park YB, Choi
YS, Seo JD, Lee YW. Assessment of mitral annulus velocity by doppler
tissue imaging in the evaluation of left ventricular diastolic function.
J Am Coll Cardiol 1997;30:474480.
16. Tavazzi L, Maggioni AP, Lucci D, Cacciatore G, ANsalone G, Olivia F, Porcu
M, on behalf of the Italian survey on Acute Heart Failure Investigators.
Nationwide survey on acute heart failure in cardiology ward services in
Italy. Eur Heart J 2006;27:12071215.
17. Gheorghiade M, Zannad F, Sopko G, Klein L, Pina IL, Konstam MA, Massie
BM, Roland E, Targum S, Collins SP, Filippatos G, Tavazzi L. Acute heart
failure syndromes: current state and framework for future research.
Circulation 2005;112:39583968.
18. Nieminen MS, Harjola VP. Denition and epidemiology of acute heart
failure syndromes. Am J Cardiol 2005;96:5G10G.
19. Rudiger A, Harjola VP, Muller A, Mattila E, Sa
ila
P, Nieminen M, Follath
F. Acute heart failure: clinical presentation, one-year mortality and
prognostic factors. Eur J Heart Fail 2005;7:662670.
20. Januzzi JL Jr, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser
DG, Tung R, Cameron R, Nagurney JT, Chae CU, Lloyd-Jones DM, Brown
DF, Foran-Melanson S, Sluss PM, Lee-Lewandrowski E, Lewandrowski KB.
The N-terminal pro-BNP investigation of dyspnea in the emergency
department (PRIDE) study. Am J Cardiol 2005;95:948954.
21. Iakobishvili Z, Behar S, Boyko V, Battler A, Hasdai D. Does current treatment of cardiogenic shock complicating the acute coronary syndromes
comply with guidelines? Am Heart J 2005;149:98103.
22. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, Hasdai
D. Age, clinical presentation, and outcome of acute coronary syndromes in
the EuroHeart acute coronary syndrome survey. Eur Heart J 2006;27:789795.
23. Lenzen MJ, Boersma E, Reimer WJ, Balk AH, Komajda M, Swedberg K,
Follath F, Jimenez-Navarro M, Simoons ML, Cleland JG. Under-utilization
of evidence-based drug treatment in patients with heart failure is only
partially explained by dissimilarity to patients enrolled in landmark
trials: A report from the Euro Heart survey on heart failure. Eur Heart
J 2005;26:27062713.

Downloaded from http://eurheartj.oxfordjournals.org/ by guest on January 16, 2016

Herrera Guttierez, Joaquin Ruiz, Juan Ramon Siles Rubio, Cabra;

Isabel Antorrena Miranda, Teresa Lozano, Isabel Selles, Pablo
Oteo, Villajoyosa; Vicente Montagud Balaguer, Antonio Salvador
Sanz, Valencia; Angeles Alonso Garcia, Alfredo Serrano, Madrid;
Fransisco Epelde Gonzalo, Terrassa; Fernando Ruiz Rejon, David
Marti Sanchez, Madrid; Inmaculada Roldan Rabadan, Madrid;
Antoni Bayes Genis, Barcelona; Jose Antonio Gomez Guindal,
Puerto del Rosario; Cristobal Lozano Cabezas, Jaen; Miguel
A. Rodriguez Garcia, Leon; Josep Comin Colet, Barcelona; Eulalia
Roig Minguell, Barcelona; Miguel Angel Ulecia Martinez, Juliana
Caballero Gueto, Granada; Maria Luaces Mendez, Pontevedra.
Switzerland: Ferenc Follath, Rita Pitsch, Zurich. The Netherlands:
J.W. Deckers, Chr. G. Jansen, Rotterdam; Christel Ephraim,
Zwolle, Meppel; R. Brons, Meppel; J.H.C. Panis, Rotterdam; C.W.
Leenders, Rotterdam; M.J. Veerhoek, M. Kamps, Rotterdam;
R. Haan, Harderwijk; L. Baur, Adrie van den Dool, Heerlen;
H.J.G.M. Crijns, R. Nieuwlaat, H. Fransen, Maastricht; Theo
Kessels, L. Eurlings, Venlo; M.J. De Boer, Zwolle; Herman Broers,
Tilburg; C. Werter, Roermond; M.Bijl, S. Versluis, Dordrecht.
Tunisia: Salem Kachboura, Zied Belhadj, Ariana. Turkey: Mustafa
Kemal Erol, Erzurum; Cihangir Uyan, Bolu; Atila Iyisoy, Ankara.
Ukraine: Vasyl Netiazhenko, Oleg Lykov, Kiev.

M.S. Nieminen et al.