Management of Acute Decompensated Heart Failure in Hospitalized Patients

• What elements of care may help optimize the discharge process?

Transition of care in hospitalized patients with ADHF to outpatient care is a critical and vulnerable period for patients given the complexity of the discharge planning for heart failure. A multidisciplinary heart failure disease management program is recommended in both the inpatient and outpatient setting to address the barriers to successful transition of care [5]. Physicians and physician extenders, nurses, pharmacists, and social workers can work together to identify risk factors for readmission and bridge the gap between the inpatient and outpatient setting.

Patients at high risk for hospital readmission should be referred to a heart failure disease management program [5,37]. Patients at high risk for hospital readmission include patients with renal insufficiency, low output state, diabetes mellitus, chronic lung disease, persistent NYHA functional class III, IV symptoms, frequent hospitalizations, multiple comorbidities, history of depression, cognitive impairment, or recurrent problems with noncompliance. There is strong evidence that a heart failure disease management program will reduce rehospitalization rates and costs while improving functional status and quality of life of the patient [37].In addition, a heart failure disease management clinic often can see the patient shortly after discharge, which may allow earlier discharge of the patient and shorter length of stay. Proven therapies such as ACE inhibitors, angiotensin-receptor blockers, beta blockers, and aldosterone antagonists can be titrated frequently in this setting.

It is strongly recommended that comprehensive written discharge instructions be provided at the end of hospitalization with special emphasis on diet, discharge medications, activity level, follow-up appointment, daily weight monitoring, and instructions for recurrence of symptoms [5].

Case Conclusion

The patient tolerated well the initiation of guideline-directed medical therapy and is continued on the ACE inhibitor and beta-blocker medications. After 4 days IV furosemide is discontinued and transitioned to oral furosemide. Precipitant causes of heart failure were addressed throughout hospitalization. It was determined that the patient had been taking high doses of nonsteroidal anti-inflammatory drugs due to knee pain. She was educated on this and other potential precipitant factors. Heart failure education was reinforced, including self-care, emergency plans, and need for medication and diet adherence. She is scheduled an early follow-up visit within 2 weeks of hospital discharge in the multidisciplinary heart failure disease management clinic.

Summary

ADHF is a major public health problem commonly encountered and often initially managed in the ED. Initial history and physical examination are important to estimate the degree of congestion and peripheral perfusion. The patient’s hemodynamic status along with the use prognostic models for short-term mortality may facilitate patient triage and encourage the use of evidence-based therapy, especially in high-risk patients. Initial treatment should target the relief of congestive symptoms and intravenous loop diuretics are the mainstay of therapy. The preferred IV vasoactive medication has yet to be determined in a large prospective randomized trial. Positive inotropic agents should be reserved for patients with signs of low cardiac output and tissue hypoperfusion, however, the risk/benefit equation should be evaluated judiciously with each treatment option before initiating therapy. For patients with refractory hemodynamic collapse, ventricular assist devices can allow stabilization until recovery or decision regarding transplantation versus destination therapy. Patients with ADHF are at increased risk for readmission to the hospital as well as increased risk for death. Risk factors need to be identified and referral to a heart disease management program should be considered for those patients deemed at increased risk for rehospitalization.