Expert consensus decision pathways on Heart Failure Hospitalizations released by ACC

American college of cardiology has released Expert consensus decision pathways (ECDP) on Heart Failure Hospitalizations. According to the statement, the clinical trajectory of HF, evaluation of the long-term course of HF, and common comorbidities such as high BP, diabetes, renal disease, pulmonary disease, and frailty should be assessed regularly throughout the patient's journey

Heart failure (HF) affects nearly 6.2 million Americans and is the primary diagnosis for hospital discharge in about 1 million and secondary diagnosis in about 2 million hospitalizations annually Heart Failure (HF) is one of the major global health risks which needs assessment and optimization of therapy to address the long-term trajectory after discharge. With this view, the American College of Cardiology has released Expert consensus decision pathways (ECDP). The ECDP aims to address patients hospitalized with HF and complements existing tools for outpatient management.

The taskforce has been constructed broadly to comprise assessment extending from the original emergency department (ED) visit through the first post-discharge visit. The primary purpose is to optimize patient care and improve outcomes, rather than to focus on reducing the length of stay and readmission.

The document focuses on assessment and goals of the therapy. It aims at providing the physicians maximum support to understand the short- and long-term outlook for their patients with HF, to institute therapies to reduce symptoms and optimize outcomes, to ensure that those plans are conveyed clearly to caregivers after discharge, and to engage patients to share in decisions and become active participants in their care.

Here are a few key points from the Expert consensus documents which discuss the pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure:

1. The document states that 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. The document defines clinical trajectories as improving towards the target, 2) stalled after an initial response, and 3) not improved/worsening and suggests its evaluation continuously during admission. The major target of management is decongestion as evidenced by improvement in signs and symptoms, a 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 a 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.

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DOI: 10.1016/j.jacc.2019.08.001