The American College of Cardiology (ACC) has developed a new expert consensus decision pathway for risk assessment, management, and clinical trajectories of patients hospitalized with heart failure (HF), which has been published in the Journal of the American College of Cardiology. The primary goal of this decision pathway is to optimize patient care and improve outcomes.

In order to create the guidelines, the writing group participants were invited to represent the various types of clinicians who are involved in the care of patients with HF. After the creation of the document, it underwent formal peer review in compliance with ACC policy. After all comments were taken into account, the guidelines were approved by the Clinical Policy Approval Committee.

The consensus contains 5 sections: Admission, Trajectory Check, Oral Therapies, Discharge, and Follow-Up Visit.


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ADMISSION

1. Evaluation in the Emergency Department

Patients presenting with HF in the emergency department, those who are critically ill, or with new-onset HF should be admitted. Patients with known HF and a marked degree of congestion and those who are not at low risk are generally admitted. Patients with a clear and correctable trigger can be treated and discharged.

2. Comprehensive Initial Assessment: Setting Inpatient Goals

If a patient is admitted for HF, a multidisciplinary care team should meet to review patient information and develop an integrated plan as soon as possible. Ideally, this team should include an attending physician, inpatient nurse, a pharmacist, and a discharge coordinator and/or advanced practice nurse. The central goals of the treatment plan should be decongestion and optimization of therapies recommended for HF.

a. Assessing Hemodynamic Profiles

The majority of patients with HF present with ≥1 symptom and ≥1 sign of congestion that can be used as targets during decongestion. Jugular venous pressure represents elevated right-sided filling pressures and can also be used as an indicator of elevated left-sided filling pressures.

If a patient has congestion, clinicians should determine whether filling pressures are elevated proportionately in both the right and the left heart.

b. Consideration of Comorbidities

Patient comorbidities should be considered as they can play a role in HF decompensation and may be independent targets for intervention.

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c. Initial Risk Assessment

There are many factors that can influence HF outcomes. Advanced age, HF  hospitalization history, decreased kidney function, high natriuretic peptide concentrations, and low blood pressure have repeatedly been identified as independent risk factors.

The ACC recommends assessing the following risk factors upon admission: Class IV symptoms, nonadherence to medication or salt/fluid restriction, renal dysfunction markers, degree of congestion at admission, hemodynamic profile, low systolic blood pressure, troponin elevation, renin-angiotensin system (RAS) therapy, and beta blocker therapy.

d. Documentation

Clinicians should systematically document information from admission through discharge in a format that is easily accessible to clinicians in and outside of the hospital.