The two central themes of care for patients hospitalized for decompensated HF are decongestion and optimization of the therapies recommended for HF, but multiple other goals also need to be met. The coordinated care plan includes evaluation as necessary of the primary etiology of the heart disease and potential aggravating factors that would require specific intervention, both cardiac and noncardiac (34) (see Table 2).
All members of the team should contribute to an initial assessment of the likely outcome both in hospital and after discharge. A profile conferring high risk from factors that do not appear modifiable should trigger early discussion with the patient and family regarding anticipated outcomes and their priorities for remaining quality and quantity of life. Regardless of prognosis, all patients admitted to the hospital should have a designated surrogate decision maker, ideally identified in the outpatient setting and documented during admission. If not already done, however, this designation should be supervised by the inpatient care team.
Most patients present with at least 1 symptom and 1 sign of congestion that can be tracked as targets during decongestion and may serve as sentinel symptoms for recurrent congestion after discharge (70,74,77,78) (Table 3).
Clinical profiles of patients with HF are shown in Figure 3.
The wet and warm clinical profile without evidence of hypoperfusion characterizes over 80% of patients admitted with reduced EF and almost all with preserved EF except those with small left ventricular cavities of restrictive or hypertrophic cardiomyopathies (39,42). The cold and wet profile describes congestion accompanied by clinical evidence of hypoperfusion, as suspected from narrow pulse pressure, cool extremities, oliguria, reduced alertness, and often recent intolerance to neurohormonal inhibition. Sleepiness, impaired concentration, and very low urine output may also be present.
Uncertainty regarding hemodynamic status is associated with worse outcomes and is an indication for invasive hemodynamic assessment (15,81).
A patient hospitalized with apparent decompensation in whom both filling pressures and perfusion appear to be normal should be carefully evaluated for other causes of symptoms, such as transient ischemia or arrhythmias, or noncardiac diagnoses such as pulmonary disease.
This document centers on evaluation of the clinical trajectory of HF, as an assessment of both daily clinical progress and the long-term disease course, incorporating the prior history with specific risk factors at admission, the day-by-day progress toward the goals of hospitalization, and the re-assessment before discharge.
Because a key message of this document is the importance of serial assessment from admission through discharge, the risk factors listed in Table 5 are categorized according to the time when they may be known during the hospitalization. In setting goals to decrease risk and improve outcomes after hospitalization and later, it may be helpful to focus on those risk factors most likely to be modifiable.
At any time between admission and discharge, recognition of high risk for unfavorable outcomes should trigger specific considerations (Table 6), including caution regarding the initiation of therapies that may be difficult to discontinue.
From admission through discharge, information should be systematically documented in a format easily accessible to clinicians both in and out of the hospital to optimize care and outcomes. Availability of that information is crucial for a patient who presents soon after discharge and is considered for readmission (Figure 2).