Rapid Clinical Updates: Heart Failure Implementation Science and Best Clinical Practices-Handout

Handout

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This rapid clinical update from the Society of Hospital Medicine addresses heart failure (HF) management, highlighting implementation science and best practices. HF rates are rising, primarily due to frequent readmissions. Current management focuses on restoring normal hemodynamics, initiating lifesaving guideline-directed medical therapy (GDMT) to rebalance neurohormonal factors, achieving euvolemia via diuresis before discharge, identifying and treating decompensation triggers, and employing risk stratification to prevent readmissions.<br /><br />Emerging evidence shows GDMT often gets discontinued in hospitalized elderly patients or those with renal dysfunction, negatively impacting mortality. However, most GDMT agents do not significantly lower blood pressure or worsen renal function, allowing for individualized initiation and monitoring during hospitalization. Adhering to evidence-based guidelines ensures appropriate therapy, as early GDMT initiation within weeks is lifesaving and reduces HF hospitalizations.<br /><br />Regarding GDMT initiation post-acute HF, best practice involves starting quadruple therapy (beta-blockers, mineralocorticoid receptor antagonists, ACE inhibitors/ARBs/ARNIs) at low doses promptly, with a flexible approach—initially starting two agents and adding others within one week, aiming for full titration within 2 weeks. This approach improves mortality, disease progression, and renal outcomes with a favorable safety profile. Notably, benefits such as reduced hospitalizations and improved quality of life manifest within 30 days.<br /><br />Implementation research emphasizes optimizing GDMT during hospitalization, especially for high-risk patients in resource-equipped settings. Challenges include outpatient GDMT underuse due to time constraints, lack of reinforcement, and insufficient education. Strategies necessitate hemodynamic and symptom monitoring and tackling clinician inertia. Cutting-edge interventions like virtual nudging across integrated healthcare systems, telehealth, and outpatient visits for lower-risk patients show promise in improving GDMT adherence and patient outcomes.<br /><br />References include recent key studies and guidelines updated through August 2024.

Keywords

heart failure

HF management

guideline-directed medical therapy

GDMT

hemodynamics

euvolemia

risk stratification

quadruple therapy

implementation science

telehealth