***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Previous studies have demonstrated that renal dysfunction is common in patients with heart failure ( HF ) , but it is not known whether chronic kidney disease ( CKD ) is associated with increased risks of long-term adverse outcomes in unselected HF patients encountered in current routine clinical practice in Japan . METHODS AND RESULTS The Japanese Cardiac Registry of Heart Failure in Cardiology ( JCARE-CARD ) prospect ively studied a broad sample of patients hospitalized with worsening HF and their outcomes with an average of 2.4 years of follow-up . The study cohort ( n=2,013 ) were classified into 3 groups by estimated glomerular filtration rate ( eGFR ) : > or = 60 ( n=579 ) , 30 - 59 ( n=1,025 ) , and < 30 ml x min(-1 ) x 1.73 m(-2 ) or patients with dialysis  ( n=409 ) ; 1,372 patients ( 70.3 % ) had an eGFR < 60 ml x min(-1 ) x 1.73 m(-2 ) and 62 patients were treated with dialysis . The multivariable adjusted risk for all-cause death or rehospitalization increased with reduced eGFR ; an adjusted hazard ratio ( HR ) 1.520 ( 95 % confidence interval ( CI ) 1.186 - 1.949 ) for eGFR 30 - 59 ml x min(-1 ) x 1.73 m(-2 ) ( P=0.001 ) and HR 2.566 ( 95%CI 1.885 - 3.492 ) for eGFR < 30 ml x min(-1 ) x 1.73 m(-2 ) or patients with dialysis ( P<0.001 ) . CONCLUSIONS CKD is common in HF and was independently associated with long-term adverse outcomes in a broad cohort of Japanese patients Background — Previous studies have associated reduced hemoglobin levels with increased adverse events in heart failure . It is unclear , however , whether this relation is explained by underlying kidney disease , treatment differences , or associated comorbidity . Methods and Results — We examined the associations between hemoglobin level , kidney function , and risks of death and hospitalization in persons with chronic heart failure between 1996 and 2002 within a large , integrated , healthcare delivery system in northern California .  Longitudinal outpatient hemoglobin and creatinine levels and clinical and treatment characteristics were obtained from health plan records . Glomerular filtration rate ( GFR ; mL · min−1 · 1.73 m−2 ) was estimated from the Modification of Diet in Renal Disease equation . Mortality data were obtained from state death files ; heart failure admissions were identified by primary discharge diagnoses . Among 59 772 adults with heart failure , the mean age was 72 years and 46 % were women . Compared with that for hemoglobin levels of 13.0 to 13.9 g/dL , the multivariable-adjusted risk of death increased with lower hemoglobin levels : an adjusted hazard ratio ( HR ) of 1.16 and 95 % confidence interval ( CI ) of 1.11 to 1.21 for hemoglobin levels of 12.0 to 12.9 g/dL ; HR , 1.50 and 95 % CI , 1.44 to 1.57 for 11.0 to 11.9 g/dL ; HR , 1.89 and 95 % CI , 1.80 to 1.98 for 10.0 to 10.9 ; HR , 2.31 and 95 % CI , 2.18 to 2.45 for 9.0 to 9.9 ; and HR , 3.48 and 95 % CI , 3.25 to 3.73 for < 9.0 g/dL. Hemoglobin levels ≥17.0 g/dL were associated with an increased risk of death ( adjusted HR , 1.42 ; 95 % CI , 1.24 to 1.63 ) . Compared with those with a GFR ≥60 mL · min−1 · 1.73 m−2 , persons with a GFR < 45 mL · min−1 · 1.73 m−2 had an increased mortality risk : adjusted HR , 1.39 and 95 % CI , 1.34 to 1.44 for 30 to 44 ; HR , 2.28 and 95 % CI , 2.19 to 2.39 for 15 to 29 ; HR , 3.26 and 95 % CI , 3.05 to 3.49 for < 15 ; and HR , 2.44 and 95 % CI , 2.28 to 2.61 for those on dialysis . Relations were similar for the risk of hospitalization . The findings did not differ among patients with preserved or reduced systolic function , and hemoglobin level was an independent predictor of outcomes at all levels of kidney function . Conclusions — Very high ( ≥17 g/dL ) or reduced ( < 13 g/dL ) hemoglobin levels and chronic kidney disease independently predict substantially increased risks of death and hospitalization in heart failure , regardless of the level of systolic function . R and omized trials are needed to evaluate whether raising hemoglobin levels can improve outcomes in chronic heart failure BACKGROUND Patients with heart failure ( HF ) are at high risk for mortality and rehospitalization in the early period after hospital discharge . We developed clinical models predictive of short-term clinical outcomes in a broad patient population discharged after hospitalization for HF . METHODS The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure ( OPTIMIZE-HF ) registry is a comprehensive hospital-based registry and performance-improvement program for patients hospitalized with HF . Follow-up data were scheduled to be prospect ively collected at 60 to 90 days postdischarge in a prespecified 10 % sample . For the 4,402 patients included in this analysis , 19 prespecified potential predictor variables were used in a stepwise Cox proportional hazards model for all-cause mortality . Logistic regression including 45 potential variables was used to model mortality or rehospitalization . RESULTS The 60- to 90-day postdischarge mortality rate was 8.6 % ( n = 481 ) , and 29.6 % ( n = 1,715 ) were rehospitalized . Factors predicting early postdischarge mortality include age , serum creatinine , reactive airway disease , liver disease , lower systolic blood pressure , lower serum sodium , lower admission weight , and depression . Use of statins and beta-blockers at discharge was associated with significantly decreased mortality . The C-index of the model was 0.74 . The most important predictors for the combined end point of death or rehospitalization were admission serum creatinine , systolic blood pressure , admission hemoglobin , discharge use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker , and pulmonary disease . From this analysis , 8 factors identified to carry significant risk were selected for use in a point scoring system to predict the risk of mortality within 60 days after discharge , with a C-index of 0.72 . CONCLUSIONS A substantial risk of mortality and mortality or rehospitalization is present in the first 60 to 90 days after discharge from a hospitalization for HF . Several factors were identified that signal high-risk patients . Application of these findings with a simple algorithm can distinguish patients who are low risk from those at high risk who may benefit from closer monitoring and aggressive evidence -based treatment Chronic obstructive pulmonary disease ( COPD ) is a frequently neglected co-morbidity in patients with heart failure ( HF ) . The aim of this study was to evaluate the prognostic impact of COPD in patients hospitalized for HF . Consecutive patients ( n=799 ) admitted for a first episode of HF in all healthcare establishments of the Somme department ( France ) during 2000 were prospect ively enrolled . Baseline characteristics and long-term prognosis were compared according to COPD status . COPD was diagnosed in 156 patients ( 19.5 % ) . Compared with the no- COPD group , patients with COPD were predominantly men , more often smokers , and had lower discharge prescription rates of beta blockers ( 6 % vs 27 % , p<0.001 ) . Five-year survival rate in patients with COPD was significantly lower than that of the no- COPD group ( 31 % vs 42 % , p=0.03 ) . Compared with the expected survival of the age- and gender-matched general population , the 5-year survival rate in patients with COPD was dramatically lower ( 31 % vs 71 % ) . On multivariable analysis , COPD was a strong predictor of poorer outcome ( hazard ratio 1.53 , 95 % confidence interval 1.21 to 1.94 , p<0.001 ) . COPD was an independent predictor of mortality in patients with preserved left ventricular ejection fraction and in patients with reduced ejection fraction . In conclusion , patients with HF and associated COPD have a poor prognosis with an impressive excess mortality compared to HF patients without COPD and the general population . Beta-blocker prescription rates remain deceptively low in this category of patients with HF Renal function and urea are frequently abnormal in patients with heart failure ( HF ) and are predictive of increased mortality . The relative importance of each parameter is less clear . We prospect ively compared the predictive value of renal function and serum urea on clinical outcome in patients with HF . Patients hospitalized with definite clinical diagnosis of HF ( n = 355 ) were followed for short-term ( 1 yr ) and long-term ( mean , 6.5 yr ) survival and HF rehospitalization . Increasing tertiles of discharge estimated  glomerular filtration rate ( eGFR ) were an independent predictor of increased long-term survival ( hazard ratio [ HR ] , 0.65 ; 95 % confidence interval [ CI ] , 0.47 - 0.91 ; p = 0.01 ) but not short-term survival . Admission and discharge serum urea and blood urea nitrogen (BUN)/creatinine ratio were predictors of reduced short- and long-term survival on multivariate Cox regression analysis . Increasing tertiles of discharge urea were a predictor of reduced 1-year survival ( HR , 2.13 ; 95 % CI , 1.21 - 3.73 ; p = 0.009 ) and long-term survival ( HR , 1.93 ; 95 % CI , 1.37 - 2.71 ; p < 0.0001 ) . Multivariate analysis including discharge eGFR and serum urea demonstrated that only serum urea remained a significant predictor of long-term survival ; however , eGFR and BUN/creatinine ratio were both independently predictive of survival . Urea was more discriminative than eGFR in predicting long-term survival by area under the receiver operating characteristic curve ( 0.803 vs. 0.787 ; p = 0.01 ) . Increasing tertiles of discharge serum urea and BUN/creatinine were independent predictors of HF rehospitalization and combined death and HF rehospitalization . This study suggests that serum urea is a more powerful predictor of survival than eGFR in patients with HF . This may be due to urea 's relation to key biological parameters including renal , hemodynamic , and neurohormonal parameters pertaining to the overall clinical status of the patient with chronic HF . Abbreviations : ADHF = acute decompensated heart failure , AUC = area under the curve , BUN = blood urea nitrogen , CI = confidence interval , eGFR = estimated glomerular filtration rate , HF = heart failure , HR = hazard ratio , MDRD = Modification of Diet in Renal Disease , ROC = receiver operating characteristic BACKGROUND Aging is associated with adverse outcomes in patients with cardiac diseases . Whether elderly patients hospitalized with heart failure ( HF ) had increased risks for mortality and rehospitalization compared with younger patients during the long-term follow-up was examined . The predictors of these adverse outcomes were also identified . METHODS AND RESULTS The Japanese Cardiac Registry of Heart Failure in Cardiology ( JCARE-CARD ) studied prospect ively the characteristics and treatments in a broad sample of 2,675 patients hospitalized with worsening HF and the outcomes were followed up . The majority of elderly patients were female , had lower body mass index ( BMI ) , a higher rate of ischemic , valvular , and hypertensive heart disease as etiologies of HF , a lower estimated glomerular filtration rate ( eGFR ) , lower hemoglobin , and higher left ventricular ejection fraction values . Even after adjustment for covariates , the elderly patients were associated with higher risks of adverse outcomes . The predictors for all-cause death were : lower eGFR , lower BMI , male sex , sustained ventricular tachycardia or fibrillation ( VT/VF ) , and the use of diuretics at discharge . CONCLUSIONS Among patients hospitalized with HF , elderly patients had a worse prognosis than younger patients . Lower eGFR , lower BMI , male sex , sustained VT/VF , and diuretic use were independent predictors for all-cause death in these patients with higher risk Background and objectives Current models used to stratify patients with heart failure are complex , difficult to use , 
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Conclusions Non-cardiovascular comorbidity and severity significantly increases the prognostic risk of poor outcomes in non-selected HF population s but there is a major gap in investigating change in comorbid status over time .
The evidence supports a step-change for the inclusion of comorbidity severity in new HF interventions to improve prognostic outcomes