What are the key drivers of hospital readmission and established predictive risk calculators for individuals with Heart Failure with Preserved Ejection Fraction (HFPEF) and Heart Failure with Reduced Ejection Fraction (HFREF)?

Hospital Readmission in Heart Failure: Key Drivers and Risk Prediction

Predictive Risk Calculators for HF Readmission

Current risk prediction tools for heart failure readmission perform poorly, with AI-based and traditional statistical models achieving only modest discrimination (AUC 0.63-0.71), indicating that established, validated calculators for gauging readmission probability in HFrEF and HFpEF patients do not yet exist. 1

• The HOSPITAL score and LACE index can predict 30-day readmissions with statistical significance (P<0.001), but their clinical utility remains limited 2
• Machine learning algorithms using large cohorts and deep learning have not substantially improved predictive accuracy beyond traditional models 1
• More work is urgently needed to enhance predictive capabilities before any calculator can be recommended for routine clinical use 1

Key Drivers of Readmission: Critical Differences Between HFpEF and HFrEF

HFpEF-Specific Readmission Drivers

HFpEF patients have the highest all-cause readmission rates compared to HFrEF and HFmrEF, driven predominantly by non-cardiovascular causes rather than heart failure itself. 3

• HFpEF independently increases readmission risk with an odds ratio of 1.77 (95% CI: 1.25-2.50, P=0.001) 2
• All-cause 30-day readmissions occur in 18.3% of HFpEF patients versus 9.5% in those without heart failure 4
• Non-HF-related hospitalizations remain the primary driver, requiring aggressive management of comorbidities 3
• Key comorbid conditions driving HFpEF readmissions include diabetes mellitus, metabolic disorders, mood disorders, renal impairment, and COPD 1
• Age ≥65 years is inversely associated with adequate follow-up despite higher comorbidity burden, creating a care gap 1

HFrEF-Specific Readmission Drivers

HFrEF patients have the highest cardiovascular and heart failure-specific readmission rates, primarily driven by inadequate guideline-directed medical therapy (GDMT) optimization. 1

• 46% of HFrEF patients have zero changes to oral GDMT in the 12 months after hospitalization despite suboptimal dosing 1
• 42% receive no GDMT within 30 days post-discharge, and 45% receive either no GDMT or monotherapy within 1 year 1
• Less than 1% achieve target doses of ACEi-ARB-ARNi, beta-blockers, and MRA within 12 months of hospitalization 1
• Graded improvement in death or rehospitalization occurs with monotherapy, dual therapy, and triple therapy versus no GDMT 1

Evidence-Based Strategies to Reduce Readmissions

For HFrEF Patients

Initiate and uptitrate GDMT aggressively during hospitalization and at discharge—this is the single most effective intervention to reduce readmissions and mortality. 1

• Beta-blocker initiation at discharge reduces 30-day all-cause mortality and 4-year mortality/readmission 1
• ACEi-ARB initiation reduces both 30-day and 1-year mortality, plus lowers 30-day all-cause readmission 1
• MRA therapy at discharge improves HF readmission rates 1
• SGLT2 inhibitors (dapagliflozin, empagliflozin) reduce HF hospitalization by 21-35% regardless of diabetes status 5
• Sacubitril-valsartan initiated before or shortly after discharge reduces cardiovascular mortality and hospitalization 1

For HFpEF Patients

Target aggressive comorbidity management and ensure early outpatient follow-up within 7-14 days, as HFpEF readmissions are predominantly non-cardiovascular. 1, 3

• SGLT2 inhibitors show significant benefit in HFpEF and should be initiated early 6
• Sacubitril-valsartan reduces readmissions in women (rate ratio 0.73,95% CI 0.59-0.90) and those with EF 45-57% (rate ratio 0.78,95% CI 0.64-0.95) 6
• Spironolactone may reduce HF hospitalization in selected patients with elevated natriuretic peptides 6
• Physician visits within 21 days of discharge significantly reduce readmissions 1
• Nurse home visits within 14 days post-discharge reduce 90-day readmission rates from 69.8% to 27.3% (P<0.001) 1

Universal Strategies for Both Phenotypes

Achieve complete decongestion before discharge and provide explicit diuretic adjustment plans—residual congestion is a major driver of early readmission. 1

• Titrate diuretics and GDMT to resolve all clinical evidence of congestion 1
• Discharge regimen must include a specific plan for diuretic adjustment 1
• Outpatient appointments within 30 days reduce 30-day mortality by 81% (95% CI 0.09-0.43) 1
• Team-based primary care reduces post-discharge ED visits compared to traditional care 1

Common Pitfalls to Avoid

• Do not withhold GDMT for mild hypotension (SBP <110 mmHg) or mild worsening renal function (≤20% decrease in eGFR)—these are not true contraindications 1
• Do not assume HFpEF and HFrEF readmissions have the same causes—HFpEF requires comorbidity-focused interventions while HFrEF requires GDMT optimization 3
• Do not rely on existing risk calculators for clinical decision-making—their predictive accuracy is insufficient 1
• Do not discharge patients with residual congestion—this directly increases rehospitalization risk 1
• Do not delay follow-up beyond 14 days—early outpatient contact is critical for both phenotypes 1