TRI-SCORE and benefit of intervention in patients with severe tricuspid regurgitation.

BACKGROUND AND AIMS: Benefit of tricuspid regurgitation (TR) correction and timing of intervention are unclear. This study aimed to compare survival rates after surgical or transcatheter intervention to conservative management according to a TR clinical stage as assessed using the TRI-SCORE. METHODS: A total of 2,413 patients with severe isolated functional TR were enrolled in TRIGISTRY (1217 conservatively managed, 551 isolated tricuspid valve surgery, and 645 transcatheter valve repair). The primary endpoint was survival at 2 years. RESULTS: The TRI-SCORE was low (≤3) in 32%, intermediate (4-5) in 33%, and high (≥6) in 35%. A successful correction was achieved in 97% and 65% of patients in the surgical and transcatheter groups, respectively. Survival rates decreased with the TRI-SCORE in the three treatment groups (all P < .0001). In the low TRI-SCORE category, survival rates were higher in the surgical and transcatheter groups than in the conservative management group (93%, 87%, and 79%, respectively, P = .0002). In the intermediate category, no significant difference between groups was observed overall (80%, 71%, and 71%, respectively, P = .13) but benefit of the intervention became significant when the analysis was restricted to patients with successful correction (80%, 81%, and 71%, respectively, P = .009). In the high TRI-SCORE category, survival was not different to conservative management in the surgical and successful repair group (61% and 68% vs 58%, P = .26 and P = .18 respectively). CONCLUSIONS: Survival progressively decreased with the TRI-SCORE irrespective of treatment modality. Compared to conservative management, an early and successful surgical or transcatheter intervention improved 2-year survival in patients at low and, to a lower extent, intermediate TRI-SCORE, while no benefit was observed in the high TRI-SCORE category.

Predictive value of the TRI-SCORE for in-hospital mortality after redo isolated tricuspid valve surgery.

OBJECTIVES: The TRI-SCORE reliably predicts in-hospital mortality after isolated tricuspid valve surgery (ITVS) on native valve but has not been tested in the setting of redo interventions. We aimed to evaluate the predictive value of the TRI-SCORE for in-hospital mortality in patients with redo ITVS and to compare its accuracy with conventional surgical risk scores. METHODS: Using a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centres between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and surgical scores were calculated. RESULTS: We identified 70 patients who underwent a redo ITVS (54±15 years, 63% female). Prior intervention was a tricuspid valve repair in 51% and a replacement in 49%, and was combined with another surgery in 41%. A tricuspid valve replacement was performed in all patients for the redo surgery. Overall, in-hospital mortality and major postoperative complication rates were 10% and 34%, respectively. The TRI-SCORE was the only surgical risk score associated with in-hospital mortality (p=0.005). The area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than for the logistic EuroSCORE (0.58) or EuroSCORE II (0.61). The TRI-SCORE was also associated with major postoperative complication rates and survival free of readmissions for heart failure. CONCLUSION: Redo ITVS was rarely performed and was associated with an overall high in-hospital mortality and morbidity, but hiding important individual disparities. The TRI-SCORE accurately predicted in-hospital mortality after redo ITVS and may guide clinical decision-making process (www.tri-score.com).

TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery.

AIMS: Isolated tricuspid valve surgery (ITVS) is considered to be a high-risk procedure, but in-hospital mortality is markedly variable. This study sought to develop a dedicated risk score model to predict the outcome of patients after ITVS for severe tricuspid regurgitation (TR). METHODS AND RESULTS: All consecutive adult patients who underwent ITVS for severe non-congenital TR at 12 French centres between 2007 and 2017 were included. We identified 466 patients (60 ± 16 years, 49% female, functional TR in 49%). In-hospital mortality rate was 10%. We derived and internally validated a scoring system to predict in-hospital mortality using multivariable logistic regression and bootstrapping with 1000 re-samples. The final risk score ranged from 0 to 12 points and included eight parameters: age ≥70 years, New York Heart Association Class III-IV, right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin, left ventricular ejection fraction <60%, and moderate/severe right ventricular dysfunction. Tricuspid regurgitation mechanism was not an independent predictor of outcome. Observed and predicted in-hospital mortality rates increased from 0% to 60% and from 1% to 65%, respectively, as the score increased from 0 up to ≥9 points. Apparent and bias-corrected areas under the receiver operating characteristic curves were 0.81 and 0.75, respectively, much higher than the logistic EuroSCORE (0.67) or EuroSCORE II (0.63). CONCLUSION: We propose TRI-SCORE as a dedicated risk score model based on eight easy to ascertain parameters to inform patients and physicians regarding the risk of ITVS and guide the clinical decision-making process of patients with severe TR, especially as transcatheter therapies are emerging (www.tri-score.com).

Isolated tricuspid valve surgery: impact of aetiology and clinical presentation on outcomes.

AIMS: The aim of this study was to identify determinants of in-hospital and mid-term outcomes after isolated tricuspid valve surgery (ITVS) and more specifically the impact of tricuspid regurgitation (TR) mechanism and clinical presentation. METHODS AND RESULTS: Among 5661 consecutive adult patients who underwent a tricuspid valve (TV) surgery at 12 French tertiary centres in 2007-2017 collected from a mandatory administrative database, we identified 466 patients (8% of all tricuspid surgeries) who underwent an ITVS. Most patients presented with advanced disease [47% in New York Heart Association (NYHA) III/IV, 57% with right-sided heart failure (HF) signs]. Tricuspid regurgitation was functional in 49% (22% with prior left-sided heart valve surgery and 27% isolated) and organic in 51% (infective endocarditis in 31% and other causes in 20%). In-hospital mortality and major complications rates were 10% and 31%, respectively. Rates of survival and survival free of HF readmission were 75% and 62% at 5 years. Patients with functional TR incurred a worse in-hospital mortality than those with organic TR (14% vs. 6%, P = 0.004), but presentation was more severe. Independent determinants of outcomes were NYHA Class III/IV [odd ratios (OR) = 2.7 (1.2-6.1), P = 0.01], moderate/severe right ventricular dysfunction [OR = 2.6 (1.2-5.8), P = 0.02], lower prothrombin time [OR = 0.98 (0.96-0.99), P = 0.008], and with borderline statistical significance, right-sided HF signs [OR = 2.4 (0.9-6.5), P = 0.06] while TR mechanism was not [OR = 0.7 (0.3-1.8), P = 0.88]. CONCLUSION: Isolated TV surgery was associated with high mortality and morbidity, both in hospital and during follow-up, predicted by the severity of the presentation but not by TR mechanism. Our results suggest that TV intervention should be performed earlier in the course of the disease.

Impact of Coronary Lesion Stability on the Benefit of Emergent Percutaneous Coronary Intervention After Sudden Cardiac Arrest.

BACKGROUND: Conflicting data exist regarding the benefit of urgent coronary angiogram and percutaneous coronary intervention (PCI) after sudden cardiac arrest, particularly in the absence of ST-segment elevation. We hypothesized that the type of lesions treated (stable versus unstable) influences the benefit derived from PCI. METHODS: Data were taken between May 2011 and 2014 from a prospective registry enrolling all sudden cardiac arrest in Paris and suburbs (6.7 million inhabitants). Patients undergoing emergent coronary angiogram were included. Decision to perform PCI was left to the discretion of local teams. We assessed the impact of emergent PCI on survival at discharge according to whether the treated lesion was angiographically unstable or stable, and we investigated the predictive factors for unstable coronary lesions. RESULTS: Among 9265 sudden cardiac arrests occurring during the study period, 1078 underwent emergent coronary angiogram (median age: 59.6 years, 78.3% males): 463 (42.9%) had an unstable lesion, 253 (23.5%) only stable lesions, and 362 (33.6%) no significant lesions. Emergent PCI was performed in 478 patients (91.4% of unstable and 21.7% of stable lesions). At discharge, PCI of unstable lesions was associated with twice-higher survival rate compared with untreated unstable lesions (47.9% versus 25.6%, P=0.013), while stable lesions PCI did not improve survival (25.5% versus 26.3%, P=1.00). After adjustment, PCI of unstable coronary lesions was independently associated with improved survival (odds ratio, 2.09 [95% CI, 1.42-3.09], P<0.001), contrary to PCI of stable lesions (odds ratio, 0.92 [95% CI. 0.44-1.87], P=0.824). Angina, initial shockable rhythm, ST-segment elevation, and absence of known coronary artery disease were independent predictors of unstable lesions. CONCLUSIONS: Emergent PCI of unstable lesions is associated with improved survival after sudden cardiac arrest, contrary to PCI of stable lesions. Accordingly, early PCI should only be performed in patients with unstable lesions. Four factors (chest pain, ST-elevation, absence of coronary artery disease history, and shockable initial rhythm) could help identify patients with unstable lesions who would, therefore, benefit from emergent coronary angiogram.

Computed tomography for transcatheter tricuspid valve development.

BACKGROUND: Patients with severe symptomatic tricuspid regurgitation (TR) are often deemed ineligible for surgical valve repair due to comorbidities. In this setting, transcatheter tricuspid valve replacement (TTVR) is undergoing development, but delivery technique and prosthesis design have yet to be optimized. We sought to assess the challenges of TTVR and the determinants of venous route using computed tomography (CT) analysis. METHODS AND RESULTS: A total of 195 end-diastolic cardiac CT performed prior to surgical correction of a severe TR (n = 38), transcatheter aortic valve replacement (n = 89), or left atrial appendage closure (n = 68) were analyzed. Patients with TR (n = 68; 19 primary and 49 secondary) were compared with patients without (n = 127). Continuous variables with normal and non-normal distributions were compared using Student t test or Mann-Whitney test respectively. The angle from the tricuspid annulus (TA) to the inferior vena cava was tighter (mean = 101 ± 18°) with a broader range of value (44° to 164°) than to the superior vena cava (mean = 143 ± 9°). Patients with TR had rounder TA (eccentricity index of 0.88 ± 0.08, p < 0.001), with a larger area (p < 0.0001), and septolateral (45.3 ± 8.0 mm, p < 0.0001) and anteroposterior (44.4 ± 7.4 mm, p < 0.0001) diameters than patients without. The distances from the TA to the coronary sinus, the right ventricular outflow tract, and the moderator band were respectively 11.4 ± 3.8 mm, 17.2 ± 3.4 mm, and 31.0 ± 6.7 mm, without differences between groups. CONCLUSION: The transjugular access for TTVR is straighter and more reproducible than the transfemoral access. Prosthesis development may be challenged by the close position of the coronary sinus, the presence of a moderator band, and the large TA size of patients with severe TR. KEY POINTS: • The tricuspid annulus is larger in patients with severe tricuspid regurgitation, confirming existing data. • The coronary sinus ostium is close to the tricuspid annulus, requiring a prosthesis with a short atrial length. • The transjugular venous route may be the preferred access to the tricuspid annulus, straighter with less inter-individual variations than the transfemoral route.

Peridevice Leak After Left Atrial Appendage Closure: Incidence, Risk Factors, and Clinical Impact.

BACKGROUND: Limited studies reported the rate and clinical impact of peridevice leaks (PDL) after percutaneous left atrial appendage closure (LAAC). METHODS: All consecutive patients with a nonvalvular atrial fibrillation admitted for LAAC between November 2011 and October 2016 were prospectively enrolled. The follow-up included clinical, transesophageal echocardiography, and/or cardiac computed tomography angiogram (CCTA). PDL was defined by the presence of contrast within the left atrial appendage on CCTA, and Major Adverse Cardiac Event (MACE) included stroke, device-related thrombosis, and cardiovascular death. RESULTS: Overall, 77 patients (mean CHA2DS2-VASc score = 4.4 ± 1.5 and mean HAS-BLED = 3.4 ± 1.1) were implanted using Amplatzer Cardiac Plug (n = 24), Amulet (n = 37), or Watchman devices (n = 16). Indications were stroke recurrence despite adequate oral anticoagulation (OAC, n = 6) or contraindication to long-term OAC (n = 71). From 3-month to 12-month CCTA follow-up, the PDL rate decreased from 68.5% to 56.7% (P = 0.02), without any difference between the various devices. Patients with PDL were more often in permanent atrial fibrillation, and had a larger landing zone diameter, a lower ratio of device compression, and a more frequent off-axis position of the device. A device compression ratio < 10% was the only parameter associated with PDL occurrence. During follow-up (median 236 days) the MACE rate was 9.1%, with no statistically significant difference between patients with vs without PDL (12% vs 4.3%, P = 0.3). CONCLUSIONS: The PDL rate detected by CCTA after LAAC was high, especially in cases with a low device compression ratio (< 10%), but decreased over time. The incidence of MACE was quantitatively greater with PDL, but the difference was not statistically significant. Larger studies are needed to determine the clinical importance of PDL.

Percutaneous Left Atrial Appendage Closure in Patients With Inferior Vena Cava Filters: A Case Series.

OBJECTIVES: Percutaneous procedures through femoral access in patients with inferior vena cava (IVC) filter may be at risk of complications. We evaluated the feasibility and safety of left atrial appendage (LAA) closure through femoral access in patients previously implanted with IVC filter. METHODS: From November 2011 to March 2018, a total of 5 patients with history of IVC filter implantation were referred to our center for percutaneous LAA closure, representing 3.6% of the 137 procedures performed during the study period. The IVC filter devices were placed from 2 to 26 months before the index procedure. RESULTS: LAA closure was successfully implanted in all cases using an Amulet device in 3 patients and a Watchman device in 2 patients. A femoral approach was performed in all patients using 12 or 14 Fr sheaths. Before crossing IVC filters, venographies did not detect any thrombus. All steps of IVC filter crossing were performed under fluoroscopic guidance. No immediate or late complications related to the procedure occurred after 10.1 ± 3.9 months of follow-up. CONCLUSION: LAA closure in patients with previously implanted IVC filter is safe as long as careful x-ray monitoring is observed.

Usefulness of echocardiographic-fluoroscopic fusion imaging in adult structural heart disease.

Percutaneous approaches to treat structural heart diseases are growing in number and complexity. Multimodality imaging is essential for planning and monitoring such interventions. The combination of three-dimensional transoesophageal echocardiography with fluoroscopy is the cornerstone of interventional imaging. However, these two modalities are displayed on separate screens, and are handled by different physicians, which requires a complex mental reconstruction for the interventional team. To overcome this issue, echocardiographic-fluoroscopic fusion imaging has been introduced recently in clinical practice. This system combines, in a single view, the precise visualization of catheter and devices provided by fluoroscopy with the continuous soft tissue information provided by echocardiography. In addition, the procedure may be guided using a marker-tracking mode. However, there are few data on how this new technology can have an impact on our routine clinical practice and patient outcomes. In this review, we provide a user manual for the system, discuss its potential clinical applications in adult structural heart diseases and consider future perspectives.

Long-term clinical outcomes in patients with cardiogenic shock according to left ventricular function: The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme.

BACKGROUND: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains a major concern. Failure of the left ventricular (LV) pump is the primary insult in most forms of CS, but other parts of the circulatory system and diastolic function contribute to shock. However, little is known of the clinical presentation, management and outcomes according to LV function in these patients. OBJECTIVES: To assess the presentation, management and clinical outcomes in patients admitted for AMI with CS according to early LV ejection fraction (LVEF), using long-term data from the French registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2010. METHODS: We analysed baseline characteristics, management and 3-year mortality in patients with CS, according to LVEF (≤40% vs>40%). The analyses were replicated in the FAST-MI 2005 cohort. RESULTS: Among 4169 patients with AMI included in the survey, the incidence of CS was 3.3%. LVEF was>40% in 43%. Early PCI (≤24hours) was used more often in patients with LV dysfunction (61% vs 42%), as was the use of optimal medical therapy at discharge (66% vs 40%). CS remained associated with a major increase in 3-year mortality, both in patients with LVEF ≤40% (55%) and in those with LVEF>40% (44%). Using Cox multivariable analysis, LVEF ≤40% was associated with higher 3-year mortality (hazard ratio 2.08, 95% confidence interval 1.15-3.78) in patients with AMI with CS. Consistent results were found in the replication cohort. CONCLUSIONS: Despite the many circulatory system contributors to the physiopathology of CS in patients with AMI, the occurrence of early LV systolic dysfunction is associated with higher long-term mortality.

Changes in One-Year Mortality in Elderly Patients Admitted with Acute Myocardial Infarction in Relation with Early Management.

BACKGROUND: Elderly patients are underrepresented in acute myocardial infarction trials. Our aim was to determine whether, in elderly patients, changes in management in the past 15 years are associated with improved 1-year mortality after hospital admission for myocardial infarction. METHODS: We used data from 4 1-month French registries, conducted 5 years apart from 1995 to 2010, including 3389 elderly patients (≥75 years of age). RESULTS: From 1995 to 2010, mean age remained stable (82.1 years), similar in ST- and non-ST-elevation myocardial infarction patients. Obesity, diabetes, hypertension, and hypercholesterolemia increased. History of prior myocardial infarction, stroke, and peripheral artery disease remained stable, while history of heart failure decreased. Major changes in management were noted: early percutaneous coronary intervention, early treatment with antiplatelet agents, low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and statins all increased. Early mortality after hospital admission decreased from 25.0% to 8.4%. One-year mortality decreased from 36.2% to 20.0% (adjusted hazard ratio 2010 vs 1995: 0.47, 0.39-0.57), both for ST-elevation myocardial infarction (36.8% to 21.1%) and non-ST-elevation myocardial infarction (34.8% to 19.1%). Mortality reduction was observed in all age groups, including those ≥85 years of age (from 46.2% to 31.4%). The study period, however, was no longer associated with decreased mortality when variables reflecting management changes were taken into account. CONCLUSIONS: Early and 1-year mortality after hospital admission of elderly patients with acute myocardial infarction has substantially decreased over the past 15 years. This improvement is likely mediated by increasing use of recommended management strategies. These data support the application of guidelines derived from trials mostly including younger patients to elderly populations as well.

Pathophysiology of dyspnoea in acute pulmonary embolism: A cross-sectional evaluation.

BACKGROUND AND OBJECTIVE: Dyspnoea in pulmonary embolism (PE) remains poorly characterized. Little is known about how to measure intensity or about the underlying mechanisms that may be related to ventilatory abnormalities, alveolar dead space ventilation or modulating factors such as psychological modulate. We hypothesized that dyspnoea would mainly be associated with pulmonary vascular obstruction and its pathophysiological consequences, while the sensory-affective domain of dyspnoea would be influenced by other factors. METHODS: We undertook a prospective study of 90 consecutive non-obese patients (mean ± SD age: 49 ± 16 years, 41 women) without cardiorespiratory disease. All patients were hospitalized with symptoms for <15 days and a confirmed PE (multi-detector computed tomography (MDCT) scan, n = 87 and high-probability ventilation/perfusion scan, n = 3). Patients underwent assessment of dyspnoea using the Borg score, modified Medical Research Council (mMRC) scale, assessment of psychological trait, state of anxiety and depression and chest pain via the Visual Analogical Scale at the time of maximum dyspnoea. Functional evaluations such as the quantitative ventilation-perfusion lung scan, echocardiography, alveolar dead space fraction and tidal ventilation measurements were completed within 48 h of admission. RESULTS: Multivariate analyses demonstrated that dyspnoea was mainly linked to pulmonary vascular obstruction and/or its consequences such as raised pulmonary arterial pressure and chest pain. The sensory-affective domain of dyspnoea showed additional determinants such as age, depression and breathing variability. CONCLUSION: Dyspnoea is mainly related to vascular consequences of PE such as increased pulmonary arterial pressure or chest pain. The sensory-affective domain of dyspnoea also correlates with age, depression and breathing variability.

ß blockers and mortality after myocardial infarction in patients without heart failure: multicentre prospective cohort study.

OBJECTIVE: To assess the association between early and prolonged ß blocker treatment and mortality after acute myocardial infarction. DESIGN: Multicentre prospective cohort study. SETTING: Nationwide French registry of Acute ST- and non-ST-elevation Myocardial Infarction (FAST-MI) (at 223 centres) at the end of 2005. PARTICIPANTS: 2679 consecutive patients with acute myocardial infarction and without heart failure or left ventricular dysfunction. MAIN OUTCOME MEASURES: Mortality was assessed at 30 days in relation to early use of ß blockers (≤48 hours of admission), at one year in relation to discharge prescription, and at five years in relation to one year use. RESULTS: ß blockers were used early in 77% (2050/2679) of patients, were prescribed at discharge in 80% (1783/2217), and were still being used in 89% (1230/1383) of those alive at one year. Thirty day mortality was lower in patients taking early ß blockers (adjusted hazard ratio 0.46, 95% confidence interval 0.26 to 0.82), whereas the hazard ratio for one year mortality associated with ß blockers at discharge was 0.77 (0.46 to 1.30). Persistence of ß blockers at one year was not associated with lower five year mortality (hazard ratio 1.19, 0.65 to 2.18). In contrast, five year mortality was lower in patients continuing statins at one year (hazard ratio 0.42, 0.25 to 0.72) compared with those discontinuing statins. Propensity score and sensitivity analyses showed consistent results. CONCLUSIONS: Early ß blocker use was associated with reduced 30 day mortality in patients with acute myocardial infarction, and discontinuation of ß blockers at one year was not associated with higher five year mortality. These findings question the utility of prolonged ß blocker treatment after acute myocardial infarction in patients without heart failure or left ventricular dysfunction.Trial registration Clinical trials NCT00673036.

Rupture of mitral valve chordae in hypertrophic cardiomyopathy.

BACKGROUND: While occasional reports of mitral valve chordal rupture have been described in hypertrophic cardiomyopathy, the exact prevalence and characteristics of this event in a large medical cohort have not been reported. AIM: To assess the prevalence of mitral valve chordal rupture in hypertrophic cardiomyopathy and the clinical, echocardiographic, surgical and histological profiles of those patients. METHODS: We searched for patients with mitral valve chordal rupture diagnosed by echocardiography among all electronic files of patients admitted to our centre for hypertrophic cardiomyopathy between 2000 and 2010. RESULTS: Among 580 patients admitted for hypertrophic cardiomyopathy, six patients (1%, 5 men, age 68-71 years) presented with mitral valve chordal rupture, symptomatic in five cases, always involving the posterior mitral leaflet. In all cases, echocardiography before rupture showed mitral valve systolic anterior motion, with anterior (and not posterior) leaflet elongation compared with a random sample of patients with non-obstructive hypertrophic cardiomyopathy (P=0.006) (and similar to that observed in obstructive hypertrophic cardiomyopathy). Significant resting left ventricular outflow tract obstruction was always present before rupture and disappeared after rupture in the five cases requiring mitral valve surgery for severe mitral regurgitation. Histological findings were consistent with extensive myxomatous degeneration in all cases. CONCLUSION: Mitral valve chordal rupture is: infrequent in hypertrophic cardiomyopathy; occurs in aged patients with obstructive disease; involves, essentially, the posterior mitral leaflet; and causes, in general, severe mitral regurgitation requiring surgery. Myxomatous degeneration may be the substrate for rupture in these patients.

Prescription of cardiovascular drugs in the French ODIN cohort of heart failure patients according to age and type of chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is a frequent severe disease. Disease-management programmes, which contain a therapeutic patient education component, will play a central role in improving delivery of care and reducing mortality and hospitalizations for CHF. AIMS: In order to have an up-to-date overview of medical treatment of CHF in France implemented by hospital and clinic cardiologists especially interested in CHF and therapeutic patient education, we described the prescription of cardiovascular drugs in the large ODIN cohort of CHF patients, according to age and type of CHF. METHODS: From 2007 to 2010 (median follow-up 27.2 months), CHF patients were prospectively enrolled in a multicentre 'real-world' French cohort by centres previously trained in therapeutic patient education. Patients were grouped according to age (< 60 years, 60 to<70 years, 70 to<80 years and ≥ 80 years) and type of CHF (characterized by level of LVEF: reduced, borderline or preserved). Medical prescription was described and mortality was assessed at long-term follow-up. RESULTS: The cohort consisted of 3237 patients (67.6 years; 69.4% men). The oldest age group had the highest LVEF. Blockers of the angiotensin-aldosterone system were prescribed progressively and significantly less frequently as the population advanced in age or as LVEF was more preserved. The mean dosages of the main prescribed CHF drugs remained ≥ 50% lower than those recommended for most drugs in all age and LVEF groups. Drug prescriptions were related to aetiology of reduced or preserved CHF. A global decrease in CHF drug prescription was observed for all medication classes except calcium blockers, according to maintenance of relatively or totally preserved LVEF. Survival was related to age but not to type of CHF. CONCLUSION: In CHF, and despite management by cardiologists particularly interested in CHF and specifically trained to deliver therapeutic patient education, medical prescription differed substantially from guidelines. Age and type of CHF (reduced versus preserved) appeared to be important factors in lack of adherence to guidelines. However, only age influenced mortality; the type of CHF did not affect survival.