The Association of Pre-Kidney Transplant Dialysis Modality with de novo Posttransplant Heart Failure

Background: Heart failure (HF) after kidney transplantation is a significant but understudied problem. Pretransplant dialysis modality could influence incident HF risk through differing cardiac stressors. However, whether pretransplant dialysis modality is associated with the development of posttransplant HF is unknown. Methods: We used the US Renal Data System to assemble a cohort of 27,701 patients who underwent their first kidney transplant in the USA between the years 2005 and 2012 and who had Medicare fee-for-service coverage for >6 months preceding their transplant date. Patients with any HF diagnosis prior to transplant were excluded. Detailed baseline patient characteristics and comorbidities were abstracted. The outcome of interest was de novo posttransplant HF. Pretransplant dialysis modality was defined as the dialysis modality used at the time of transplant. We conducted time-to-event analyses using Cox regression. Death was treated as a competing risk in the study’s primary analysis. Graft failure was included as a time-varying covariate. Results: Among eligible patients, 81% were treated with hemodialysis prior to transplant, and hemodialysis patients were more likely to be male, had a shorter dialysis vintage, and had more diabetes and vascular disease diagnoses. When adjusted for all available demographic and clinical data, pretransplant treatment with hemodialysis (vs. peritoneal dialysis) was associated with a 19% increased risk in de novo posttransplant HF, with sub-distribution HR 1.19 (95% CI: 1.09–1.29). Conclusions: Our results suggest that choice of pretransplant dialysis modality may impact the development of posttransplant HF.

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SLCO1B3 polymorphisms and clinical outcomes in kidney transplant recipients receiving mycophenolate

Pharmacogenomics ◽

10.2217/pgs-2021-0102 ◽

2021 ◽

Author(s):

Lauren Schumacher ◽

Fang Fang ◽

Kelley M Kidwell ◽

Faisal Shakeel ◽

Daniel L Hertz ◽

...

Keyword(s):

Adverse Effects ◽

Acute Rejection ◽

Kidney Transplant ◽

Patient Survival ◽

De Novo ◽

Transplant Recipients ◽

Kidney Transplant Recipients ◽

Primary Analysis ◽

Adult Kidney ◽

Increased Risk

Aim: Determine the influence of SLCO1B3 polymorphisms on outcomes in kidney transplant recipients. Materials & methods: We retrospectively evaluated 181 adult kidney transplant recipients receiving mycophenolate. Outcomes included treated biopsy-proven acute rejection (tBPAR), de novo donor specific antibody (dnDSA) formation, graft survival, patient survival and mycophenolate-related adverse effects among SLCO1B3 genotypes. Results: The presence of SLCO1B3 variants was not associated with increased risk of tBPAR (HR: 1.45, 95% CI: 0.76–2.74), dnDSA (HR: 0.46, 95% CI: 0.16–1.36) or composite of tBPAR or dnDSA (HR: 1.14, 95% CI: 0.64–2.03). Graft and patient survival were reduced among variant carriers; however, inconsistent findings with the primary analysis suggest these associations were not due to genotype. Adverse effects were similar between groups. Conclusion: Presence of SLCO1B3 polymorphisms were not predictive of rejection or dnDSA in kidney transplant recipients.

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Urinary Carnosinase-1 Excretion is Associated with Urinary Carnosine Depletion and Risk of Graft Failure in Kidney Transplant Recipients: Results of the TransplantLines Cohort Study

Antioxidants ◽

10.3390/antiox10071102 ◽

2021 ◽

Vol 10 (7) ◽

pp. 1102

Author(s):

Angelica Rodriguez-Niño ◽

Diego O. Pastene ◽

Adrian Post ◽

M. Yusof Said ◽

Antonio W. Gomes-Neto ◽

...

Keyword(s):

Kidney Transplant ◽

Graft Failure ◽

Cox Regression ◽

Carbonyl Stress ◽

Transplant Recipients ◽

Kidney Transplant Recipients ◽

Increased Risk ◽

High Concentrations ◽

Kidney Function Decline

Carnosine affords protection against oxidative and carbonyl stress, yet high concentrations of the carnosinase-1 enzyme may limit this. We recently reported that high urinary carnosinase-1 is associated with kidney function decline and albuminuria in patients with chronic kidney disease. We prospectively investigated whether urinary carnosinase-1 is associated with a high risk for development of late graft failure in kidney transplant recipients (KTRs). Carnosine and carnosinase-1 were measured in 24 h urine in a longitudinal cohort of 703 stable KTRs and 257 healthy controls. Cox regression was used to analyze the prospective data. Urinary carnosine excretions were significantly decreased in KTRs (26.5 [IQR 21.4–33.3] µmol/24 h versus 34.8 [IQR 25.6–46.8] µmol/24 h; p < 0.001). In KTRs, high urinary carnosinase-1 concentrations were associated with increased risk of undetectable urinary carnosine (OR 1.24, 95%CI [1.06–1.45]; p = 0.007). During median follow-up for 5.3 [4.5–6.0] years, 84 (12%) KTRs developed graft failure. In Cox regression analyses, high urinary carnosinase-1 excretions were associated with increased risk of graft failure (HR 1.73, 95%CI [1.44–2.08]; p < 0.001) independent of potential confounders. Since urinary carnosine is depleted and urinary carnosinase-1 imparts a higher risk for graft failure in KTRs, future studies determining the potential of carnosine supplementation in these patients are warranted.

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Abstract 14922: Prognostic Value of Baseline BNP and NT-ProBNP and its Interaction With Spironolactone in Patients With Heart Failure and Preserved Ejection Fraction in the TOPCAT Trial

Circulation ◽

10.1161/circ.132.suppl_3.14922 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Inder S Anand ◽

Scott D Solomon ◽

Brian Claggett ◽

Sanjiv J Shah ◽

Eileen O’Meara ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Primary Outcome ◽

Cox Regression ◽

Selection Criterion ◽

Adverse Outcomes ◽

Preserved Ejection Fraction ◽

Patient Selection Criterion ◽

Increased Risk ◽

Patients With Heart Failure

Background: Plasma natriuretic peptides (NP) are helpful in the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) and predict adverse outcomes. Levels of NP beyond a certain cut-off level are often used as inclusion criteria in clinical trials to ensure that the patients have HF, and to select patients at higher risk. Whether treatments have a differential effect on outcomes across the spectrum of NP levels is unclear. In the I-Preserve trial a benefit of irbesartan on all outcomes was only seen in HFpEF patients with low but not high NP levels. We hypothesized that in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, spironolactone might have a greater benefit in patients with lower NP levels. Methods and Results: BNP (n=468) or NT-proBNP (n=400) levels were available at baseline in 868 patients with HFpEF enrolled in the natriuretic peptide stratum (BNP ≥100 pg/mL or an NT- proBNP ≥360 pg/mL) of the TOPCAT trial. In a multi-variable Cox regression model, that included age, gender, region (Americas vs. Russia/Georgia), atrial fibrillation, diabetes, eGFR, BMI and heart rate, higher BNP or NT-proBNP as a continuous, standardized log-transformed variable or grouped by terciles (see Figure for BNP & NT-proBNP tercile values) was independently associated with an increased risk of the primary endpoint of cardiovascular mortality, aborted cardiac arrest, or hospitalization for heart failure (Figure-1). There was a significant interaction between the effect of spironolactone and baseline BNP or NT-proBNP terciles for the primary outcome (P=0.02, Figure-2), with greater benefit of the drug in the lower compared to higher NP terciles. Conclusions: The benefit of spironolactone in lower risk HFpEF patients may indicate effects of the drug on early, but not late higher-risk stage of the disease. These findings question the strategy of using elevated NP as a patient selection criterion in HFpEF trials.

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The association of hepatic steatosis and fibrosis with heart failure and mortality

Cardiovascular Diabetology ◽

10.1186/s12933-021-01374-8 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Jiyun Park ◽

Gyuri Kim ◽

Hasung Kim ◽

Jungkuk Lee ◽

You-Bin Lee ◽

...

Keyword(s):

Heart Failure ◽

General Population ◽

Fatty Liver ◽

Hepatic Steatosis ◽

Patient Group ◽

Cox Regression ◽

Nonalcoholic Fatty Liver ◽

Fatty Liver Index ◽

Increased Risk ◽

All Cause Mortality

Abstract Background Nonalcoholic fatty liver disease (NAFLD) is a hepatic manifestation of metabolic disease and independently affects the development of cardiovascular (CV) disease. We investigated whether hepatic steatosis and/or fibrosis are associated with the development of incident heart failure (iHF), hospitalized HF (hHF), mortality, and CV death in both the general population and HF patients. Methods We analyzed 778,739 individuals without HF and 7445 patients with pre-existing HF aged 40 to 80 years who underwent a national health check-up from January 2009 to December 2012. The presence of hepatic steatosis and advanced hepatic fibrosis was determined using cutoff values for fatty liver index (FLI) and BARD score. We evaluated the association of FLI or BARD score with the development of iHF, hHF, mortality and CV death using multivariable-adjusted Cox regression models. Results A total of 28,524 (3.7%) individuals in the general population and 1422 (19.1%) pre-existing HF patients developed iHF and hHF respectively. In the multivariable-adjusted model, participants with an FLI ≥ 60 were at increased risk for iHF (hazard ratio [HR], 95% confidence interval [CI], 1.30, 1.24–1.36), hHF (HR 1.54, 95% CI 1.44–1.66), all-cause mortality (HR 1.62, 95% CI 1.54–1.70), and CV mortality (HR 1.41 95% CI 1.22–1.63) in the general population and hHF (HR 1.26, 95% CI 1.21–1.54) and all-cause mortality (HR 1.54 95% CI 1.24–1.92) in the HF patient group compared with an FLI < 20. Among participants with NAFLD, advanced liver fibrosis was associated with increased risk for iHF, hHF, and all-cause mortality in the general population and all-cause mortality and CV mortality in the HF patient group (all p < 0.05). Conclusion Hepatic steatosis and/or advanced fibrosis as assessed by FLI and BARD score was significantly associated with the risk of HF and mortality.

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Abstract 14541: Incidence, Risk Factors, and Outcomes of Heart Failure in Patients With Graves’ Disease

Circulation ◽

10.1161/circ.142.suppl_3.14541 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jwan A Naser ◽

Sorin Pislaru ◽

Marius N Stan ◽

Grace Lin

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Cardiovascular Events ◽

De Novo ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Graves Disease ◽

Increased Risk ◽

All Cause Mortality ◽

Overt Hyperthyroidism

Background: Graves’ disease (GD) can both aggravate pre-existing cardiac disease and cause de novo heart failure (HF). Due to the rarity of thyrotoxic HF, population-based studies are lacking, and data from smaller studies are widely variable. Methods: We reviewed the medical records of 1371 consecutive patients with GD evaluated at our clinic between 2009 and 2019. HF was defined according to Framingham criteria. GD-related HFrEF was defined by left ventricular ejection fraction of <50%, while HFpEF was defined according to the Heart Failure Association of the European Society of Cardiology. Outcomes of major cardiovascular events, all-cause mortality, and cardiac hospitalizations were analyzed with adjustments for age, gender, and history of coronary artery disease (CAD). 1:1 matching with controls (age, gender, and CAD) was additionally done. Results: HF occurred in 74 patients (31 HFrEF; 43 HFpEF). Incidence of GD-related HF, HFrEF, and HFpEF was 5.4%, 2.3%, and 3.1%, respectively. In HFrEF, atrial fibrillation (AF) (RR 10.05, p <0.001) and thyrotropin receptor antibodies (TRAb) level (RR 1.05 per unit, p=0.005) were independent predisposing factors. In HFpEF, independent risk factors were COPD (RR 5.78, p < 0.001), older age (RR 1.48 per 10 years, p = 0.003), overt hyperthyroidism (RR 5.37, p = 0.021), higher BMI (1.06 per unit, p = 0.003), and HTN (RR 3.03, p = 0.011). Rates of cardiac hospitalizations were higher in HFrEF (41.9% vs 3.2%, p <0.001) and HFpEF (44.2% vs 4.7%, p < 0.001) compared to controls. Furthermore, while both increased risk of strokes (HFrEF: RR 4.12, p = 0.027; HFpEF: RR 4.64, p = 0.009), only HFrEF increased risk of all-cause mortality (RR 3.78, p = 0.045). Conclusion: De novo HF occurs in 5.4% of patients with GD and increases the rate of cardiovascular events. HF occurs more frequently in GD patients with AF, higher TRAb, higher BMI, and overt hyperthyroidism, suggesting that these may be targets for treatment to prevent cardiovascular complications, especially in older multimorbid patients.

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Myocardial reperfusion reverses the J-curve association of cardiovascular risk and diastolic blood pressure in patients with left ventricular dysfunction and heart failure after myocardial infarction: insights from the EPHESUS trial

European Heart Journal ◽

10.1093/eurheartj/ehaa132 ◽

2020 ◽

Vol 41 (17) ◽

pp. 1673-1683 ◽

Cited By ~ 5

Author(s):

Michael Böhm ◽

João Pedro Ferreira ◽

Felix Mahfoud ◽

Kevin Duarte ◽

Bertram Pitt ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Blood Pressure ◽

Diastolic Blood Pressure ◽

Cox Regression ◽

Cardiovascular Death ◽

Left Ventricular ◽

Coronary Perfusion ◽

Increased Risk ◽

The Impact

Abstract Aims The described association of low diastolic blood pressure (DBP) with increased cardiovascular outcomes could be due to reduced coronary perfusion or is simply due to reverse causation. If DBP is physiologically relevant, coronary reperfusion after myocardial infarction (MI) might influence DBP–risk association. Methods and results The relation of achieved DBP with cardiovascular death or cardiovascular hospitalization, cardiovascular death, and all-cause death was explored in 5929 patients after acute myocardial infarction (AMI) with impaired left ventricular function, signs and symptoms of heart failure, or diabetes in the EPHESUS trial according to their reperfusion status. Cox regression models were used to assess the impact of reperfusion status on the association of DBP and systolic blood pressure (SBP) with outcomes in an adjusted fashion. In patients without reperfusion, lower DBP <70 mmHg was associated with increased risk for all-cause death [adjusted hazard ratios (HRs) 1.80, 95% confidence interval (CI) 1.41–2.30; P < 0.001], cardiovascular death (HR 1.70, 95% CI 1.3–3.22; P < 0.001), cardiovascular death or cardiovascular hospitalization (HR 1.54, 95% CI 1.26–1.87; P < 0.001). In patients with reperfusion, the risk increase at low DBP was not observed. At low SBP, risk increased independently of reperfusion. A sensitivity analysis in the subgroup of patients with optimal SBP of 120–130 mmHg showed again risk reduction of reperfusion at low DBP. Adding the treatment allocation to eplerenone or placebo into the models had no effects on the results. Conclusion Patients after AMIs with a low DBP had an increased risk, which was sensitive to reperfusion therapy. Low blood pressure after MI identifies in patients with particular higher risk. These data support the hypothesis that low DBP in patients with stenotic coronary lesions is associated with risk, potentially involving coronary perfusion pressure and the recommendations provided by guidelines suggesting lower DBP boundaries for these high-risk patients.

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Serum Sulfhydryl Groups, Malondialdehyde, Uric Acid, and Bilirubin as Predictors of Adverse Outcome in Heart Failure Patients due to Ischemic or Nonischemic Cardiomyopathy

Oxidative Medicine and Cellular Longevity ◽

10.1155/2021/6693405 ◽

2021 ◽

Vol 2021 ◽

pp. 1-14

Author(s):

Celina Wojciechowska ◽

Wojciech Jacheć ◽

Ewa Romuk ◽

Anna Ciszek ◽

Patryk Bodnar ◽

...

Keyword(s):

Oxidative Stress ◽

Heart Failure ◽

Uric Acid ◽

Cox Regression ◽

Laboratory Data ◽

Sulfhydryl Groups ◽

Nonischemic Cardiomyopathy ◽

Oxidative Stress Biomarkers ◽

Risk Of Death ◽

Increased Risk

Oxidative stress plays a significant role in the pathogenesis of heart failure (HF). The aim of the study was to investigate the prognostic value of oxidation-reduction (redox) markers in patients with HF due to ischemic and nonischemic cardiomyopathy. The study included 707 patients of HF allocated into two groups depending on ethology: ischemic cardiomyopathy (ICM) ( n = 435 ) and nonischemic cardiomyopathy (nICM) ( n = 272 ), who were followed up for one year. The endpoint occurrence (mortality or heart transplantation) in a 1-year follow-up was similar in the ICM and nICM group. The predictive value of endpoint occurrence of oxidative stress biomarkers such as the serum protein sulfhydryl groups (PSH), malondialdehyde (MDA), uric acid (UA), bilirubin, and MDA/PSH ratio and other clinical and laboratory data were assessed in both groups (ICM and nICM) separately using univariate and multivariate Cox regression analyses. In multivariate analysis, the higher concentrations of UA ( p = 0.015 , HR = 1.024 , 95% CI (1.005-1.044)) and MDA ( p = 0.004 , HR = 2.202 , 95% CI (1.296-3.741)) were significantly associated with adverse prognosis in patients with ICM. Contrastingly, in patients with nICM, we observed that higher bilirubin concentration ( p = 0.026 , HR = 1.034 , 95% CI (1.004-1.064)) and MDA/PSH ratio ( p = 0.034 , HR = 3.360 , 95% CI (1.096-10.302)) were significantly associated with increased risk of death or HT. The results showed the association of different oxidative biomarkers on the unfavorable course of heart failure depending on etiology.

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MO131THE SHRUNKEN PORE SYNDROME IS ASSOCIATED WITH POOR PROGNOSIS AND LOWER QUALITY OF LIFE IN HEART FAILURE PATIENTS- THE HARVEST-MALMÖ STUDY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab092.009 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Liana Xhakollari ◽

Anders Grubb ◽

Amra Jujic ◽

Erasmus Bachus ◽

Peter M Nilsson ◽

...

Keyword(s):

Quality Of Life ◽

Heart Failure ◽

Poor Prognosis ◽

Kansas City ◽

Cox Regression ◽

Cardiorenal Syndrome ◽

Risk Of Death ◽

Increased Risk ◽

Health Related Qol

Abstract Background and Aims The cardiorenal syndrome was studied in heart failure (HF) patients with respect to the “Shrunken pore syndrome” (SPS) that is characterized by a difference in renal filtration between cystatin C and creatinine, resulting in a low eGFRcystatin C/eGFRcreatinine-ratio. Method 373 patients hospitalized for HF were retrieved from the HeARt and brain failure inVESTigation trial (HARVEST-Malmö). We used CKD-EPI formulas for estimated glomerular filtration rate (eGFR). Presence of SPS was defined as eGFRcystatinC ≤60% of eGFRcreatinine. In Cox regression multivariate models, associations between SPS, risk of death and risk of 30-day re-hospitalization were studied. Associations between SPS and impaired quality of life (QoL) were studied using multivariate logistic regressions. Results SPS was associated with all-cause mortality (124 events; hazard ratio (HR) 2.35; confidence interval (CI95%) 1.17-4.71; p=0.016 and with 30-day re-hospitalization (70 events; HR 1.82; CI95% 1.04-3.18; p=0.036). Analyses of QoL, based on a Kansas City Cardiomyopathy Questionnaire overall score <50, revealed that SPS was associated with increased risk of low health-related QoL (odds ratios (OR) 2.15 (CI95% 1.03-4.49; p=0.042). Conclusion The results of this observational study show for the first time an association between SPS and poor prognosis in HF. Further studies are needed to confirm the results in HF cohorts and experimental settings to identify pathophysiological mechanisms.

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Left atrial coupling index versus left atrial function index in heart failure with reduced ejection fraction and iron deficiency

European Heart Journal ◽

10.1093/eurheartj/ehab724.0887 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

A Tsarouchas ◽

C Bakogiannis ◽

D Mouselimis ◽

E.D Pagourelias ◽

I Kelemanis ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Left Atrial ◽

Cox Regression ◽

Relevant Literature ◽

Reduced Ejection Fraction ◽

Function Index ◽

Coupling Index ◽

Increased Risk

Abstract Background Left atrial (LA) form and function has been the focus of extensive research in heart failure with reduced ejection fraction (HFrEF). The LA coupling index (LACI, see Picture 1 for definition) and the LA function Index (LAFI) have both been proposed as potent predictors of morbidity and mortality in HFrEF. Albeit promising, both parameters have drawbacks that could limit their usefulness in clinical settings - LACI can only be measured during sinus rhythm (SR), while LAFI calculation is arguably more involved. A side-by-side comparison of the two indices has not yet been performed. Purpose Investigate and compare the feasibility and efficacy of using LACI and LAFI as prognostic factors in HFrEF. Methods HFrEF patients that visited our outpatient HF clinic were invited to participate in the study. Clinical examination, 6-minute walk testing, and a full echocardiographic study were performed, the latter enabling quantification of LACI, LAFI, as well as most traditional echocardiographic predictors of HF prognosis (Picture 1). LACI and LAFI cut-offs of 6 and 25 respectively were defined in accordance with the relevant literature. Cox regression was performed to assess each parameter's correlation with risk of HF-related hospitalization and mortality over a 6-month follow-up period. Results In the end, 63 patients were included in the study (aged 69.3±9.7 years, 84% male). LACI could not be measured in 19 patients due to atrial tachycardia. The median LACI was 6.2 (8.7) while the median LAFI of the entire sample was 24.8 (44.5). LACI and LAFI correlated strongly (r=−0.813, p<0.001). Neither correlated significantly with the risk of HF-related hospitalization (Picture 1) or death in our sample (Picture 2). 6MWD was the only parameter to independently correlate with increased risk of hospitalization (HR=0.39, p<0.001) or death (HR=0.42, p=0.02). Conclusions The collinearity detected between LACI and LAFI indicate that both quantify similar aspects of left atrial (dys)function. That said, neither index had significant capability to predict hospitalization or death in our sample of HFrEF patients. Although a non-significant trend for higher LACI in patients with poorer prognosis was detected in our sample, it was also incalculable in 30% of patients, who were not in SR during echocardiography. Extended follow-up of an expanded sample size will enable more refined investigation of LACI's and LAFI's prognostic capacity. FUNDunding Acknowledgement Type of funding sources: None. Hospitalization Cox regression results LACI and LAFI survival curves

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Relationship Between The Place Of Living And Mortality In Patients With Advanced Heart Failure.

10.21203/rs.2.22957/v2 ◽

2020 ◽

Author(s):

Miguel-Angel Munoz ◽

Raquel Garcia ◽

Elena Navas ◽

Julio Duran ◽

José-Luis Del Val-Garcia ◽

...

Keyword(s):

Heart Failure ◽

Primary Care ◽

New York ◽

Rural Areas ◽

Cox Regression ◽

Heart Association ◽

Population Based ◽

Advanced Heart Failure ◽

Functional Class ◽

Increased Risk

Abstract Background Social and environmental factors in advanced heart failure (HF) patients may be crucial to cope with the end stages of the disease. This study analyzes health inequalities and mortality according to place of residence (rural vs urban) in HF patients at advanced stages of the disease.Methods Population-based cohort study including 1148 adult patients with HF attended in 279 primary care centers. Patients were followed for at least one year after reaching New York Heart Association IV functional class, between 2010 and 2014.Data came from primary care electronic medical records. Cox regression models were applied to determine the hazard ratios (HR) of mortality. Results Mean age was 81.6 (SD 8.9) years, and 62% were women. Patients in rural areas were older, particularly women aged >74 years (p=0.036), and presented lower comorbidity. Mortality percentages were 59% and 51% among rural and urban patients, respectively (p=0.030). Urban patients living in the most socio-economically deprived neighborhoods presented the highest rate of health service utilization, particularly with primary care nurses (p-trend <0.001). Multivariate analyses confirmed that men (HR 1.60, 95% confidence interval (CI) 1.34-1.90), older patients (HR 1.05, 95% CI 1.04-1.06), Charlson comorbidity index (HR 1.16, 95% CI 1.11-1.22), and residing in rural areas (HR 1.35, 95% CI 1.09 to 1.67) was associated with higher mortality risk.Conclusions Living in rural areas determines an increased risk of mortality in patients at final stages of heart failure.

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