From Hospital to Home

Figures

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  Figure 1. Global Burden of Heart Failure Regions circled in red represent prevalence estimates per 100,000 based on 2019 Global Burden of Disease Data. Not all 21 regions depicted. Data for mortality and readmission are from sources of international epidemiologic and clinical trials.1, 2, 3, 4 HF = heart failure; HHF = hospitalization for heart failure.

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  Figure 2. Strategies to Effectively Decongest Patients Hospitalized for Worsening Heart Failure Inpatient decongestion should begin with intravenous loop diuretic therapy starting early in admission. In absence of adequate natriuresis and diuresis within 6 hours, the loop diuretic dose can be increased, and add-on diuretic therapy can be added. This should be pursued until the patient is dry. Initiation and optimization of GDMT should occur in parallel, as additionally outlined in Figure 2. Adapted and modified with permission from Mullens et al.7 eGFR = estimated glomerular filtration rate; GDMT = guideline-directed medical therapy; HCTZ = hydrochlorothiazide; IV = intravenous; MRA = mineralocorticoid receptor antagonist; RCT = randomized controlled trial; SGLT2i = sodium-glucose transport inhibitors; UOP = urine output.

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  Figure 3. Recommendation for GDMT Initiation in Patients With HF The SGLT2i has a Class I level of recommendation in the 2023 focused update of the 2021 European Society of Cardiology guidelines34 in HFmrEF and HFpEF, though it holds a Class IIa level of recommendation for these conditions in the 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America guidelines.5 The evidence supporting the use of ACEI/ARB/ARNI and MRA is modest for HFpEF, with a reduction in HF hospitalizations.35 There is no evidence to support the use of beta blockers in HFpEF,35 and use should be limited unless other indications are present. Color legend: green = class of recommendation 1; orange = class of recommendation 2b. ∗Preferred as a first-line anti-hypertensive in HFmrEF and HFpEF. †In HFpEF, indications for beta blockers should be balanced against risk of chronotropic incompetence. ACEI = angiotensin converting enzyme inhibitors; ARB = angiotensin receptor blockers; ARNI = angiotensin receptor-neprilysin inhibitors; BB = beta-blockers; COR = class of recommendation; HFmrEF = heart failure with mid-range ejection fraction; HFpEF = heart failure with preserved ejection…

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  Central Illustration. Steps to Optimize Care Following Admission for Heart Failure Attention must be given to addressing precipitating causes, ensuring adequate decongestion, optimizing disease-modifying GDMT, and ensuring continuity of care to optimize GDMT following discharge. ∗Algorithm for decongestion is discussed in Figure 2. D-1 = 1 day prior to discharge; D-2 = 2 days prior to discharge; D+7 = 7 days following discharge; D+14 = 14 days following discharge; GDMT = guideline-directed medical therapy; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; IV = intravenous; PO = by mouth.