ACC Releases Expert Consensus Decision Pathway for Hospitalized Patients With Heart Failure

Daily Trajectory Check

The 3 main in-hospital trajectories are: (1) improving towards target, (2) stalled after initial response, and (3) not improved/worsening.

Patients in category 1 should be considered for initiation and/or further optimization of guideline-directed medical therapy (GDMT). For patients in category 3, clinicians should intensify therapy and consider additional diagnoses. Patients in category 2 will need more consideration to determine whether intensifying therapy will result in complete decongestion or if the treatment target should be modified.

1. Targets for Decongestion

Generally, clinicians should aim for complete decongestion, with no signs or symptoms of elevated resting filling pressures. The National Heart, Lung, and Blood Institute recommends resolution of edema, orthopnea, and jugular venous distension.

2. Diuretic and Adjunctive Therapy

An effective diuretic treatment regimen is integral for achieving decongestion. Patients generally require their first dose of intravenous (IV) diuretic upon presentation, and these are continued throughout hospitalization until the patient is transitioned to oral diuretics. If the patient experiences stalled improvement or worsening congestion, IV diuretics should be increased until a response is seen.

3. Trajectory: Improving Towards Target

Patients on the improving towards target trajectory will have stable vital signs and make progress toward the resolution of congestion. In these patients, net fluid loss and weight loss — generally at least 1 kg weight loss/day — are normal with IV diuretics. As patients progress, clinicians should initiate or up-titrate components of the GDMT regimen.

4. Optimization of GDMT

If possible, clinicians should continue GDMT with neurohormonal antagonists throughout patient hospitalization or initiate it before discharge. Generally, patients should be started on a low dose and slowly titrated upward as tolerated. The ACC recommends consulting the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment for reference.

a. RAS Therapy

In patients who do not have hypotension or unstable kidney function, RAS inhibition should be continued or initiated.

b. Angiotensin Receptor-Neprilysin Inhibitors

For chronic HF, ACEI, ARB, and ARNI are improved inhibitors of the RAS.

c. Beta Blockers

Beta blockers should be continued in patients with HF who have the wet and warm profile upon admission, unless they have low blood pressure. If their HF is refractory to diuretics, the dose should be halved. If congestion remains unresponsive or if IV inotropic therapy is added, beta blockers should be discontinued. They can be initiated or resumed in the absence of symptomatic hypotension or bradycardia.

d. Aldosterone Antagonists

Without proper care and consideration, aldosterone antagonist therapy can increase the risk for hyperkalemia and other adverse events. Patients who have initiated or are continuing an aldosterone antagonist while receiving IV loop diuretics need to be closely monitored for rebound hyperkalemia.

5. Trajectory: Initial Improvement, Then Stalled

Patients in the initial improvement, then stalled trajectory class will have shown some improvement in congestion but will not have met the targeted goals of decongestion. Patients in this trajectory tend to have more advanced disease, a history of frequent hospitalizations, and worse baseline kidney function.

Currently, there are no large randomized trials that provide evidence for the management of these patients. The ACC recommends intensifying the diuretic regimen with higher doses of IV loop diuretics or adding a second diuretic. Other therapies such as IV nitroglycerin may be considered.

Clinicians should consider whether symptoms in these patients can be attributed to comorbidities.

6. Trajectory: Not Improved or Worsening

Patients in the not improved or worsening trajectory do not respond to therapy. They have either not improved at all or their condition has worsened during hospitalization. Generally, intensifying diuretic therapy is warranted even if kidney function has worsened.

Clinicians should consider additional diagnostic strategies or specialist consultation. Patients may need to be admitted to an intensive care unit. If patients continue to worsen, clinicians should review the long-term care trajectory regarding prognosis and goals of care.

a. Unexpected Sudden Event

Unexpected events such as cardiac or respiratory arrest, shock, or arrhythmia can cause patients to deteriorate quickly. Clinicians should determine the acute precipitating factors and treat them if possible. Of note, clinicians need to determine whether the event was an independent, unexpected event, or is a reflection of end-stage HF. If the latter is true, palliative care and end of life options may be better than aggressive treatment.

Transition Point

1. Need for a Distinct Transition Phase

The transition point begins after the initial decompensation has been resolved or addressed, and clinicians must then focus on maintaining the stability of compensation. Patients should only be discharged following ≥24 hours of observation after discontinuing IV diuretics in order to reduce the risk for readmission.

2. Planning Diuretic Therapy for Discharge

Clinicians should plan maintenance diuretic dosing, with the knowledge that lower doses are needed for fluid balance than for net diuresis. They should also include a rescue dosing plan that specifies both the increased diuretic therapy and the personalize trigger for patients to require the rescue dose.

3. Evaluating Tolerance of GDMT and Opportunities for Optimization

During the transition point, clinicians should consider the opportunity to optimize a patient’s GDMT in the outpatient setting. Tolerability should be confirmed. Clinicians who are assuming care of a patient after hospitalization should be informed about any anticipated further titration and what factors may limit titration.

4. Additional Drug Therapy Considerations

In addition to GDMT, some patients may benefit from further optimization, such as beta blocker therapy or digoxin.

Clinicians should also consider medication regimens for patients’ comorbidities, taking into account potential interactions with HF.

5. Assessment of Risk at Discharge

The effectiveness of decongestion, enhancement of guideline-recommended therapies for patients with reduced LVEF, and improvement in patient education for adherence are the most significant contributors to risk reduction from admission to discharge. Risk factors that carry over from admission include advanced age, history of prior hospitalizations, and socioeconomic status. Patients with residual congestion, discharge without angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors; discharge without beta blockers; or consideration for advanced therapies should be prioritized for follow-up.