Shortly after discharge from hospital for cardiac decompensation, many problems can still occur. Reducing the length of stay shortens the time to observe the tolerance of the prescribed treatment. Furthermore, treatment for heart failure is often not yet optimal at the time of discharge from hospital and titration of this treatment must be done during the first weeks after discharge.

These patients should therefore be closely monitored shortly after discharge from hospital with regular clinical checks until their condition stabilizes and the heart failure treatment is optimized as quickly as possible (maximum within 3 to 6 months after diagnosis).

When leaving hospital, the patient must receive concrete information for their subsequent follow-up.

ESC guidelines have long recommended a close follow-up consultation (1 to 2 weeks after hospital discharge). A clinical re-evaluation should then be performed, including a small blood test to check renal function and the ionogram.

In the 2023 update of the ESC guidelines, after the STRONG-HF trial, it is also recommended to closely monitor patients during the first weeks after hospitalization. In this study, patients were seen again 1,2,3 and 6 weeks after discharge.

However, the practical application of such intensive monitoring of heart failure patients is organizationally difficult for many cardiology departments due to the lack of consultation capacity.

Reorganizational considerations must therefore be considered in order to be able to practically apply this more intensive monitoring of patients when they leave the hospital.

Possible options could be:

• Blocking of specific time slots (1-2 weeks) for these patients who need to be seen again quickly.
• Follow-up with consultations by the heart failure nurses, under the supervision of a heart failure
• Spreading these consultations over 1 to 4 weeks after discharge from the hospital depending on the patient's clinical profile (described below).

The general practitioner also plays a very important role in the follow-up of heart failure patients. Read.

This care pathway therefore proposes a combined and more flexible follow-up by the cardiologist (preferably via the heart failure clinic) and by the general practitioner. The timing of the consultations and with whom it is planned is determined by the patient profile. However, there are no specific clinical trials on this follow-up based on the clinical risk profile. This proposed policy is therefore based on expert consensus.

The profiles of patients with heart failure (particularly those with HF with reduced ejection fraction, HFrEF) are diverse and determined by many factors, including:

• Blood pressure.
• Whether or not atrial fibrillation (AF).
• Whether or not chronic renal failure (CRF) and/or hyperkalemia.
• The degree of impairment of the LV ejection fraction (LVEF).
• The presence of signs of terminal heart failure or persistent fluid retention.
• …

Overall, the risk profile of patients can be classified into 3 groups based on several parameters (see table below). The clinical risk is determined by the most abnormal parameter and/or a combination of these parameters.

Notice:

• HFpEF is classified as low risk because it mainly requires adjustment of diuretic titration. This can therefore also be done by the general practitioner. However, as euvolemia becomes more difficult to maintain, with poorer renal function and/or a higher maintenance dose of diuretics, more frequent monitoring by a cardiologist and/or nephrologist is indicated.
• A new diagnosis of HFrEF is classified as high risk, because many titrations and optimizations of the treatment must be performed. In addition, systematic follow-up must be organized to evaluate the need for an implantable device after 3 to 6 months of optimal drug therapy. This means that more frequent check-ups by the cardiologist are necessary in this type of patient.

Discharge from hospital after admission due to cardiac decompensation does not mean that the patient is considered “stable”. We can only speak of “stable heart failure” if the patient has had unchanged symptoms of heart failure for more than one month.

The first month after hospitalization for cardiac decompensation is called the transition phase. During this transition phase from hospital to home, there is an increased risk of clinical destabilization with increased risks of readmission and mortality. That is why these first weeks are sometimes referred to as the vulnerable phase.

Possible causes of readmission or mortality shortly after hospitalization include:

• Rapid recurrence of cardiac decompensation due to suboptimal treatment at discharge :
  • Insufficient decongestion and persistent fluid retention.
  • Suboptimal heart failure treatment (none or at a too low dose).
• Rapid recurrence of cardiac decompensation due to insufficient education and patient-related errors:
  • Bad therapeutic compliance upon returning home: not taking the medication, taking the prescribed medication incorrectly, lack of prescription, etc.
  • Dietary errors: much higher salt/ fluid consumption at home compared to in the hospital.
  • Insufficient support and care at home.
• Rapid recurrence of cardiac decompensation due to other factors or rapidly progressive heart failure.
• Too little adaptations of the medications after discharge from hospital. A too high a dose of diuretics or other treatments for heart failure with progression to dehydration, hypotension, bradycardia, renal failure, ionic disorders, etc.
• Other cardiac problems, not related to heart failure : acute coronary syndrome, arrhythmias, etc.
• Other non-cardiac problems : infections, bleeding, falls (with or without fractures), precarious social or family situation, etc.

A patient with heart failure is considered stable only if symptoms, clinical condition and treatment remain stable for more than one month.

Concretely, this means:

• Stable weight and euvolemia for more than 1 month.
• Stable blood pressure, without orthostatism.
• A stable heart rate, preferably around 60/min at rest (especially in HFrEF patients).
• Stable renal function and ionogram.
• Maximum tolerated heart failure medication.

Note: An apparently asymptomatic patient may nevertheless have an elevated NT-proBNP level and subclinical disease progression. Assessment by NYHA functional class alone is therefore sometimes insufficient. In NYHA class II, the maximum tolerated heart failure medication should always be pursued and, if necessary, an appropriate implantable device (CRT/ICD) should be implanted. Furthermore, several studies have shown that the beneficial effects of treatments are greater in patients with only mild symptoms (NYHA class II) than in patients with more pronounced complaints and therefore more advanced heart failure (NYHA class III or IV). This has been demonstrated, among others, with ARNI, SGLT2 inhibitors, ICD, ...

When monitoring heart failure patients, new problems must be detected in time and treated correctly.

Read: Early problem detection.

Read: Interventions: What to do when…?

Special attention and more intensive follow-up should be given to patients with high-risk heart failure. These patients are at higher risk of decompensation, arrhythmia, hospitalization, and/or death.

Heart failure patients at a higher risk of new problems are :

• Persistent NYHA class III - IV or persistent signs of congestion.
• A very severely reduced LVEF < 25%.
• Need for high maintenance doses of diuretics (> furosemide 80 mg or bumetanide 2 mg daily).
• Hospitalization for heart failure in the last 6 to 12 months.
• Repeated episodes of cardiac decompensation, with or without hospitalization.
• No optimal heart failure therapy or still need for therapy titration.
• Recent implantation of an ICD/CRT or recent VT/VF type with intervention of the ICD.
• Comorbidities, such as:
  • Chronic renal failure (eGFR < 40 ml/min).
  • A geriatric profile with fragility and/or risk of falling.
  • COPD .
• Lack of motivation, knowledge of the disease and/or a high risk of non-compliance with treatment.

Depending on eligibility criteria, some of these patients may eventually need to be referred for LVAD implantation and/or heart transplantation. This is assessed by the cardiologist and, if necessary, specified in the medical report.

Read: Heart Transplant and LVAD