What medications should be started upon discharge from the hospital for a patient with conditions such as heart failure or atrial fibrillation?

Discharge Medication Management for Heart Failure and Atrial Fibrillation

For patients with heart failure or atrial fibrillation being discharged from the hospital, evidence-based medications should be initiated prior to discharge, with ACE inhibitors/ARBs and beta-blockers as cornerstone therapies for heart failure, and rate control agents plus anticoagulation for atrial fibrillation.

Heart Failure Discharge Medications

For Heart Failure with Reduced Ejection Fraction (HFrEF):

1. ACE Inhibitors/ARBs

   • Start in all patients with LVEF ≤40% 1
   • Begin with low dose and titrate upward (e.g., lisinopril 2.5-5 mg daily) 2
   • Check renal function and electrolytes within 1-2 weeks after initiation 1
   • Target doses: lisinopril 20-35 mg daily, enalapril 10-20 mg BID, ramipril 5 mg BID 1
   • Consider ARNI (sacubitril/valsartan) in place of ACE inhibitor/ARB for patients who remain symptomatic despite optimal therapy 1

2. Beta-Blockers

   • Initiate after optimization of volume status and discontinuation of IV diuretics/vasodilators 1
   • Start at low dose (e.g., carvedilol 3.125 mg BID, metoprolol succinate 12.5-25 mg daily, bisoprolol 1.25 mg daily) 1
   • Use caution in patients who required inotropes during hospitalization 1
   • Target doses: carvedilol 25-50 mg BID, metoprolol succinate 200 mg daily, bisoprolol 10 mg daily 1

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Add for patients who remain symptomatic despite ACE inhibitor/ARB and beta-blocker 1
   • Start spironolactone 25 mg daily or eplerenone 25 mg daily 1
   • Monitor potassium and renal function closely

4. Diuretics

   • Transition from IV to oral diuretics with careful attention to dosing 1
   • Adjust dose to maintain euvolemia
   • Monitor electrolytes closely, especially when used with ACE inhibitors/ARBs and MRAs 1

Atrial Fibrillation Discharge Medications

1. Rate Control Agents

   • Beta-blockers (first-line): metoprolol, carvedilol, bisoprolol 1
   • Non-dihydropyridine calcium channel blockers (if no HF): diltiazem, verapamil 1
   • Target resting heart rate <80 bpm for symptomatic management 1
   • Avoid non-dihydropyridine calcium channel blockers in decompensated HF 1

2. Anticoagulation

   • Initiate based on CHA₂DS₂-VASc score
   • Continue for at least 4 weeks after cardioversion 1
   • Long-term anticoagulation decision should be based on thromboembolic risk profile 1

3. Rhythm Control (if appropriate)

   • Amiodarone is preferred for patients with HF and AF 1
   • For patients without HF, options include amiodarone, sotalol, or class 1A agents 1
   • Consider 4-6 weeks of antiarrhythmic therapy after cardioversion 1

Special Considerations for Concomitant HF and AF

When both conditions coexist, prioritize:

1. Anticoagulation unless contraindicated 3, 4
2. Optimize fluid balance with appropriate diuretic therapy 3
3. Target initial heart rate <110 bpm 3
4. Renin-angiotensin-aldosterone system modification with ACE inhibitors/ARBs 3
5. Consider rhythm control strategies, particularly catheter ablation in appropriate candidates 5

Discharge Planning and Follow-up

• Provide comprehensive written discharge instructions focusing on medication adherence 1, 6
• Schedule follow-up appointment within 7 days of discharge 6
• Arrange telephone follow-up within 3 days if possible 6
• Monitor for medication side effects, particularly:
  • ACE inhibitors: hypotension, worsening renal function, hyperkalemia 1
  • Beta-blockers: bradycardia, hypotension, worsening HF symptoms 1
  • Antiarrhythmics: QT prolongation, proarrhythmia 1

Common Pitfalls to Avoid

• Delaying initiation of evidence-based therapies until outpatient follow-up
• Inadequate dose titration instructions for post-discharge care
• Failure to transition from IV to oral diuretics before discharge
• Omitting anticoagulation in eligible AF patients
• Starting beta-blockers before optimizing volume status
• Drug interactions between multiple cardiac medications
• Inadequate patient education about medication purpose and side effects

By implementing this structured approach to discharge medication management, you can significantly reduce morbidity, mortality, and readmission rates in patients with heart failure and atrial fibrillation.