Continuing Cardiology Education

REVIEW ARTICLE

Treatment goals and discharge criteria for hospitalized

patients with acute heart failure
G. Bakosis1,*, I. Christofilis1 & A. Karavidas1,2
1
Heart Failure Unit, 2nd Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
2
Heart Failure Clinic, George Gennimatas Hospital, Athens, Greece

Keywords
Acute heart failure, discharge criteria,
hospitalization
Correspondence
G. Bakosis, HF Unit, 2nd Department of
Cardiology, Attikon Hospital, 1 Rimini Str.,
12461, Haidari, Athens, Greece.
Tel: +30 6973858639; Fax: +30 210 5832351;
E-mail: gbako77@yahoo.gr
Funding Information
No funding information provided.
Continuing Cardiology Education, 2017;
3(3), https://doi.org/10.1002/cce2.58
Abstract
Acute heart failure (AHF) represents a potentially fatal disease that needs
immediate hospital care. In-hospital management can be divided into three
consecutive phases: an early phase of intensive management of symptoms, an
intermediate phase of stabilization and transition from intravenous to oral
medication, and a late phase of discharge and outpatient management. How-
ever, despite its life-threatening features (increased mortality and readmission
rates), many treatment decisions are opinion based and only few are evidence
based. The present paper describes in-hospital treating modalities and attempts
to provide clinical and laboratory criteria for patient evaluation that will help
doctors determine readiness and safety of discharge. In addition, it highlights
some unresolved issues that need to be addressed by future research.
Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/
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syndrome with significant morbidity and dismal progno-

Introduction
Heart failure (HF) constitutes a major public health prob-
lem, affecting nearly 6 million people in the United States
only (2.2% of total population) [1] and 26 million people
worldwide [2]. An aging population along with improved
survival from cardiovascular diseases is expected to fur-
ther increase its prevalence [3]. At the same time, HF
leads to an enormous financial burden (2% of total health
care expenditure) [1, 2, 4]. Acute HF (AHF) accounts for
about 69% of it [5].
AHF is defined as the rapid onset or worsening of
symptoms and signs of HF that requires immediate medi-
cal attention and usually leads to urgent hospitalization
[6, 7]. Development of symptoms may be abrupt, as in
de novo AHF presenting with acute pulmonary edema, or
more progressive, as in decompensated chronic HF. In
these later cases, the time of transition from chronic to
acute HF may not be clear.
Over 80% of emergency department (ED) patients with
AHF are admitted to the hospital [8], leading to approxi-
mately 1 million admissions per year in the United States
[1]. Despite therapeutic advances, AHF remains a
sis, since treatment decisions are often made without ade-
quate evidence. Moreover, hospitalization for AHF is
followed by unacceptably high event rates. In-hospital
mortality ranges between 4% and 7%, post-discharge
mortality during the first 2–3 months is as high as 7–11%
and reaches 36% in a year, while readmission occurs in
25–30% of patients during the first 2–3 months and in
66% during the first year [7, 9].
Based on available evidence and guidelines, the present
paper attempts to provide concise and practical therapeu-
tic recommendations for in-hospital management of
AHF, focusing primarily on clinical and laboratory crite-
ria that may be used for the evaluation of patient’s status
in the different phases of care and the ability to exit
hospital safely.
In-Hospital Management
Treatment of AHF may often be a challenge for the clini-
cian. Traditionally, congestion is considered the hallmark
of the disease and therefore therapy primarily aims to the
alleviation of symptoms. However, it seems that a number

Continuing Cardiology Education, doi: 10.1002/cce2.58 (100 of 106) ª 2017 Hellenic College of Cardiology
G. Bakosis et al.
of additional issues have to be addressed. Schematically,
in-hospital management can be divided into three consec-
utive phases: the early phase of intensive treatment of
symptoms, the intermediate phase of stabilization and
transition to oral medication, and the later phase of dis-
charge and outpatient treatment.
Early Phase Management
The early phase of therapy has as main goals the immedi-
ate and intensive management of congestion and/or
peripheral hypoperfusion along with patient’s hemody-
namic stabilization, preservation of tissue perfusion, and
protection of vital organs from further damage (heart,
brain, kidney). Symptoms and signs of congestion con-
cern dyspnea, peripheral edema, distended jugular veins,
hepatomegaly, hepatojugular reflux, and ascites, while
those of hypoperfusion concern cold extremities, mottled
skin, narrow pulse pressure, mental status impairment,
oliguria, or even anuria [10]. Intravenous (i.v.) therapies
are used for this reason, including loop diuretics,
vasodilators, inotropes, and/or vasopressors.
Loop diuretics relieve symptoms but may transiently
deteriorate renal function [11], so their dose should be
limited to the smallest amount necessary to provide the
adequate clinical effect [12]. In cases of new-onset HF or
without any previous diuretic therapy, 20–40 mg bolus of
(i.v.) furosemide is recommended, while in chronic HF
decompensation or chronic diuretic therapy, the dose
administered bolus should be at least equal to oral [13,
14]. Intravenous vasodilators (nitroglycerine, nitroprus-
side, nesiritide) or even sublingual nitrates are indicated
in patients with rather normal or elevated blood pressure
(SBP > 90 mmHg) and without symptomatic hypoten-
sion [13, 14]. On the other hand, inotropic agents (beta
adrenergic receptor agonists, phospodiesterase III inhibi-
tors, calcium sensitizers) have significant adverse effects
(arrhythmias, myocardial ischemia) that compromise
their use [13, 14]. Therefore, they should be administered
only in cases of low cardiac output (cardiac
index < 2.0 L/min per m2) and elevated filling pressures
(pulmonary capillary wedge pressure > 18–20 mmHg)
[15, 16] or in critically ill patients with abnormal hemo-
dynamics followed by severe exercise limitation, conges-
tion with concomitant diuretic resistance, and renal or
hepatic function impairment.
In patients with cardiogenic shock (SBP < 90 mmHg)
not responsive to initial inotropic agents or rapidly dete-
riorating hemodynamic instability, vasopressors should be
considered, or even short-term mechanical circulatory
support (MCS), as a “bridge to recovery,” “bridge to
decision,” or “bridge to bridge” strategy [17]. Conven-
tional oxygen therapy or even non-invasive positive
ª 2017 Hellenic College of Cardiology Continuing Cardiology Education, doi: 10.1002/cce2.58 (101 of 106)
Discharge of Patients With Acute Heart Failure
pressure ventilation is recommended in cases of severe
respiratory distress (SpO2 < 90%, respiratory rate > 25
per min, increased work of breathing, or even orthopnea),
while intravenous opiates should be used cautiously and
only in anxious, restless patients with severe dyspnea [13,
14]. Finally, prevention of thromboembolism with heparin
or other anticoagulants should not be neglected.
Key parameters for patient evaluation in this early
phase include:
1 symptoms/signs of congestion and/or peripheral
hypoperfusion,
2 vital signs—systolic and mean blood pressure (SBP/
MBP), heart rate (HR) and rhythm, respiratory rate
(RR), oxygen saturation (SpO2), and
3 urine output.
Laboratory assessment of natriuretic peptides (NP),
troponin, hemoglobin, arterial blood gases, lactate, and
electrolytes, along with renal and liver function tests pro-
vide additional information and should not only be
performed upon admission, but should also be monitored
regularly, often daily, during hospitalization, in order to
guide initial therapy [14]. Chest X-ray depicts pulmonary
congestion and may unveil other cardiac and non-cardiac
causes that contribute to patient’s symptoms. Doppler
echocardiography, besides its fundamental role in the
confirmation of the diagnosis and the assessment of AHF
etiology, may also evaluate hemodynamic status (mitral
inflow velocities, E deceleration time, E/e’ ratio, triscupid
regurgitant flow velocity, diameter and respiratory response
of inferior vena cava, and time–velocity integral and
cross-sectional area of LV outflow track) [18]. Therefore,
it should be performed immediately in cases of hemody-
namic instability and within 48 h when cardiac structure
or function are unknown or may have changed [14]. On
the other hand, pulmonary artery catheterization should
be confined in selected cases of refractory hypotension or
shock, despite optimal medical therapy, but with uncer-
tain LV filling pressures or for surgical candidates [14,
19]. It is clear that AHF reversible causes or precipitant
factors requiring early and particular management,
such as acute coronary syndromes, arrhythmias, hypov-
olemia, hypertensive crisis, acute mechanical cause or
pulmonary embolism, should be recognized and treated
efficiently [14].
The majority of ED patients with AHF are admitted
either to intensive care unit (ICU)/coronary care unit
(CCU) or to a HF clinic. However, up to 50% of these
admissions may not be necessary [20] and subjects can be
safely discharged from the ED after a brief period of
observation [21]. With increasing pressure to avoid
unnecessary hospitalizations and costs, there is great
interest in defining this cohort of patients. Disposition
decisions should be based primarily on good clinical
Discharge of Patients With Acute Heart Failure
judgment; this means clinical examination upon presenta-
tion (lack of hypotension, hypoxia, or peripheral hypop-
erfusion) along with pulse oxymetry, electrocardiogram,
chest radiography, and laboratory tests (cardiac troponins,
serum creatinine), absence of high-risk precipitating fac-
tors requiring in-hospital management (ACS, arrhythmias,
infection) or significant comorbidities (severe renal dys-
function or COPD exacerbation), and finally, adequate
response to the initial therapy (loop diuretics with or
without nitrates) that will lead to rapid and substantial
improvement in signs and symptoms of congestion.
Patients eligible for early discharge must feel better, main-
tain sufficient BP even when standing, have resting
HR < 100 bpm, oxygen saturation >95% in room air,
and adequate diuresis without developing new symptoms,
ischemia, renal dysfunction or other major complications
[13]. Evaluation of mental status should not be disre-
garded and subjects must be able to manage their illness
as outpatients, since compliance is one of the most
important precipitating factors of AHF [22].
Intermediate Phase Management
During this stage, stabilization of patient’s condition
allows weaning from intravenous to oral medication and
initiation of titration of chronic heart failure (CHF) ther-
apies. Since there seems to be a lack of evidence-based
guidance for AHF events, good clinical judgment is
required not only for the timing of transition and the
dose of oral diuretics, but also for the sequence and the
time interval for weaning a second agent, when intra-
venous diuretics plus inotropes or vasodilators are being
used. The resolution of symptoms described above, the
improvement of vital signs (SBP, HR, RR, SpO2), and the
reduction of body weight toward “dry” values due to ade-
quate diuresis, may be useful in this setting [13, 14]. That
is why, routine monitoring of vital functions, along with
daily weighing and an accurate record of fluid balance
must continue, despite transfer from ICU/CCU to the
clinical ward. Additional criteria include amelioration of
dyspnea NYHA scales, NP reduction, and improvement
of hemodynamic parameters, either indirect (mitral E/e’,
IVC) or direct–invasive (PCWP, CI) [14, 18, 19].
However, the most crucial step in this setting is the
implementation of evidence-based disease-modifying oral
therapies (DMT) of CHF. In cases of de novo HF, initia-
tion of angiotensin-converting enzyme inhibitors (ACEi)
or angiotensin receptor blockers (ARBs) and beta-blockers,
followed by mineralocorticoid receptor antagonists
(MRAs) is of utmost importance, as outlined in ESC HF
guidelines [1, 10, 14]. Simple clinical parameters to
guide the handling of DMT during AHF hospitalization
include blood pressure, heart rate, serum potassium,
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G. Bakosis et al.
serum creatinine, and estimated glomerular filtration rate
(eGFR). In cases of hypotension (SBP < 85 mmHg),
hyperkalemia (>5.5 mmol/L), or severe renal dysfunction
(serum creatinine >2.5 mg/dl or eGFR <30 mL/min per
1.73 m2), ACEi, ARBs, and MRAs should be reduced
(usually halved) or discontinued temporarily [18]. The
same applies for beta-blockers, in cases of bradycardia
(<50 bpm), shock, or severe pulmonary edema. On the
other hand, in patients with acute deterioration of CHF
already treated with DMT, every attempt should be made
to continue them on admission, unless serious contradic-
tions occur. For beta-blockers particularly, as recent meta-
analysis demonstrated, discontinuation of the drug in the
acute phase led to significantly increased in-hospital and
short-term mortality [23].
During hospitalization, patients should be assessed for
the possible presence of comorbidities, a phenomenon
with high prevalence, especially in HF with preserved ejec-
tion fraction [7, 24, 25]. Non-cardiovascular comorbid
conditions include COPD, thyroid gland diseases, diabetes,
renal dysfunction, obesity, iron deficiency, and depression,
and are strong predictors of rehospitalization [26], since
they seem to affect patient’s status and prognosis [2, 27].
Nevertheless their identification and management are often
neglected. Finally, evaluation for further HF treatment
modalities (implantable cardioverter defibrillator [ICD],
cardiac resynchronization therapy [CRT]) must take place
before disposition or at the near future post-discharge and
may prove life-saving [28]. In cases of advanced HF,
appropriate patients should be programmed for transplan-
tation or ventricular assist device therapy [29].
Late Phase Management: Discharge
and Follow-Up
AHF is associated with increased post-discharge readmis-
sion rates. Interestingly, 30% of readmissions occur
within the first week after hospital discharge and 60%
within the first two [29]. Moreover, these early HF read-
missions are associated with worse long-term outcomes
(death, worsening of HF) [30, 31]. Although two third of
HF readmissions are preventable [32], at least 30% of
them are due to HF itself [33] and are inextricably
related to incomplete decongestion during the index
hospitalization.
Current therapies do not provide optimal relief from
AHF signs and symptoms and even after several days of
in-hospital treatment, residual dyspnea is common [34].
As shown by Mazzioni and colleagues, 24% of patients
hospitalized for HF have signs of congestion at discharge
[35], while persistence of congestion 4–6 weeks after hos-
pital discharge predicts poor survival [36]. Aside from
this, the inability to identify the underlying cause or
ª 2017 Hellenic College of Cardiology
G. Bakosis et al.
precipitating factor that led to hospital care, the lack of
proper titration of chronic HF treatment, the decreased
length of hospital stay [37], the poor education of
patients, and the luck of a specific post-discharge plan are
the most important factors resulting to readmission [7].
As a result, the need to clearly define clinically meaning-
ful end points to guide therapy and determine readiness
for discharge in AHF patients is indispensable. Complete
resolution of signs and symptoms of congestion should
remain the most crucial goal of treatment. However, due
to its subjective nature, dyspnea relief cannot be used as a
sole measurement of improvement. Moreover, dyspnea
correlates poorly with in-hospital HF exacerbations and
post-discharge events (e.g., readmission and mortality)
and thus it is difficult to rely on exclusively [34, 38–40].
Perhaps, fatigue and body swelling may be evenly used as
well, as important patient-centered endpoints [41].
During clinical evaluation, patients must maintain
SBP ≥ 90 mmHg, HR < 80 bpm or <100 per min in cases
with AFib, and oxygen saturation of ≥95% (≥90% in
COPD), without the adverse events of the treatments used
(e.g., dizziness or orthostatic hypotension). Discontinua-
tion of inotropes and vasodilators must take place at least
24 h before disposition and at the same time the patient
must maintain stable renal function and sufficient diuresis
with oral diuretic regiments. Although natriuretic peptide
levels are strongly associated with cardiac dysfunction,
studies with NP-guided management have yield mixed
results [42, 43]. However, NP reduction of ≥30% is consid-
ered an acceptable index of decongestion. Perhaps, non-
invasive tools, such as finger cuff pulse-wave analysis or
bioimpedance/bioreactance, that detect transthorasic fluid
volume or electrical alterations and allow indirect monitor-
ing of hemodynamic parameters, such as cardiac output,
can be useful in many clinical settings and may allow clini-
cians optimize time of discharge and early follow-up [44].
A detailed post-discharge schedule of subsequent visits
and further investigations, regarding evaluation for
advanced therapies (ICD, CRT, LVAD, cardiac transplant)
or management of comorbidities along with health
information-related behavior and motivation for patient’s
active participation should be planned prior to hospital
disposition. The different aspects of a disease manage-
ment program for AHF patients are presented in Table 1
and include consecutive visits to HF clinic within the first
4 weeks (≤2 weeks for high-risk patients), phone follow-
up, and regular laboratory tests (electrolytes, renal func-
tion, INR, if needed). Patient’s tailored education toward
a healthier lifestyle is crucial and includes general mea-
sures (cessation of smoking, physical exercise), training in
dietary habits (salt and alcohol retention), self-assessment
of symptoms of congestion, and diuretic dosing adjust-
ments. Influenza and pneumococcal vaccination in CHF
ª 2017 Hellenic College of Cardiology Continuing Cardiology Education, doi: 10.1002/cce2.58 (103 of 106)
Discharge of Patients With Acute Heart Failure
adults over the age of 65 seems to reduce mortality [45],
while rehabilitation programs ameliorate functional status
and quality of life, and may help as well.
Guideline recommended HF therapies have well-
recognized benefits, so the need of up-titration before exit-
ing hospital or in the near future is of utmost importance.
However, large registries indicate that <25% of patients
with CHF are titrated to the maximal indicated beta-
blocker dose [14], and therefore this proportion is expected
to be even lower in cases of recent decompensation. Per-
haps, the final step in these prevention strategies involves
close collaboration between tertiary and local hospitals or
primary health care providers. The expected benefits of a
discharge letter to the attending physician include better
guideline adherence and therefore reduction of further
readmissions, mortality, and costs along with improve-
ments in patient’s quality of life [46–48] and recent ESC
guidelines recommend an early visit to the general practi-
tioner, within 1 week of discharge, for all HF patients [14].
Open Issues and Future Perspectives
In AHF patients, a number of open issues require further
investigation. From a novel definition of advanced and
end-stage HF to a better understanding of the pathophys-
iology regarding AHF with preserved EF, as this entity
Table 1. Post-discharge follow-up plan in AHF.
A. Education
Self-assessment of congestion symptoms (dyspnea, peripheral
edema)
Body weight monitoring
Diet, salt, and water intake
Physical activities, exercise training, rehabilitation programs
Diuretic dosing adjustments
“Red flags” to seek medical advice
B. Follow-up visits
General practitioner/treating physician: within 1st week
Phone visit: within 1st week (2- to 4-week intervals)
HF specialist: within 4 weeks 1 (3- to 6-month intervals)
C. Laboratory and further assessments
Renal function, electrolytes within a week from drug onset/titration
Basic chemistry in 3-month intervals
INR in monthly intervals (if on warfarin)
Evaluation for specific HF therapies (e.g., ICD, CRT)
Evaluation for comorbidities
Assessment of quality of life, psychososial status, and compliance to
treatment
Evaluation for LVAD implantation or transplantation (in advanced
disease)
Modified from Int J Cardiol, D Farmakis, J Parissis, A Karavidas, et al.
In-hospital management of acute heart failure: Practical recommenda-
tions and future perspectives, p 231-236. Copyright (2015).
1
Within 2 weeks in high-risk patients (borderline vital signs, residual
congestion, significant comorbidities).
Discharge of Patients With Acute Heart Failure
seems totally different from HFrEF and this luck of
understanding may account for the hitherto absence of
evidence-based therapies in the particular population.
Several therapeutic modalities used in AHF are not yet
established, particularly in terms of long-term outcomes
(safety of inotropes, effectiveness of pulsed inotropic infu-
sions, ultrafiltration), while the efficacy of implementing
chronic HF treatments in the early stages of AHF is still a
matter of debate. Novel promising vasodilating agents (e.g.,
serelaxin, omecamtiv mecarbil, clevidipine, ularitide) are
already tasted in phase III/IV trials and results are expected
anxiously. On the other hand, the use of biomarkers in risk
stratification and treatment guidance needs more extensive
study. New and more accurate biomarkers need to be iden-
tified and standardized along with non-invasive hemody-
namic assessment devices. Finally, the idea of home visits
by doctors or trained nurses, all part of a “multi-
professional HF team,” in order to avoid or decrease
emergency department visits and hospitalizations, or
even the use of Internet and computer technology for
telemonitoring/telemedicine, seems an appealing concept
for the near future.
In conclusion, AHF hospitalizations have a huge
socioeconomic impact. Several unresolved issues remain
in the understanding and treatment of AHF and need to
be addressed by carefully planned research studies. How-
ever, using the existing knowledge to clearly define the
main steps in the management of these patients and to
establish specific criteria to guide decision making in each
step, may improve outcomes, and help alleviate the
socioeconomic impact of the syndrome.
Conflict of Interest
All authors have nothing to disclose.
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ª 2017 Hellenic College of Cardiology