When should a patient with known heart disease be admitted to the hospital?

When to Admit a Heart Disease Patient

Admit patients with heart disease who present with new or worsening heart failure symptoms, objective evidence of decompensation, and require initiation or intensification of treatment—particularly those with high-risk features including hemodynamic instability, severe dyspnea, hypoxemia, or signs of end-organ hypoperfusion. 1

Mandatory Admission Criteria for Heart Failure Patients

Admit immediately if ANY of the following are present:

• Hemodynamic instability: Systolic blood pressure <90 mmHg, heart rate <60 or >120 bpm, or evidence of cardiogenic shock 1
• Respiratory compromise: Respiratory rate >25 breaths/min, SaO₂ <90% despite supplemental oxygen, or use of accessory muscles for breathing 1
• Signs of hypoperfusion: Oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, or SvO₂ <65% 1
• Need for intubation or already intubated 1
• Acute coronary syndrome with heart failure symptoms—these patients require coronary care unit admission 1

Clinical Presentation Requiring Hospitalization

The ACC/AHA defines heart failure hospitalization as:

• Length of stay ≥24 hours (or extends over a calendar date if admission/discharge times unavailable) 1

• New or worsening symptoms on presentation (at least ONE of the following):

  • Dyspnea (at rest, with exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, tachypnea) 1
  • Decreased exercise tolerance 1
  • Fatigue with lack of energy and inability to complete usual activities 1
  • Worsened end-organ perfusion (confusion, altered mental status, syncope, nausea, abdominal pain, cold extremities, reduced urine output, chest pain) 1
  • Volume overload symptoms (peripheral edema, increased abdominal girth, weight gain, skin breakdown in lower extremities) 1

• Objective evidence of heart failure (at least TWO physical findings OR ONE physical finding plus ONE laboratory criterion) 1

• Initiation or intensification of treatment specifically for heart failure 1

Risk Stratification for Admission Decision

High-risk patients requiring ICU/CCU admission:

The ADHERE registry identified patients with in-hospital mortality of 22% who should be directed to intensive care environments: 1

• Blood urea nitrogen ≥43 mg/dL 1
• Systolic blood pressure <115 mmHg 1
• Creatinine ≥2.75 mg/dL 1

Additional ICU criteria include: 1

• Respiratory rate >25 breaths/min 1
• SaO₂ <90% 1
• Use of accessory muscles for breathing 1
• Systolic blood pressure <90 mmHg 1
• Evidence of right heart failure with organ hypoperfusion 1

Patients Who May Be Managed Without Admission

Consider ED observation or discharge ONLY if ALL of the following are met:

• Low-risk features: No high-risk laboratory values (normal BUN, creatinine, blood pressure >115 mmHg) 1
• Good response to initial ED therapy: Symptom improvement, stable vital signs, adequate oxygenation 1
• No comorbidities requiring inpatient management 1
• Adequate psychosocial support and ability to follow up within 72 hours 1, 2
• Not de novo heart failure—these patients need further evaluation and should not be discharged quickly 1

Research suggests up to 50% of heart failure patients could potentially be safely discharged from the ED after brief observation, though this requires careful risk stratification. 2

Monitoring Requirements During Hospitalization

For admitted patients:

• Daily weights and accurate fluid balance charts 1
• Standard noninvasive monitoring of pulse, respiratory rate, and blood pressure 1
• Daily measurement of renal function and electrolytes 1
• Pre-discharge natriuretic peptide measurement for post-discharge planning (patients whose levels fall during admission have lower 6-month mortality and readmission rates) 1

Arrhythmia Monitoring Indications

Continuous cardiac monitoring is recommended for:

• First 24 hours for all acute decompensated heart failure patients requiring hospitalization 1
• Beyond 24 hours if patient is not discharged and remains at intermediate or high risk 1
• Patients with ICD shock requiring hospitalization—monitor for duration of hospitalization until precipitating event is treated 1
• New arrhythmias during heart failure exacerbation are common and associated with higher inpatient and 60-day morbidity/mortality 1

Common Pitfalls to Avoid

• Do not discharge patients with de novo heart failure without thorough evaluation—they require admission for diagnostic workup 1
• Do not rely solely on clinical judgment for admission decisions—use objective risk stratification tools (BUN, creatinine, blood pressure, natriuretic peptides) 1
• Do not discharge patients who have not demonstrated response to therapy in the ED 1
• Do not admit low-risk patients to ICU based on clinical judgment alone—this leads to overutilization of higher levels of care 1
• Do not discharge patients without ensuring close follow-up within 72 hours and adequate psychosocial support 1, 2

Discharge Criteria

Patients are medically fit for discharge when: 1

• Hemodynamically stable 1
• Euvolemic 1
• Established on evidence-based therapy 1
• Adequate response to treatment demonstrated 1
• Close follow-up arranged (ideally within 72 hours) 1