What is the recommended follow-up plan for a patient with Heart Failure with Reduced Ejection Fraction (HFrEF) and a history of Myocardial Infarctions (MIs) after discharge?

Follow-up Plan for HFrEF Patients with History of MI After Discharge

Patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and a history of Myocardial Infarctions (MIs) should have a follow-up appointment within 7-14 days after hospital discharge, with early telephone follow-up within 3 days, to reduce mortality and rehospitalization risk. 1

Initial Post-Discharge Follow-up Timeline

1. Early telephone follow-up (within 3 days) 1

   • Assess symptoms
   • Review medication adherence
   • Address any immediate concerns
   • Confirm upcoming in-person appointment

2. First in-person follow-up visit (within 7-14 days) 1

   • Comprehensive assessment of clinical status
   • Medication review and optimization
   • Laboratory testing as indicated

3. Subsequent follow-up (within 6 weeks) 1

   • Focused on rapid up-titration of evidence-based treatment
   • Reassess volume status and symptoms

Key Components of Follow-up Visits

Clinical Assessment

• Vital signs with special attention to blood pressure and heart rate
• Weight and assessment for fluid retention/congestion
• Symptoms evaluation (NYHA class)
• Physical examination focusing on signs of congestion
• Assessment of volume status and supine/upright hypotension 1

Laboratory Monitoring

• Basic metabolic panel (renal function, electrolytes)
• BNP/NT-proBNP levels 1
• Complete blood count
• Liver function tests
• Iron studies
• Thyroid function tests
• HbA1c 1

Medication Management

• Titration and optimization of guideline-directed medical therapy (GDMT) 1

  • ACE inhibitors/ARBs/ARNI
  • Beta-blockers (bisoprolol, carvedilol, sustained-release metoprolol succinate, or nebivolol)
  • Mineralocorticoid receptor antagonists (MRAs)
  • SGLT2 inhibitors
  • Diuretics (adjust based on volume status)

• Avoid medications that may worsen HF (NSAIDs, most antiarrhythmic drugs, calcium channel blockers with negative inotropic effects) 1

Imaging and Diagnostic Follow-up

• Repeat echocardiography after 3-6 months of optimal GDMT to assess for improvement in LVEF and to guide decisions regarding device therapy 1
• ECG to monitor for arrhythmias, especially in patients with history of MI 1

Special Considerations for Post-MI HFrEF Patients

1. Device therapy evaluation

   • Consider ICD for primary prevention if LVEF remains ≤35% despite ≥3 months of optimal medical therapy 1
   • Note: ICD implantation should not be performed within 40 days post-MI 1

2. Cardiac rehabilitation

   • All patients should be referred to cardiac rehabilitation programs 1
   • Exercise training is beneficial to improve functional status 1

3. Arrhythmia monitoring

   • Pay particular attention to patients with rapid arrhythmias of supraventricular origin (atrial flutter/fibrillation) 1
   • Consider rhythm control strategy for patients with atrial fibrillation and HF 1

Patient Education and Self-Care

• Dedicated healthcare professionals should provide HF-specific education 1
• Teach symptom recognition and self-monitoring
• Sodium restriction guidance 1
• Daily weight monitoring
• Medication adherence strategies
• When to contact healthcare providers

Risk Stratification for Readmission

Consider using clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for post-discharge clinical events 1. High-risk features include:

• Prior HF hospitalizations
• Elevated BNP/NT-proBNP despite treatment
• Renal dysfunction
• Persistent congestion at discharge
• Difficulty achieving optimal GDMT doses

Common Pitfalls to Avoid

1. Delayed follow-up - Early follow-up is critical as readmissions often occur within the first month after discharge 2

2. Inadequate medication titration - Only 16.9% of eligible patients are discharged on ≥50% of target doses of HF medications 3

3. Underutilization of MRAs - Less than half of eligible patients receive MRAs despite their benefits 4, 3

4. Failure to adjust diuretics - Discharge regimen should include a plan for diuretic adjustment to prevent rehospitalization 1

5. Missing comorbidity management - Addressing hypertension, diabetes, and other comorbidities is essential 1

By implementing this structured follow-up plan, healthcare providers can significantly reduce the risk of readmission and mortality in patients with HFrEF and a history of MI after discharge.