For patients hospitalised with heart failure (HF), a step-wise plan addresses the dual goals of decongestion and re-construction of long-term therapy, adapted to disease trajectory before and during hospitalisation. Professor Lynne Stevenson (Vanderbilt University, Nashville, USA), Writing Committee Vice Chair for the 2019 American College of Cardiology Expert Consensus Decision Pathway for HF hospitalisation,1 outlines how the recommended route applies to different patient types.
“The initial goal for all patients is to achieve decongestion, primarily through the use of intravenous (IV) diuretics, with patients monitored daily to assess their trajectory. When nearing successful decongestion, the focus of treatment shifts toward re-construction of the chronic regimen to maintain freedom from re-congestion and improve long-term outcomes. The hospitalisation provides a pivot point from which to set the patient on the best path with the triad of renin-angiotensin inhibition (for some patients paired with neprilysin inhibition), for many patients including separate therapy with mineralocorticoid receptor antagonists, and titration of beta blockers. It is crucial to recognise that optimal titration of these agents is a stepwise process that will take place over weeks but that can be re-constructed and mapped during hospitalisation.
At the other end of the spectrum are patients who do not improve, or who worsen after admission. Consideration should be given to re-evaluation of their haemodynamic profile and compounding diagnoses and intensification of therapy. When there are no other options, an unfavourable trajectory should trigger discussions about prognosis and goals of care. An intermediate category comprises patients whose progress stalls after an initial response.
Systematic focus on the goal of decongestion will reveal when a compromise with congestion is unavoidable, most often because of dominant right heart failure, renal dysfunction, symptomatic hypotension, or limitations to patient adherence. This introduces a new label of Wet And Sent Home (WASH), which emphasises the urgency of identifying WASH patients to provide intense follow-up, as they are at the highest risk for future events. This target population is poorly understood – there are no trials specifically addressing these patients – and we urgently need to identify how we can improve their outcomes.
After addressing the dual goals of decongestion and reconstruction of the chronic regimen, movement towards hospital discharge can begin. One of the most important milestones on this path is the transition day, generally triggered by the transition from IV to oral diuretics and a discharge regimen coordinated to continue into the outpatient setting. Communication between the in-hospital and outpatient teams is crucial. Implementation of a concise, standardised discharge hand-off template ensures that all the information required by subsequent care teams is reliably accessible. Transition is also the time to make sure that patients and their caregivers have written and verbal information on their medications, recommended self-care, HF nurse contacts and follow-up appointments.
Following discharge, a designated member of the multidisciplinary team should contact the patient within 48–72 hours to ensure that they understand their treatment plan and self-care advice. This should be checked again at the follow-up visit, 7–10 days after discharge, along with clinical status, the titration plan for recommended medications and factors that could lead to readmission, all tailored to the individual patient’s needs.
Finally, we must recognise the remarkable advances in treatment that have allowed so many HF patients to survive and thrive without hospitalisation. Today’s hospitalised patients are so much sicker than those of 20 years ago. We need to recognise and report the diversity of their trajectories in and out of the hospital, and design trials to improve their intermediate and long-term outcomes after hospital discharge.”
- Hollenberg SM, et al.J Am Coll Cardiol 2019;74:1966–2011.