Discharge Criteria for Heart Failure Secondary to Valvular Heart Disease
A patient with heart failure secondary to valvular heart disease should be discharged only when they have been hemodynamically stable and euvolemic with stable renal function for at least 24 hours while established on evidence-based oral medications. 1
Core Discharge Readiness Criteria
Before discharge is appropriate, the following conditions must be met:
Hemodynamic Stability (Minimum 24 Hours)
- Stable blood pressure without orthostatic hypotension (both supine and upright measurements) 1
- Resolution of acute decompensation with successful transition from intravenous to oral diuretic therapy 1
- Discontinuation of all parenteral therapies including IV diuretics, vasodilators, and inotropic agents for at least 24-48 hours 1, 2
Volume Status Optimization
- Achievement of euvolemia with resolution of congestion (no pulmonary edema, minimal peripheral edema, normal jugular venous pressure) 1, 2
- Stable oral diuretic regimen established for at least 48 hours 1
- Daily weights stable without significant fluctuation 1
Renal Function Stability
- Stable creatinine and electrolytes for at least 24 hours before discharge 1, 2
- No worsening renal function with current medication regimen 1
Medication Optimization Prior to Discharge
Guideline-Directed Medical Therapy (GDMT)
For patients with reduced ejection fraction, initiate and optimize quadruple therapy before discharge: 2
- ACE inhibitor/ARB (or ARNI) - initiated in stable patients prior to discharge 1, 2
- Beta-blocker - started at low dose only after volume optimization and discontinuation of IV therapies 1, 2
- Mineralocorticoid receptor antagonist 2
- SGLT2 inhibitor 2
Critical Medication Considerations
- Continue existing ACE inhibitors/ARBs and beta-blockers during hospitalization unless true hemodynamic instability or contraindications exist 1, 2
- Do not delay GDMT initiation until outpatient follow-up 2
- Monitor carefully for hypotension and worsening renal function with all medication changes 1
Pre-Discharge Assessment and Planning
Natriuretic Peptide Measurement
- Measure natriuretic peptides before discharge for post-discharge planning 1, 2
- Patients whose natriuretic peptide concentrations fall during admission have lower cardiovascular mortality and readmission rates at 6 months 1, 2
Mandatory Discharge Education
Provide comprehensive written discharge instructions emphasizing six critical aspects: 1, 2
- Diet restrictions
- Discharge medications with focus on adherence and uptitration plans
- Activity level recommendations
- Follow-up appointment schedule
- Daily weight monitoring technique
- Action plan for worsening symptoms
Post-Discharge Follow-Up Requirements
Establish and communicate clear follow-up plans before discharge: 1, 2
- Telephone follow-up within 3 days of discharge 1, 2
- General practitioner visit within 1 week 1, 2
- Hospital cardiology team visit within 2 weeks 1, 2
- Enrollment in disease management program or multi-professional heart failure service 1
Special Considerations for Valvular Heart Disease
Valvular-Specific Assessment
While the general discharge criteria apply, patients with valvular heart disease require additional consideration:
- Evaluation for definitive valve intervention (surgical or percutaneous) should be completed or planned before discharge 3
- For severe symptomatic valvular disease causing decompensation, stabilization alone may not be sufficient - definitive valve treatment planning is essential 3
Common Pitfalls to Avoid
- Do not discharge patients on IV therapies - they must be transitioned to oral medications with demonstrated stability 1
- Do not discontinue beta-blockers or ACE inhibitors during acute exacerbation unless true hemodynamic instability exists 2
- Do not discharge without 24-hour stability period on oral medications 1
- Do not delay follow-up arrangements - these must be confirmed before discharge 1, 2