"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.
Hospital admission occurs almost universally at some point in the heart failure (HF) journey. The disease is one of the most common reasons for hospital admission in the United States.
National HF hospitalization rates are on the rise, increasing from 4.4 per 1,000 U.S. adults in 2010 to 4.9 per 1,000 in 2017, according to a of Nationwide Readmission Database trends. Pandemic impacts on lifestyle and healthcare were expected to contribute to worsening of chronic conditions associated with HF, suggesting the potential for further rise in the rates.
Acute coronary syndrome requiring urgent revascularization and inflammatory heart disease will account for some of these decompensation cases, but the vast majority arise from gradually rising cardiac filling pressures with preexisting structural heart disease.
Hospitalization is recommended for HF patients with hypotension; declining renal function; change in mental status; dyspnea at rest; atrial fibrillation with a rapid heart rate, ventricular tachycardia (including after an implanted cardioverter-defibrillator shock) or other arrhythmia; and acute coronary syndromes.
Inpatient care focuses on hemodynamic stabilization, symptom relief, and preventing short-term morbidity and mortality. Care starts with hemodynamic assessment to determine the severity of congestion and the adequacy of perfusion.
Management is then guided by investigation of the overall patient trajectory and precipitating factors, such as uncontrolled hypertension, acute infection, medication or lifestyle nonadherence, or use of medications that increase sodium retention, such as nonsteroidal anti-inflammatory drugs and steroids.
Decongestion
For acute decompensated HF, reducing congestion is a key goal of inpatient treatment.
Some studies have shown that natriuresis (as measured by urinary sodium output) is associated with a . However, the randomized controlled trial did not show a difference in outcomes using a natriuresis-guided strategy versus usual care.
Loop diuretics are the most commonly used, with careful attention to dosing. Higher doses can be required for patients with severe renal insufficiency or low cardiac output to make sure enough of the drug reaches the site where it's needed. Resistance to oral diuretics can also occur because splanchnic congestion leads to bowel wall edema and thus poor gastrointestinal absorption of the medication.
Adding a thiazide diuretic or a mineralocorticoid receptor antagonist (MRA) with diuretic effects can also be effective.
In terms of the diuretic, the did not show an advantage of bolus doses of furosemide rather than continuous infusion, although with some trend for greater diuresis and symptom improvement at the expense of transient worsening of renal function. The TRANSFORM-HF trial showed similar outcomes for furosemide and torsemide. However, the ADVOR trial showed that adding IV acetazolamide to loop diuretics boosted early decongestion.
Guidelines suggest use of IV nitroglycerin or nitroprusside as an option to consider as an add-on to diuretics for dyspnea relief for patients without systemic hypotension.
While the need for IV diuretics has been a leading reason for admission to rapidly reduce congestion, outpatient management with ambulatory or clinic-based diuretic use is gaining support. At-home dosing with an IV-equivalent formulation of furosemide (Furoscix) is also approved for patient self-administration using a pre-filled cartridge for 5-hour subcutaneous injection.
In one of day-case unit or home IV treatment, only 11 of 79 patients needed to be admitted for higher doses than could be administered on an outpatient basis. The outpatient treatment group actually had a lower rate of 30-day mortality or HF readmission than seen with usual-care inpatient treatment (17.5% vs 32.6%, P=0.02). Another larger showed a similar association.
Medication dose adjustments are guided by daily laboratory testing for serum electrolytes, urea nitrogen, and creatinine concentrations, as well as careful monitoring of fluid intake and output, vital signs, standing body weight, clinical signs and symptoms of congestion, and hypoperfusion.
Residual congestion merits "careful consideration for further intervention before and after discharge, because [these patients] face higher risk for rehospitalization and death," note the 2022 American Heart Association .
Inotropic Support
While positive inotropes weren't shown to improve survival for hospitalized HF patients overall in the , their role in increasing cardiac output and improving hemodynamics gives short-term use a recommendation as "reasonable" for hospitalized patients with documented severe systolic dysfunction who present with low blood pressure and significantly low cardiac index.
"To minimize adverse effects, lower doses of parenteral inotropic drugs are preferred, although the development of tachyphylaxis should be acknowledged, and the choice of agent may need to be changed during longer periods of support," according to the HF guidelines. "Similarly, the ongoing need for inotropic support and the possibility of discontinuation should be regularly assessed."
In cases of cardiogenic shock, though, IV inotropes have a class 1 recommendation, followed by temporary mechanical circulatory support when that isn't enough to maintain end-organ function.
Despite limited evidence to guide use of IV inotropic agents, the guidelines point to "broad availability, ease of administration, and clinician familiarity favor such agents as the first therapeutic consideration when signs of organ hypoperfusion persist despite empiric volume replacement and vasopressors." Selection can be guided by blood pressure, concurrent arrhythmias, and availability.
Guideline-Directed Medical Therapy
"Hospitalization for HF is a sentinel event that signals worse prognosis and the need to restore hemodynamic compensation but also provides key opportunities to redirect the disease trajectory," the HF guidelines argue.
Central to that effort is optimization of guideline-directed medical therapy (GDMT).
Once diuresis is working, underutilized drugs can be initiated and doses uptitrated toward the target. The and others have shown that few patients get target doses of GDMT in the community and more than 40% anytime soon after hospitalization. The opportunity is particularly great for MRAs, which 67% of HF patients weren't on in the CHAMP data despite generic availability.
Thus, guidelines recommend not routinely stopping medications despite mild drops in renal function or asymptomatic blood pressure reduction in the hospital. Beta-blockers should be continued unless the patient is in shock. Any GDMT that is stopped during hospitalization due to clinical condition should be restarted and optimized "as soon as possible."
Electronic health record prompts from a virtual care team helped boost optimization of GDMT in the IMPLEMENT-HF trial.
Trials have pointed to outcome advantages to starting medications during HF hospitalizations. For example, the EMPULSE trial showed more than a 15 percentage point reduction in composite all-cause mortality, HF events, and HF symptoms with the SGLT2 inhibitor empagliflozin (Jardiance) started in the hospital.
The COACH trial showed that even for patients discharged from the emergency department, a strategy of protocolized nurse-led rapid outpatient follow-up reduced 30-day all-cause mortality or hospitalization for cardiovascular causes by a relative 12%.
"However, care and attention in both inpatient and outpatient settings need to go beyond stabilization and decongestion if we want to reduce readmissions for any cause," argued an in the New England Journal of Medicine accompanying the COACH publication. "Strategies such as carefully reconciling medication lists to mitigate the risks associated with polypharmacy, improving nutritional status, providing supportive measures when cognitive impairment is present, recruiting services to promote physical function, and activating the social network, possibly augmented by home health care, are all crucial."
Read previous installments of this series:
Part 1: Heart Failure: A Look at Low Ejection Fraction
Part 2: Exploring Heart Failure With Preserved Ejection Fraction
Part 3: Heart Failure With Reduced Ejection Fraction: Diagnosis and Evaluation
Part 4: Case Study: Lightheadedness, Fatigue in Man With Hypertension
Part 5: Heart Failure With Preserved Ejection Fraction: Diagnosis and Evaluation
Part 6: Heart Failure Medical Management
Part 7: Managing Heart Failure Comorbidities
Part 8: Case Study: Heart Failure Exacerbation Due to an Often Overlooked Cause