What discharge plan is appropriate for a 71‑year‑old man with dilated cardiomyopathy, ejection fraction approximately 20 %, heart‑failure with reduced ejection fraction, type 2 diabetes mellitus, hypertension, peripheral vascular disease, and chronic obstructive pulmonary disease?

Discharge Plan for 71-Year-Old with Severe HFrEF and Multiple Comorbidities

This patient must be discharged on four foundational HFrEF medications simultaneously (SGLT2 inhibitor, beta-blocker, ARNI or ACE inhibitor, and MRA), established on stable oral therapy for at least 24 hours, hemodynamically stable, euvolemic with stable renal function, and enrolled in a multidisciplinary heart failure disease management program with follow-up within 1 week. 1, 2, 3

Pre-Discharge Medical Optimization

Guideline-Directed Medical Therapy (GDMT) - Four Pillars

Start all four medication classes simultaneously at low doses rather than sequential uptitration: 2, 3

• SGLT2 Inhibitor (First Priority): Initiate dapagliflozin 10 mg daily or empagliflozin 10 mg daily immediately—these are the safest and most effective options with no dose adjustment required, minimal blood pressure effects, and work quickly to enhance tolerability of subsequent agents 2, 3

• Beta-Blocker: Start carvedilol 3.125 mg twice daily, bisoprolol 1.25 mg daily, or metoprolol succinate 12.5-25 mg daily; target doses are carvedilol 25-50 mg twice daily, bisoprolol 10 mg daily, or metoprolol succinate 200 mg daily 2, 3

• ARNI or ACE Inhibitor: Given the EF of 20%, initiate sacubitril/valsartan 24/26 mg twice daily (target 97/103 mg twice daily) if blood pressure tolerates; if not, use an ACE inhibitor such as lisinopril 2.5-5 mg daily 2, 3

• Mineralocorticoid Receptor Antagonist (MRA): Start spironolactone 12.5-25 mg daily if potassium <5.0 mEq/L, even though recent evidence shows MRAs remain effective when eGFR declines below 30 2

Critical Medication Adjustments for Comorbidities

Diabetes Management: 1, 2

• Continue SGLT2 inhibitor for dual cardiovascular and glycemic benefit
• Discontinue metformin immediately if eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 2
• Adjust insulin as needed for glycemic control (target HbA1c <7%)

COPD Considerations: 1

• Beta-blockers are NOT contraindicated in COPD and should be continued for HFrEF mortality benefit
• Use cardioselective beta-blockers (bisoprolol or metoprolol succinate) preferentially

Peripheral Vascular Disease: 1

• Continue aspirin 81 mg daily for secondary prevention
• Consider low-dose rivaroxaban 2.5 mg twice daily plus aspirin if symptomatic lower extremity artery disease, though balance bleeding risk

Diuretic Management

• Optimize loop diuretic dose (furosemide equivalent) to achieve euvolemia before discharge 1, 2
• SGLT2 inhibitors enhance diuretic efficacy and may reduce need for loop diuretic intensification 2
• Patient must be euvolemic with stable weight for at least 24 hours before discharge 1

Pre-Discharge Stability Criteria

Patient is medically fit for discharge only when ALL of the following are met: 1

• Hemodynamically stable (systolic BP >100 mmHg, heart rate controlled)
• Euvolemic (no peripheral edema, clear lungs, stable weight for 24 hours)
• Established on evidence-based oral medications for at least 24 hours
• Stable renal function (creatinine stable or <30% increase from baseline is acceptable)
• No intravenous diuretics, vasodilators, or inotropes for at least 24 hours

Pre-Discharge Monitoring and Assessment

• Measure natriuretic peptides (BNP or NT-proBNP) before discharge—falling levels predict lower 6-month cardiovascular mortality and readmission rates 1
• Document daily weights and fluid balance 1
• Check final renal function and electrolytes (potassium, creatinine) 1
• Assess volume status clinically (jugular venous pressure, peripheral edema, lung auscultation)

Patient Education Requirements

Provide face-to-face instruction reinforced with written materials covering: 1

• Medication regimen: Type, purpose, dose, frequency, and side effects of each medication 1
• Daily self-monitoring: Weigh daily at same time; call physician if weight increases >2-3 pounds in 1 day or >5 pounds in 1 week
• Symptom recognition: Worsening dyspnea, orthopnea, peripheral edema, decreased exercise tolerance 1
• Dietary sodium restriction: <2 grams daily
• Fluid restriction: 1.5-2 liters daily if severe HF

Emergency instructions: 1

• If new or worsening chest pain, severe dyspnea at rest, or inability to lie flat develops, call 9-1-1 immediately
• If gradual worsening of symptoms (increased dyspnea with exertion, new ankle swelling), contact physician within 24 hours

Structured Follow-Up Plan

Mandatory follow-up schedule to reduce 30-day readmissions: 1

1. Telephone follow-up within 3 days of discharge to reinforce education, assess symptoms, and confirm medication adherence 1

2. Primary care physician visit within 1 week of discharge for clinical assessment, weight check, and medication review 1

3. Cardiology/heart failure clinic visit within 2 weeks of discharge for medication titration and optimization 1

4. Enroll in multidisciplinary heart failure disease management program with nurses, dietitians, pharmacists, and rehabilitation specialists for ongoing support 1

Post-Discharge Medication Titration Strategy

Monitoring protocol: 2

• Check potassium and renal function weekly for first 2-4 weeks after initiating or uptitrating GDMT
• Then check every 2 weeks until stable
• Up to 30% creatinine increase is acceptable and should not prompt medication discontinuation 3

Titration sequence over 4-8 weeks: 3

• Uptitrate beta-blocker to target dose first (every 2 weeks if tolerated)
• Uptitrate ARNI/ACE inhibitor to target dose (every 2 weeks if tolerated)
• Uptitrate MRA cautiously with close potassium monitoring
• SGLT2 inhibitor requires no titration 2

Critical Pitfalls to Avoid

• Never delay initiation of all four foundational therapies—the conventional sequential approach requiring ≥6 months leads to major treatment gaps and preventable deaths 3
• Never discontinue medications for modest creatinine elevations—up to 30% increase is acceptable 3
• Never withhold SGLT2 inhibitors due to low eGFR—they are safe and effective down to eGFR 20 2
• Never discharge patients who are not hemodynamically stable, euvolemic, or on stable oral medications for at least 24 hours 1
• Never fail to arrange follow-up before discharge—lack of early follow-up is a major contributor to 30-day readmissions 1