Hospital admission is our opportunity to influence management and improve the lives of patients with heart failure (HF). Clinical assessment of the patient's New York Heart Association functional classification, ACC and American Heart Association (AHA) staging, and echocardiographic findings guide our therapy. Being involved early in the patient's hospital stay allows us to educate and treat the patient with initial management focusing on diuresis and consideration for starting pharmacologic therapy with mortality benefits. We also need to determine etiology and explore further diagnostic work-up. Multidisciplinary collaboration with hospitalists, dieticians and physical therapists is a valuable resource to treat comorbid conditions. The 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure1 is an invaluable resource that highlights all of the considerations for navigating patients through their hospital stays and beyond.

As cardiology providers, our role is to continually evaluate the patient's clinical volume status, response to medications and consideration for guideline-directed medical therapies. As we know, there are several classes of drugs that have been shown to improve mortality or reduce hospitalizations for patients with heart failure with reduced ejection fraction (HFrEF) (ejection fraction less than or equal to 40%). For example, the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in HF) trial has shown better outcomes with sacubitril-valsartan over enalapril, and the PIONEER-HF (Comparison of Sacubitril–Valsartan vs. Enalapril on Effect on NT-proBNP in Patients Stabilized From an Acute HF Episode) trial demonstrated efficacy and safety with initiation in the hospital setting. We must document the initiation or contraindications to prescribing the following medications with regard to mortality benefits: 

• Angiotensin-converting enzyme inhibitor (ACEI), angiotensin-receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril-valsartan)
• Evidence-based beta-blocker (carvedilol, metoprolol, bisoprolol)
• Mineralocorticoid-receptor antagonist (MRA) (spironolactone, eplerenone)
• Isosorbide dinitrate/hydralazine for African-American patients

References such as the newly updated TreatHF app, help guide medication selection and dosing for patients with HFrEF. The CHAMP-HF (Change the Management of Patients With HF) registry2, published in 2018, has taught us to be more diligent with complying with the guidelines and reaching target doses of medications. The trialists found that out of 3,518 eligible patients in the registry, 27% were not prescribed an ACEI/ARB/ARNI, 33% were not prescribed a beta-blocker, and 67% were not prescribed an MRA. And of those who were prescribed the appropriate medications, 17% on an ACEI/ARB, 14% on an ARNI, 23% on beta-blockers were not at target doses.

The opportunity to improve the quality of life for patients with HF is a privilege we have as cardiology providers. A patient's initial hospitalization guides medical management, and our continual assessment of that patient's functional status guides future consideration of advanced therapies.

References

1. Hollenberg SM, Stevenson LW, 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;74:1966-2011.
2. Greene SJ, Butler J, Albert NM, et al. Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry. J Am Coll Cardiol 2018;72:351-66.