Updated Content from the 2019 ECDP Patients Hospitalized with Heart Failure

In August 2024, the American College of Cardiology (ACC) published a focused update on the  Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure that harmonizes their 2019 ACC ECDP with the 2022 ACC/AHA Heart Failure guidelines to provide updated recommendations regarding inpatient heart failure (HF) clinical decision pathways. Integrating new and emerging evidence, this update emphasizes achieving favorable clinical responses during hospitalization for patients with HFrEF through inpatient initiation and optimization of the 4 pillars of guideline-directed medical therapy (GDMT). This update further bolsters improved clinical and shared decision-making by underscoring the need for effective follow-up to monitor tolerance and continue treatment titration, aiming to reduce the risk of adverse events after discharge by integrating management considerations that take into account the long-term trajectory while still in the hospital.

Some key changes in this 2024 update compared to the 2019 ECDP include:
  • This update emphasizes SGLT inhibitor therapy throughout hospitalization regardless of LVEF, and places a greater emphasis on initiation of the other pillars of therapy for HFrEF after stabilization.
    • Recent trials demonstrated safety and efficacy in having SGLT inhibitor therapy initiated while in the hospital for patients with acute decompensated heart failure, provided they meet specific stability criteria, particularly given the benefits of  enhanced diuretic response and reduced hospital stay length when integrated into an inpatient management plan. 
  • Recommended patients for hospital admission from the ED indications, including new diagnosis of HF with rapidly progressive symptoms, severe congestion, or higher complexity of disease; some low-risk patients may potentially be eligible to receive care in an observation unit or Hospital at Home (HaH) setting instead of inpatient.
    • The Acute Hospital Care at Home (AHCaH or HaH) program, is being explored as a way to improve care value and manage hospital capacity by allowing hospitals to treat acutely ill patients at home with methods like telehealth, remote monitoring, and in-person visits as means of reducing costs, improving outcomes, decreasing readmission rate, and providing more equitable care access. 
  • When not eligible for HaH or observation care, HF admission is typically indicated for newly diagnosed patients, patients with chronic HF with previous therapy, or advanced HF with chronic Class IV symptoms despite previous recommended therapies, with emphasis on the systematic introduction of all 4 major classes of therapy for HFrEF & diuretic agents prn after stabilization. 
    • The use of an RNI/ACE inhibitor/ARB or switch from ACE inhibitor/ARB to ARNI, and in combination with beta-blockers initiated in the hospital had been shown to correlate with a reduction in events after discharge & higher likelihood of continued prescribing at 12 months after discharge.
    • Likewise, the use of SGLT inhibitors and mineralocorticoid antagonists can be safely initiated for indicated patients any time while hospitalized, and have little effect on lowering blood pressure
  • Daily trajectory reviews of HF patients can allow more comprehensive care and individualized management approaches by trending progress toward effective decongestion and stabilization for initiation of guideline-directed neurohormonal therapies, and can also allow early detection of stalling after an initial response, failure to respond, or worsening HF that may indicate the need for additional adjunctive diuretics, reassessment of the HF etiology & goals of care, and the potential need for escalated care.
    • Clinical outcomes in heart failure (HF) depend on effective decongestion and hemodynamic stability. Patients who respond well to diuresis should have guideline-directed medical therapy (GDMT) gradually increased, with a focus on all four components for HFrEF. 
  • The 2024 update also underscores the importance of continuity of care and continued close monitoring for medication titration and tolerance, with discharge planning recommended to include things like: 
    • Detailed information regarding diagnoses
    • Discharge regimen and plans that should be given to both to patients and referring providers and used as a reference for the follow-up and post discharge appointments, including those conducted via telehealth.
    • Having goals of care discussions, particularly when palliative care approaches are being done for HF management, given the benefit shown when palliative care referral tools and palliative care consultations are provide in increasing the rates of completion of advance directives and reduce hospital readmission rates.

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