The Effect of Computerized Wobble Board and Core Stabilization Exercises on Balance Performance and Exercise Capacity in Patients With Heart Failure: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effects of computerized wobble board exercise training (CWBET) and core stabilization exercise training (CSET) on balance performance, and exercise capacity in patients with heart failure (HF). DESING: Single-blind randomized controlled prospective study. SETTING: Cardiology department of a local university hospital. PARTICIPANTS: Fifty-one patients with HF with reduced ejection fraction, whose clinical status and medication had been stable for the previous 3 months, were included (N=51). Nine patients could not complete the follow-up period due to personal reasons. No patient experienced any adverse events during exercise training. INTERVENTIONS: Patients were randomized to CWBET, CSET, and control group. CWBET and CSET groups participated in their own exercise programs, 3 days a week for 8 weeks. The control group received no exercise program. MAIN OUTCOME MEASURES: All patients were evaluated at baseline and after 8 weeks. Postural stability, static and functional balance, and exercise capacity were evaluated with the Sensamove Balance Test Pro with Miniboard, the one-leg stance test (OLS), the Berg Balance Scale (BBS), and the six-minute walk distance (6MWD), respectively. Core stabilization and health-related quality of life (HRQOL) were assessed with OCTOcore app, and Minnesota Living with Heart Failure Questionnaire, respectively. RESULTS: A mixed model repeated-measures ANOVA revealed significant group × time interaction effect for static postural stability performance (P<.001, ηp2=0.472), vertical (P<.001, ηp2=0.513), horizontal performance (P<.001, ηp2=0.467), OLS (P<.001, ηp2=0.474), BBS (P<.001, ηp2=0.440) scores, 6MWD (P<.001, ηp2=0.706), and HRQOL. Post hoc analysis revealed CWBET and CSET groups had similar improvements balance performance, exercise capacity, and HRQOL and both groups significantly improved compared with control group (P<.001). Core stabilization was significantly improved only in CSET group after 8 weeks. CONCLUSION: CWBET and CSET programs were equally effective and safe for improving balance performance and exercise capacity in patients with HF.

The association between ABO blood groups and TASC II classification in patients with peripheral artery disease.

OBJECTIVE: The aim of this study was to investigate the association between blood groups and severity of peripheral artery disease (PAD) using TASC II classification. METHODS: The patients who were diagnosed with PAD were retrospectively analyzed. The patients with 50% or more stenosis in the aorto-iliac or femoro-popliteal region detected by conventional or CT angiography were included in the study. These patients were divided into TASC II A, B, C, and D groups considering the severity of PAD. All patients' blood groups were recorded and compared between TASC II groups. RESULTS: While 38% of the study population was O blood group, 61% were non-O group. On the other hand, 90% of the entire study population were RH positive and 10% were RH negative. Non-O blood ratio was found to be significantly higher in patients with higher TASC II groups. (TASC IIA 51.6% vs. TASC IIB 57.9% vs. TASC IIC 61.3% vs. TASC IID 76.6%, p< .001) However, the frequencies of Rh types were similar in all groups. Multiple logistic regression analysis was applied for determining the predictors of severity and complexity of PAD (TASC II C and TASC II D lesions). CONCLUSIONS: Our study results revealed a clear association between ABO blood groups and severity of peripheral arterial disease. Non-O blood group was found to be the independent predictor of severe and complex PAD.

Triphasic mitral flow pattern may indicate subclinical left ventricular systolic dysfunction.

PURPOSE: In this study, the presence and severity of left ventricular (LV) systolic dysfunction were investigated by speckle tracking echocardiography (STE) technique in patients with mitral triphasic mitral flow pattern (TMFP). The aim of the study was to evaluate the possible role of TMFP in the ethiopathogenesis of congestive heart failure. METHODS AND RESULTS: A total of 45 patients who were diagnosed with TMFP and 30 age- and gender-matched healthy volunteers were included in the study. The mean age in the study and control groups was 64 ± 12 and 62 ± 11 (P = .642), respectively. When echocardiographic parameters were evaluated, LV ejection fraction was found to be 63% ± 14 and 64 ± 12 (P = .745), in the study and control groups, respectively. LV end-diastolic and systolic diameters and LV mass index were also similar (P < .05). When LV diastolic parameters were compared, diastolic dysfunction was detected in 38 (84.4%) patients in the study population and 13 patients (43.3%) in the control group (P < .001). When STE findings were evaluated, both global longitidunal strain and global circumferential strain were significantly lower in the TMFP group when compared to controls (18.3 ± 1.7 vs 21.5 ± 1.5, P < .001 and 17.9 ± 1.6 vs 21.3 ± 2.1, P < .001, respectively). CONCLUSION: TMFP results in LV systolic dysfunction. Therefore, these patients may develop congestive heart failure in the long term. It will be rational that the patients with TMFP should be followed up more closely in terms of preventing manifest heart failure symptoms.

Association between fragmented QRS complexes and left ventricular dysfunction in healthy smokers.

OBJECTIVE: Smoking is a known risk factor for cardiovascular diseases and may cause myocardial damage independently of coronary artery disease. Fragmented QRS (fQRS) is an important marker of myocardial fibrosis, while speckle-tracking echocardiography is a method used to show subclinical left ventricle dysfunction. METHODS: Our study included 230 healthy individuals aged 18-40 years. The patients included were separated into two groups: those smokers (n = 130) and non-smokers (n = 100). After that healthy smokers group were divided into two groups: those with fQRS (n = 24) and those without (n = 106). In both groups, the arithmetic mean of three images was used to obtain the left ventricle global longitudinal strain (LV-GLS). The E/SRe ratio was also calculated and analyzed. RESULTS: There were significant differences between the smokers and non-smokers in terms of, E/SRe (55.7 ± 17.9 vs 50.3 ± 14.8; P = 0.015), LV-GLS (23.1 ± 1.9 vs 24.0 ± 1.7; P = 0.001), and fQRS (18.5% vs 6%; P = 0.005). As a result of subgroup analysis, pack-year history was higher in the fQRS positive group (16.7 ± 3.7 vs 11.2 ± 3.7, P < 0.001). While a negative correlation was observed between pack-year history and LV-GLS (r = -0.678, P < 0.001), there was a positive correlation between pack-year history and E/SRe (r = 0.730, P < 0.001). CONCLUSION: In conclusion, our study demonstrated that fQRS is a parameter that can be used to determine left ventricle subclinical systolic and diastolic dysfunction in smokers, and that left ventricle dysfunction is related to the duration and intensity of smoking.

Prediction of no-reflow and major adverse cardiovascular events with a new scoring system in STEMI patients.

BACKGROUND: No-reflow is associated with a poor prognosis in STEMI patients. There are many factors and mechanisms that contribute to the development of no-reflow, including age, reperfusion time, a high thrombus burden, Killip class, long stent use, ejection fraction ≤40, and a high Syntax score. In this study, we aimed to evaluate the parameters associated with no-reflow prediction by creating a new scoring system. METHODS: The study included 515 consecutive STEMI patients who underwent PCI; 632 STEMI patients who had undergone PCI in another center were included in the external validation of the scoring system. The correlations between 1-year major adverse cardiac events and low/high risk score were assessed. RESULTS: In this study, seven independent variables were used to build a risk score for predicting no-reflow. The predictors of no-reflow are age, EF ≤40, SS ≥22, stent length ≥20, thrombus grade ≥4, Killip class ≥3, and pain-balloon time ≥4 h. In the derivation group, the optimal threshold score for predicting no-reflow was >10, with a 75% sensitivity and 77.7% specificity (Area under the curve (AUC) = 0.809, 95%CI: 0.772-0.842, P < 0.001). In the validation group, AUC was 0.793 (95%CI: 0.760-0.824, P < 0.001). CONCLUSION: This new score, which can be calculated in STEMI patients before PCI and used to predict no-reflow in STEMI patients, may help physicians to estimate the development of no-reflow in the pre-PCI period.

Association of Serum Cholesterol Levels with Short-term Mortality in Patients with Acute Pulmonary Embolism.

BACKGROUND: Serum cholesterols play an important role in pathophysiology and prognosis of acute thrombotic diseases. The aim of the present study was to investigate the prognostic value of serum lipid parameters in acute pulmonary embolism (APE). METHODS: From January 2008 to January 2014 a total of 275 patients who were hospitalised with a diagnosis of APE were retrospectively screened. Clinical data, laboratory parameters, serum cholesterol levels were recorded and pulmonary embolism severity index (PESI) scores were calculated. Mortality rate at 30 days was investigated as the clinical outcome. RESULTS: In our study population, 24 patients (8.7%) died within 30 days. Serum total cholesterol, LDL-C, HDL-C and triglyceride levels were significantly lower in deceased patients when compared to the survived patients (3.1 ± 0.6 vs. 4.7 ± 1.2 mmol/L, p < 0.01; 1.8 ± 0.9 vs. 2.9 ± 0.9 mmol/L, p < 0.01; 0.9 ± 0.3 vs. 1.2 ± 0.3 mmol/L, p < 0.01; 1.4 ± 0.7 vs. 1.7 ± 0.6 mmol/L, p = 0.04, respectively). In multivariate regression analysis; PESI scores (OR: 1.06 95% CI: 1.01-1.11, p < 0.01), right ventricular diameter (OR: 11.31 95% CI: 3.25-52.64, p < 0.01), total cholesterol (OR: 1.09 95% CI: 1.02-1.17, p < 0.01), LDL-C (OR: 1.06 95% CI: 1.01-1.12, p = 0.02), HDL-C (OR: 1.21 95% CI: 1.04-1.41, p < 0.01) and triglyceride (OR: 1.03 95% CI: 1.01-1.05, p < 0.01) levels were independently correlated with mortality. CONCLUSIONS: Serum total cholesterol, LDL-C, HDL-C and triglyceride levels, obtained within the first 24hours of hospital admission, may have prognostic value in patients with APE.

Evaluation of the effect of percutaneous mitral balloon valvuloplasty on left ventricular systolic function via strain and strain rate in patients with isolated rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Percutaneous balloon mitral valvuloplasty (PMBV) has an established role in the treatment of rheumatic mitral stenosis. The study aim was to evaluate the effects of PMBV on left ventricular function in patients with rheumatic mitral stenosis (MS) by using strain and strain rate imaging modalities. METHODS: The study included 30 consecutive patients (21 women, nine men; mean age 44 ± 14 years) with moderate to severe MS. Left ventricular long-axis strain and strain rate color tissue Doppler imaging of the septal, lateral, inferior and anterior basal segments were performed one day before and seven days after PMBV. RESULTS: Compared with pretreatment findings, lateral systolic strain (-13.4 ± 2.9% versus -18.4 ± 3.9%; p = 0.024), inferior systolic strain (-14.7 ± 2.3% versus -17.6 ± 2.1%; p = 0.016), anterior systolic strain (-15.2 ± 2.4% versus -17.2 ± 2.2%; p = 0.02), and septal systolic strain (-15.7 ± 1.6% versus -18.1 ± 1.9%; p = 0.018) values were significantly increased after the procedure, but no significant change was observed in strain rate analysis. CONCLUSION: A rapid improvement in strain values after PMBV in patients with isolated MS showed that the LV systolic dysfunction in isolated MS is strongly associated with impaired. hemodynamic parameters. Significantly increased strain values can be added to the criteria of successful PMBV.

Circadian blood pressure pattern in sarcoidosis patients.

OBJECTIVES: Autonomic dysfunction (AD) is frequent in sarcoidosis and considered a result of small fiber neuropathy. A non-dipper blood pressure (BP) pattern, which is also linked to AD, is associated with increased risk of cardiovascular and renal diseases. The aim of the present study was to evaluate the non-dipping BP pattern in normotensive patients with pulmonary sarcoidosis (PS). METHODS: Sixty-three normotensive patients with PS (group 1) and 49 healthy subjects (group 2) were prospectively enrolled. Ambulatory BP monitoring was performed in all participants over a 24-h period. RESULTS: The non-dipping BP pattern was significantly more frequent in patients with PS compared with the control group (80% vs 53%, respectively, p = 0.002). More advanced PS (grade 2) was an independent predictor of non-dipper BP pattern (odds ratio = 10.4, 95% confidence interval 1.1-95.4, p = 0.03). Masked hypertension and body mass index were also found to be other predictors of non-dipping BP pattern. CONCLUSIONS: The present study showed that non-dipping BP pattern is frequently observed in normotensive patients with PS. The probable mechanism underlying the non-dipping BP in PS is autonomic nervous system dysfunction. PS represents an independent risk factor for non-dipping BP and these patients have increased cardiovascular risk.

What should be done in the event of simultaneous massive pulmonary embolism and myocardial infarction with ST elevation?

Massive pulmonary embolism (MPE) and acute myocardial infarction (AMI) are life-threatening conditions with well-known diagnosis and treatment. Symptoms and findings such as dyspnea, chest pain, hypotension, ECG changes and elevation of cardiac enzymes are seen in both diseases. However, MPE and AMI are rarely simultaneous in a single case. This report presents an 85-year-old patient with simultaneous MPE and AMI with ST elevation. While treatment strategies for both MPE and AMI have been adequately described, it is not clear which treatment to choose when both emergency pathologies occur simultaneously in one patient. This case report discusses the treatment of these two diseases in such a case.

[Relation of heart-type fatty acid-binding protein with the degree and extent of atherosclerosis in patients with non-ST elevation acute coronary syndrome]. / ST segment yükselmesiz akut koroner sendromlu hastalarda kalp tipi yag asidi baglayici proteinin koroner arter hastaliginin yayginlik ve ciddiyeti ile iliskisi.

OBJECTIVES: The relationship between markers of myocardial ischemia and severity of coronary artery disease (CAD) has been investigated in several studies. In this study, we examined the relationship between severity of CAD and heart-type fatty acid-binding protein (H-FABP), a new marker of ischemia in patients with non-ST-segment elevation acute coronary syndrome (ACS). STUDY DESIGN: This prospective study comprised 49 patients who were referred to the emergency room with a diagnosis of non-ST elevation myocardial infarction. Troponins, creatine kinase-MB, lactate dehydrogenase, and aspartate aminotransferase levels were measured quantitatively, while blood H-FABP levels were measured qualitatively in the 4th-8th hour from the onset of symptoms. All patients underwent coronary angiography within 72 hours after admission. Clinical and coronary angiographic characteristics of patients with positive and negative values of H-FABP were compared. Gensini and SYNTAX scores were used to determine the severity of CAD. RESULTS: There were no statistically significant differences in mean age, gender distribution, risk factors for CAD, ischemic changes on ECG, or Gensini and SYNTAX scores between the H-FABP-negative and -positive groups (p>0.05). The duration of chest pain in the H-FABP-positive group was significantly longer than in the negative group (p<0.001). Troponin, CK-MB, and AST levels as well as thrombolysis in myocardial infarction (TIMI) risk scores were found to be significantly higher in the H-FABP-positive group (p<0.05). CONCLUSION: H-FABP is a useful marker for the diagnosis and risk evaluation of patients with non-ST elevation ACS. However, it is insufficient in evaluating the severity of CAD.

Well-Developed Coronary Collateral Circulation Is Associated With Higher Thrombus Burden in the Setting of ST-Segment Elevation Myocardial Infarction.

BACKGROUND: This study investigated the relationship between coronary collateral circulation (CCC) and intracoronary thrombus burden in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). CCC and thrombus burden are predictive of clinical outcomes in patients with STEMI. METHODS: Patients with STEMI undergoing primary percutaneous coronary intervention were enrolled (n = 172). CCC was graded according to the Cohen-Rentrop classification. Patients were classified as insufficient (grade 0 or 1, n = 134) or well-developed (grade 2 or 3; n = 38) CCC. The Thrombolysis in Myocardial Infarction scale was used to evaluate intra-coronary thrombus burden. The low-thrombus-burden group comprised those with grades 0 to 2, and the high-thrombus-burden group comprised those with grades 3 or 4. RESULTS: Right coronary artery infarcts had a 13.830-fold higher chance of having well-developed CCC than did left anterior descending artery infarcts (P < .001). Circumflex artery infarcts had a 7.904-fold higher chance of well-developed CCC than did left anterior descending artery infarcts (P = .016). High thrombus burden was associated with a 4.393-fold higher chance for well-developed CCC than was low thrombus burden (P = .030). Low albumin levels were related to a greater chance of having well-developed CCC (P = .046). CONCLUSION: Patients with well-developed CCC have higher thrombus burden than do those with insufficient CCC. Because well-developed CCC is an indicator of more severe underlying lesions, we speculate that patients with severe lesions are more prone to experience more complicated STEMI with high thrombus burden.

A New Insight Into Pathophysiological Mechanism of Abdominal Aortic Aneurysm With Novel Parameters Salusin-ß and Arterial Stiffness.

BACKGROUND: Abdominal aortic aneurysm (AAA) has risk factors similar to those of atherosclerosis. Salusin-ß and arterial stiffness are novel parameters that have been shown to predict atherosclerosis and related cardiovascular disorders. However, their predictive value for detecting AAA remains unclear. METHODS: Forty-eight patients with AAA and 47 age- and sex-matched participants without AAA were enrolled in the study. Arterial stiffness parameters were obtained via an oscillometric Mobil-O-Graph PWA Monitor device (IEM GmbH) with integrated ARCSolver software (Australian Institute of Technology). Plasma salusin-ß levels were analyzed using an enzyme-linked immunosorbent assay reagent kit (Abbkine, Inc). The measured salusin-ß levels and arterial stiffness parameters of the AAA and control groups were compared. RESULTS: Salusin-ß levels were significantly lower in patients with AAA (P = .014). There was a significant negative correlation between salusin-ß levels and abdominal aorta diameter. No significant difference was detected between AAA and control groups in terms of arterial stiffness parameters (P > .05). In backward multiple regression analysis, the presence of AAA, platelet count, and augmentation index were found to be independent predictors of salusin-ß levels (P = .006 and P = .023, respectively). CONCLUSION: Arterial stiffness parameters were not found to be associated with AAA. Contrary to previous results regarding atherosclerosis and related cardiovascular disorders, salusin-ß levels were found to be lower in patients with AAA. Although AAA is thought to have similar risk factors as atherosclerosis, the exact pathophysiologic mechanism remains unclear.

The outcome of primary percutaneous coronary intervention for stent thrombosis causing ST-elevation myocardial infarction.

BACKGROUND: There are very few scientific data about the effectiveness of primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) due to stent thrombosis (ST). The purpose of the present study is to investigate the efficacy and outcome of primary PCI for STEMI due to ST in the largest consecutive patient population with ST reported to date. METHODS: A total of 2,644 consecutive STEMI patients undergoing primary PCI were retrospectively enrolled into the present study. The primary end point of this study was successful angiographic reperfusion defined as postprocedural Thrombolysis In Myocardial Infarction grade III flow. The secondary end points were cardiovascular death and reinfarction. RESULTS: Stent thrombosis was the cause of STEMI in 118 patients (4.4%). In patients with ST, angiographic success (postprocedural Thrombolysis In Myocardial Infarction grade III flow) was worse than in patients with de novo STEMI (76.3% vs 84.8%, P = .01). Patients with ST had significantly higher incidence of in-hospital cardiovascular mortality than patients with de novo STEMI (10.2% vs 5.3%, P = .02). In-hospital reinfarction rate was similar in both groups. In addition, long-term (mean 22 months) cardiovascular mortality and reinfarction rates were significantly higher in patients with ST compared with those without (17.4% vs 10.5%, P = .02 and 15.6% vs 9.5%, P = .03, respectively). CONCLUSIONS: Primary PCI for treatment of ST is less effective, and these patients are at increased risk for in-hospital and long-term mortality compared with patients undergoing primary PCI due to de novo STEMI.

Which is worst in patients undergoing primary angioplasty for acute myocardial infarction? Hyperglycaemia? Diabetes mellitus? Or both?

OBJECTIVE: The objective of this study was to evaluate the effect of admission hyperglycaemia and/or diabetes mellitus (DM) on the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). METHODS: 2482 consecutive patients with STEMI (mean age 56.5 +/- 11.9, years, 2064 men) undergoing primary PCI between October 2003 and March 2008 were retrospectively enrolled into the present study. Hyperglycaemia was defined as a venous plasma glucose level > or =200 mg/dl on admission. Patients were classified into four groups: non-diabetic/non-hyperglycaemic (NDNH, n=1806) patients; diabetic/non-hyperglycaemic (DNH, n=271) patients; non-diabetic/hyperglycaemic (NDH, n=64); and diabetic/hyperglycaemic (DH, n=341). RESULTS: In-hospital mortality was higher in NDH (12.5%) compared to DH (8.5%), DNH (6.3%), and NDNH (0.9%) patients (P < 0.001). The composite end points including death, reinfarction, and target-vessel revascularization (major adverse cardiac events [MACE]) in the hospital were also higher in NDH (18.8%) compared with other patients (DH, 13.8% vs. DNH, 10.3% vs. NDNH, 3.7%, P < 0.001). The median follow-up time was 21 months.The Kaplan-Meier survival plot for long-term cardiovascular death was worst for DH patients (log rank P < 0.001). After adjustment for potentially confounding factors, NDH (OR 3.04, 95% CI 1.06-8.73; P = 0.03), and DH (OR 2.3,95% CI 1.29-4.09; P = 0.005), but not DNH (OR 1.22,95% CI 0.57-2.6; P = 0.6) status, remained independent predictors of long-term cardiovascular mortality. CONCLUSIONS: STEMI patients with NDH represent the highest risk population for in-hospital mortality, and MACE. The worst outcomes for long-term cardiovascular mortality occur in DH patients.

Impact of day versus night as intervention time on the outcomes of primary angioplasty for acute myocardial infarction.

BACKGROUND: Conflicting datas exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) when the intervention is performed during night hours. METHODS AND RESULTS: 2,644 consecutive patients with STEMI (mean age 56.7 +/- 11.9, years, 2,188 male) undergoing primary PCI between October 2003 and March 2008 were retrospectively enrolled into this study (single high-volume center: >3,000 PCIs/year). Day time was defined according to intervention between 08:00 am and 06:00 pm and night as intervention time between 06:00 pm and 08:00 am. 1,141 patients (43.2%) were treated during the day and 1,503 (56.8%) at night. The baseline characteristics of both groups were similar except for more frequent hypertension (42.6 vs. 36.5%; P = 0.002), women (19.7 vs. 15.4%; P = 0.003), and old (> or =75 y) patients (9.6 vs. 7.4; P = 0.046) in the day time group. Compared with those treated during night time, day time patients had longer angina-reperfusion times (mean, 205 vs. 188 minutes, P = 0.016). Door-to-balloon times were similar (P = 0.87), and less than 90 minutes in both groups. There were no differences concerning clinical events and PCI success between the two groups. Hospital mortality was 6.1% during the day and 5.2% during the night (OR 0.98, 95% CI 0.7-1.36; P = 0.89). The median follow-up time was 21 months. The Kaplan-Meier survival plot for long-term cardiovascular death was not different for both groups (P = 0.78). In-hospital and long-term cardiovascular mortality was also similar in shock and nonshock subgroups. CONCLUSIONS: Primary PCI can be performed safely during the night at a high-volume PCI center with suitable and effective organization of cardiology department and catheterisation laboratory with 24 hours per day, 7 days per week onsite staffing.

The prognostic value of altitude in patients with heart failure with reduced ejection fraction.

OBJECTIVE: It is well known that the altitude may affect the cardiovascular system. However, there were a few data related to the effect of altitude on the adverse outcome in patients with heart failure with reduced ejection fraction (HFREF). The aim of the present study was to investigate the role of intermediate high altitude on the major adverse cardiovascular outcome in patients with HFREF. METHODS: Patients with HFREF admitted to the outpatient clinics at the first center at sea level and the second center at 1890 m were prospectively enrolled in the study. HFREF was defined as symptoms/signs of heart failure and left ventricular ejection fraction <40%. The major adverse cardiac outcome (MACE) was defined as all-cause death, stroke, and re-hospitalization due to heart failure. The median follow-up period of the study population was 27 months. RESULTS: The study included 320 (58.55% male, mean age 65.7±11.2 years) patients. The incidence of all-cause death was 8.5%, stroke 6.1%, re-hospitalization due to decompensated heart failure 34.3%, and MACE 48.9%. In Kaplan-Meier analysis, patients with HFREF living at high altitude had more MACE (71.1% vs. 25.3%, log rank p=0.005) and presented with more stroke (11.3% vs. 2.1%, log rank p=0.001) and re-hospitalization due to heart failure (65.1% vs. 20.1%, log rank p<0.001) rates than those at low altitude in the follow-up; however, the rate of all-cause death was similar (9.4% vs. 8.1%, log rank p=0.245). CONCLUSION: In the present study, we demonstrated that the intermediate high altitude is the independent predictor of MACE in patients with HFREF. High altitude may be considered as a risk factor in decompensating heart failure.