ACC Consensus Decision Pathway for Heart Failure Hospitalizations

Hollenberg SM, Warner Stevenson L, Ahmad T, et al.
2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2019;Sep 13:[Epub ahead of print].

The following are key points to remember from the 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure:

  1. Each stage of a heart failure admission, beginning with admission/emergency department through the first post-discharge follow-up, is an opportunity to address the current and long-term clinical trajectory and to improve outcomes.
  2. Clinical trajectory of HF should be evaluated continuously during admission. The clinical trajectories have been defined as: 1) improving towards target, 2) stalled after initial response, and 3) not improved/worsening. The major target of management is decongestion as evidenced by improvement in signs and symptoms, decrease in natriuretic peptides, and decrease in weight. The clinical trajectory determines management.
  3. Evaluation of the long-term trajectory of heart failure should be performed during the initial assessment, should be reviewed on the day of transition to oral therapy, and re-assessed at the first follow-up visit.
  4. Consideration of comorbid conditions, such as diabetes, pulmonary disease, renal disease, and frailty, is a key component of the comprehensive initial assessment. Comorbidities are highly prevalent in heart failure patients, increase heart failure severity, and contribute to decompensation. These should be addressed and treated during the hospitalization.
  5. Risk factors, such as nonadherence, degree of decongestion, and appropriateness and tolerance of guideline-directed medical therapy, should be assessed during hospitalization and modified when possible.
  6. The transition day, typically the day when therapy changes from intravenous diuretics to oral, is a critical point in the admission where the focus shifts to maintaining stability. Determining the effectiveness of the diuretic regimen is a key component of the transition phase, and observation of an intended discharge diuretic regimen for ≥24 hours is associated with significant reductions in 30- and 90-day mortality. In addition, patient education, caregiver education, and plans for discharge should be considered at this time.
  7. The day of discharge should focus on review and identification of and communication with providers rather than initiation of new therapies.
  8. Discharge planning should include summarization of hospital course and trajectory, documentation of plans that are most important for continuity of care, including goals of care/discussions regarding palliative care, education of patients and family, and identification of continuing care clinicians. Documentation should be made readily available to all members of the outpatient team and should be easily accessible in the event a patient calls or returns with worsening symptoms.
  9. The first post-discharge visit, ideally occurring within 7-14 days of hospital discharge, is an opportunity to reassess clinical status, provide additional patient education, review medications and doses, and address risk factors for readmission and potential indications for advanced therapies or revision of goals of care.
  10. Palliative care consultation may be helpful when the trajectory is unfavorable and requires discussion regarding prognosis, options for therapy, and decision making with patients/families/caregivers.

Keywords: Caregivers, Comorbidity, Consensus, Decision Making, Diabetes Mellitus, Diuretics, Emergency Service, Hospital, Heart Failure, Hospitalization, Lung Diseases, Medication Adherence, Natriuretic Peptides, Outpatients, Palliative Care, Patient Discharge, Patient Readmission, Renal Insufficiency, Risk Assessment, Risk Factors, Risk Management

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