From the Guidelines
CHF exacerbation requires hospital admission when patients exhibit severe symptoms or significant clinical deterioration, as indicated by the most recent guidelines 1. When managing CHF exacerbations, it's crucial to assess the severity of symptoms and the patient's overall condition. Mild exacerbations can often be managed on an outpatient basis with adjustments to medications such as diuretics, ACE inhibitors, ARBs, and beta-blockers. However, hospital admission is necessary for patients experiencing severe symptoms like:
- Respiratory distress
- Oxygen saturation below 90%
- Significant fluid overload unresponsive to oral diuretics
- Hypotension
- Worsening kidney function
- Altered mental status Other indications for hospitalization include new-onset heart failure requiring diagnostic workup, complicating factors like pneumonia or arrhythmias, or inability to take oral medications. The decision to hospitalize balances clinical judgment with patient safety, considering that some exacerbations indicate cardiac decompensation requiring immediate intervention with IV diuretics, continuous monitoring, and advanced therapies that cannot be provided in an outpatient setting 1. Key considerations in the management of hospitalized patients with HF include addressing precipitating factors, comorbidities, and previous limitations to ongoing disease management related to social determinants of health, as well as optimizing volume status and initiating or increasing recommended medical therapies toward target doses once the efficacy of diuresis has been shown 1.
From the Research
CHF Exacerbation and Hospital Admission
- CHF exacerbation often requires hospital admission, especially in patients with complex comorbidity and frequent hospitalizations prior to index hospitalizations 2.
- Patients with CHF who are readmitted within 30 days of discharge often have typical clinical profiles, such as fluid overload, and are frequently discharged with suboptimal medication regimens 2.
- The choice of appropriate diuretic is essential for successful management of CHF and is mainly guided by patient clinical situations and the presence of other co-morbidities 3.
Factors Influencing Hospital Readmission
- Patients with CHF who have underlying chronic renal insufficiency/failure (CRI/CRF) are more likely to be readmitted within 30 days 4.
- Medication optimization, including the use of evidence-based beta-blockers, angiotensin-converting enzyme inhibitors, and mineralocorticoid receptor antagonists, can help reduce hospital readmission rates 5.
- The use of intravenous diuretics, such as furosemide, and inotropes, such as dobutamine and milrinone, can also impact hospital readmission rates, although the evidence is mixed 6.
Medication Regimens and Readmission Rates
- Patients with CHF who are receiving treatment with one or more pillars of therapy, as recommended by the American College of Cardiology, may have lower hospital readmission rates 5.
- However, many patients with CHF are not receiving optimal medication regimens, and medication optimization may be an important strategy for reducing hospital readmission rates 5.