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JACC Heart Fail. 2018 Apr;6(4):298-307. doi: 10.1016/j.jchf.2018.01.018. Epub 2018 Mar 7.

Is Time of the Essence? The Impact of Time of Hospital Presentation in Acute Heart Failure: Insights From ASCEND-HF Trial.

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Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina. Electronic address:
Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, North Carolina, Durham, North Carolina.
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
Division of Cardiology, Stony Brook University, Stony Brook, New York.
Duke Clinical Research Institute, North Carolina, Durham, North Carolina.
Cardiology, University of Brescia, Brescia, Italy.
Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Section of Cardiology, San Francisco Veteran Affairs Medical Center, and School of Medicine, University of California-San Francisco, San Francisco, California.
University of Groningen, Groningen, the Netherlands.
Inova Heart and Vascular Institute, Falls Church, Virginia.



As the largest acute heart failure (AHF) trial conducted to date, the global ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial database presented an opportunity to systematically describe the relationship among time of hospital presentation, clinical profile, inpatient management, and outcomes among patients admitted with AHF.


Time of hospital presentation has been shown to impact outcomes among patients hospitalized with many conditions. However, the association among time of presentation and patient characteristics, management, and clinical outcomes among patients hospitalized with AHF has not been well characterized.


A post hoc analysis of the ASCEND-HF trial was performed, which enrolled 7,141 patients hospitalized for AHF. Patients were divided based on when they presented to the hospital; regular hours were defined as 9 am to 5 pm, Monday through Friday, and off hours were defined as 5 pm to 9 am, Monday through Friday and weekends. Clinical characteristics and outcomes were compared by time of presentation.


Overall, 3,298 patients (46%) presented during off hours. Off-hour patients were more likely to have orthopnea (80% vs. 74%, respectively) and rales (56% vs. 49%, respectively) than regular-hour patients. Off-hour patients were more likely to receive intravenous (IV) nitroglycerin (18% vs. 11%, respectively) and IV loop diuretics (92% vs. 86%, respectively) as initial therapy and reported greater relief from dyspnea at 24 h (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.04 to 1.24; p = 0.01) than regular-hour patients. After adjustment, off-hour presentation was associated with significantly lower 30-day mortality (OR: 0.74; 95% CI: 0.57 to 0.96; p = 0.03) and 180-day mortality (hazard ratio [HR]: 0.82; 95% CI: 0.72 to 0.94; p = 0.01) but similar 30-day rehospitalization rates (p = 0.40).


In this AHF trial, patients admitted during off hours exhibited a distinct clinical profile, experienced greater dyspnea relief, and had lower post-discharge mortality than regular-hour patients. These findings have implications for future AHF trials.


ASCEND-HF; heart failure; presentation


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