Acute Management of Hospitalized Patients

Goals

• Address reversible factors.
• Establish optimal volume status.
• Advance GDMT toward optimization of dosing.

Recommendations

• Triage severity of congestion and adequacy of perfusion to dictate initial therapy.
• Identify precipitating factors:
  • Acute coronary syndrome
  • Uncontrolled hypertension
  • Arrythmias (i.e., atrial fibrillation)
  • Other cardiac diseases (i.e., endocarditis)
  • Infections
  • Noncompliance with medications and/or diet
  • Anemia
  • Hyperthyroidism or hypothyroidism
  • Use of medications that should be avoided (i.e., medications that increase sodium retention and medications with negative inotropic effects)
• Initiate GDMT during hospitalizations as soon as patient is clinically stable.
• Continue established GDMT throughout hospitalization, unless contraindicated.
• If temporary discontinuation of pre-existing GDMT is necessary, reinstitute it as soon as possible.
• IV loop diuretics provide the most rapid and effective treatment for decongestion therapy.
  • Start at a dose at least two times the chronic daily home oral dose and administer by bolus or infusion.
  • Increase diuretic or add another diuretic if diuresis is inadequate.
  • Monitor serum electrolytes, urea nitrogen and creatinine, fluid intake/output, daily weights, vital signs, and clinical signs and symptoms of fluid overload.
  • In patients admitted with decompensated HF, without systemic hypotension, IV nitroglycerin or nitroprusside may be used with diuretics to relieve dyspnea.
  • The discharge regimen should include a plan for diuretic dose adjustment to reduce rehospitalizations.
  • Manage cardiogenic shock.
    • Use a multidisciplinary team approach of clinicians experienced in shock management and palliative care.
    • Use IV inotropic support to increase cardiac output and improve hemodynamics, maintain systemic perfusion, and avoid end-organ damage.
    • Consider temporary mechanical circulatory support (MCS) when pharmacological strategies are not sufficient to maintain end-organ perfusion.
    • Consider placement of a pulmonary artery catheter to guide therapy when MCS is being used or in setting of hemodynamic uncertainly.
    • Seek transfer to higher level of centers when needed. Triage and initiate transfer early to help mitigate a trajectory of worsening end-organ malperfusion.
  • Ensure thrombosis/thromboembolism prophylaxis. In patients with adequate renal function, use enoxaparin 40 mg subcutaneously once daily, unfractionated heparin 5000 units subcutaneously every 8 hours, or rivaroxaban 10 mg orally once daily.

Considerations for Patients with Comorbidities

• Iron deficiency with or without anemia: IV iron therapy is reasonable to improve functional status and quality of life.
• Sleep disorders: conduct formal sleep assessment to confirm diagnosis and treat with continuous positive airway pressure as needed.
• Hypertension: treat according to current clinical guidelines.
• Type 2 DM: use SGLT2i.
• Atrial fibrillation and LVEF ≤50%: if rhythm control strategies fail, consider AV nodal ablation and CRT implantation.

Recommendations for Hospital Discharge

• Transition from inpatient to outpatient care is a vulnerable time when patients are at highest risk for decompensation and rehospitalization.
• Use clinical risk-prediction tools and/or biomarkers to identify higher-risk patients.
• Refer to multidisciplinary HF disease team management to reduce risk of rehospitalization.
• Provide clearly written discharge instructions to patient, family members or caregiver including medications, activity level, diet, follow-up appointments, weight monitoring, cardiac rehab, and action plan for what to do if symptoms worsen.
• Arrange for early outpatient follow-up care to minimize gaps in education, care and monitoring of symptoms and disease progression.
• Transmit details of hospital course and transition of care plan as soon as possible to all clinicians who will be participating in follow-up care.
• Before hospital discharge, at the first post-discharge visit, and in subsequent follow-up visits, the following should be addressed:
  • Initiation of GDMT if not done and not contraindicated
  • Causes of HF, barriers to care, and limitations in support
  • Assessment of volume status and BP with adjustment of HF therapy
  • Titration and optimization of chronic oral HF therapy
  • Assessment of renal function and electrolytes
  • Management of comorbid conditions
  • HF education, self-care, emergency plans, and adherence
  • Palliative or hospice care
• Schedule follow-up visit within 7 to 14 days and a telephone follow-up within 3 days of hospital discharge.

Strategies for Achieving Optimal GDMT

• Titrate medications slowly. Aim for dose titration every 1-2 weeks, as tolerated.
• Frequent follow-up visits and lab monitoring during dose titration (elderly & impaired renal function).
• Monitor vital signs, including orthostatic BPs before, during, and after titrations.
• Alternate adjustments of different medication classes.
• Monitor renal function and electrolytes for increasing creatinine and potassium levels.
• Reassure patients that symptoms of fatigue and weakness without instability are transient and usually resolve in a few days.
• Discourage sudden discontinuation of GDMT medications without discussion with prescriber.
• Carefully review doses of other medications for HF symptom control during up-titration.

Advanced Heart Failure

Some patients with chronic HF will develop severe symptoms despite optimal GDMT. These patients are classified with ACCF/AHA stage D HF and include “end-stage HF” and “refractory HF.”
 
European Society of Cardiology Definition of Advanced HF

• Severe symptoms of HF with dyspnea and/or fatigue at rest with minimal exertion (NYHA class III or IV)
• Fluid retention (pulmonary and/or systemic congestion, peripheral edema) and/or decreased cardiac output at rest (peripheral hypoperfusion)
• Objective evidence of severe cardiac dysfunction - at least one of the following:
  • LVEF ≤ 30%
  • Isolated right ventricular failure
  • Nonoperable severe valve disease or congenital heart disease
  • EF ≥ 40% with elevated natriuretic peptide levels and evidence of significant diastolic dysfunction
• Severe impairment of functional capacity - one of the following:
  • Inability to exercise
  • 6-minute walk distance ≤ 300 m
  • Peak VO₂ < 12 to 14 mL/kg/min
• History of 1 or more hospitalizations in prior 6 months for the management of:
  • Congestion requiring high-dose intravenous diuretics
  • Low cardiac output requiring inotropes or vasoactive medications
  • Malignant arrhythmias