Post discharge HF Care

Heart Failure
Readmission Syndromes
Dr Asadullah Khan Soomro
Adult Cardiologist
King Abdullah Medical City Holy Makkah
Email, hssbasadsoomro@gmail.com
Post Discharge
Heart Failure
Clinic Experience.
“ Scince or Art”

Ist Post Discharge Heart failure , Case Experience
Transition from in patient ( ADCHF 15.10.2018 ) to home & OPD 30th May 2021.
“ Heart failure journey from recurrent decompensation to compensated phase , 0% readmission in > 2 Years
High altitude Heart Failure exacerbation in mountains of Taif ( unique Experience)

Post Discharge Heart Failure Care to
Prevent readmission syndrome
Ist Inpatient sacubitril case of KAMC HF registry
( 15.10.2018 to 30.5.2021 )
KAMC Regular Heart Failure clinic was reactivated on Tuesday afternoon on
2.10. 2018
This was our first inpatient intra departmental heart failure consultation
service case, after being rejected from LVAD implantation on 15.10.2018.
47 year male Retired, father of 4 children , no DM,HTN Ex smoker. Resident on
mountains of Taif Known to have familial dilated cardiomyopathy
( 5 brothers all DCM ) for 17 years.
Admitted on 3rd October 2018 as an non ischemic advanced heart failure
syndrome ( misinterpreted )with severe global LV systolic dysfunction EF 20-
25%, in cardiac surgical ward under care of surgical colleague .

Ist Inpatient sacubitril ( 15.10 2018 ) case of KAMC HF registry
With previous back ground H/O recurrent heart failure
hospitalization & ER visits since 2017,therefore CRTD was
implanted on 13.11.2017 at KAMC .
Yet continued to had worsening of symptoms of heart failure
especially exacerbation at home in mountains of Taif , and remained
compensated while in Makkah or Jeddah ,henceforth family decided
to shift home to Jeddah. Meanwhile case was discussed in LVAD heart
team meeting in October 2018 and was recommended for LVAD
implant. Under went imaging studies and right heart study indeed.

With the introduction of new inpatient
heart failure consultation service ,he was re-evaluated by heart
failure team ,he had typical history of symptoms exacerbation at
high altitude. ( which was reconfirmed by Arabic colleague ).
On Examination his dry weight 95 Kg , JVP was raised, parasternal
heave palpable ,apex beat displaced and sustained S1 S2
with S3 gallop , no murmur .
Chest and abdominal examination was unremarkable.
Peripheral pulses were equally palpable no edema.
EKG sinus rhythm ,old LBBB.

Last Echo in Oct 2018,showed
Severely dilated LV , moderately dilated RV, Global LV
systolic dysfunction, EF 20-25%,normal RV function
.Moderate to severe eccentric MR , Severe TR RSVP 40-
45mm.
Admission BNP was 418, Troponin 0.038,no major
organ dysfunction , Na 137, K 4.5.CBC normal.
Coronaries were normal ( 2017)

Clinical impression; Acute decompensation of chronic heart failure
( ADCHF). Stage C , Precipitated by high altitude, FC 11 .Wet and
warm. Post CRTD.
Note, There were no features suggestive of advanced heart failure
syndrome. Discussed with primary physician and patient ,LVAD
implant was deferred .( had known precipitant)
HF team reviewed him, he was in transitional phase on oral furosemide
Captopril was switched to Sacubitril 50 mg ( After 36 hour wash out )
before discharge from hospital.

He was reviewed after two weeks on 31.10.2018, as early
first post discharge heart failure review, his quality of life
improved tremendously no visit to ER no readmission, Could
sleep comfortably in same home in mountains of Taif.
His BNP, renal function and electrolytes were OK, sacubitril
titrated to 100mg bid. Bit relaxed missed one appointment
and was seen in HF clinic on 5.2.2019,no ER visit, no
readmission in first 3 months ( Vulnerable readmission phase )
, Labs were OK, and sacubitril titrated to 200 mg bid. Since
then ( Oct 2018 to May 2021) remain compensated and was
closely followed virtually during COVID crisis and fasted
successfully during month of Ramdan indeed .

Ist In patient sacubitril ( 15.10 2018 to 30.5.201 )
case of KAMC HF registry
Labs Feb 2019 Jan 2020 Sep 2020 May 2021
BNP 96 93 63 79
Trop 0.038 0.004 0.006
T bil 0.6 0.8
D bil 0.1 0.2
AST 19 22
ALT 61 51
T prot 7.3 8.1
Albumin 3.9 4.0
Labs Feb 2019 Jan 2020 Sep 2020 May 2021
Creatnine 0.8 1.2 1.2 1.1
BUN 17.4 25.4 29.0 19.0
Uric Acid 8.4 7.9 9.2 7.9
Na 136 134 135 134
K 4.0 4.0 4.1 3.9
HB 17.2
Wbc 5.1
Plt 259
others Thyroid
profile
Normal. COVID
Negative

Ist In patient sacubitril ( 15.10 2018 ) case of KAMC HF registry
Echo on 3rd October 2018
LVAD Preparation study
The left ventricle is severely dilated.There is normal
left ventricular wall thickness.
Left ventricular systolic function is severely reduced.EF=
20-25 %
The transmitral spectral Doppler flow pattern is
suggestive of restrictive physiology.
There is severe global hypokinesis of the left ventricle.
The right ventricle is moderately dilated.The left atrium
is mildly dilated.The right atrium is severely dilated.
The reduced mitral leaflet separation suggests
decreased flow through the mitral valve and poor
cardiac output.
There is moderate to severe mitral
regurgitation.The mitral regurgitant jet is eccentrically
directed.
Vena contracta=0.6cm.Effective regurgitation orifice
area (EROA) : 0.26 cm2 ,Regurgitant Volume:38 ml
There is severe tricuspid regurgitation.Right
ventricular systolic pressure is elevated at 40-
45mmHg.
The aortic valve is normal in structure and function.
The aortic root is normal size.There is no pericardial
effusion.
Echo 23.7.2019
The left ventricle is severely dilated with
severely reduced. systolic function.
EF= 15-20 %
There is severe global hypokinesis of the left
ventricle.
There is no thrombus. No apical aneurysm.
Left ventricular diastolic dysfunction grade II.
The right ventricle is not well visualized but appears normal
in size (basal diameter is 38mm, RVOT PLAX diameter 30mm)
RV/LV diameter ratio is 0.5
The right ventricular systolic function is normal. TAPSE is 28
mm. RV S' is 11cm/s
There is ICD lead in the right ventricle.
There is moderate functional mitral regurgitation.
There is mild tricuspid regurgitation.
Right ventricular systolic pressure is elevated at 30-40mmHg.
In comparison with the previous study
(2018/3/10), there is a reduction in the
degree of mitral and tricuspid
regurgitation as well as the RV and RA
size.
Last Echo January 2021
After 2 years of target dose of
Entresto
The left ventricle is moderately dilated.
Left ventricular systolic function is
moderate to severely reduced.
Calculated EF~30 %.
Left ventricular diastolic dysfunction
grade II.
The right ventricle is normal in size and
function.
There is ICD lead in the right ventricle
The left atrium is mildly dilated.
There is mild mitral regurgitation.
Right ventricular systolic pressure is
elevated at 30-40mmHg.
There is no pericardial effusion.
There is an improvement in the LV
volume and EF compared to the
last study 2020.

SUMMARY
1) Acute decompensation of chronic heart failure are different from advanced heart failure
syndromes. ADCHF, if appropriately treated ,usually recover to compensated phase.
2) ADCHF has usually precipitating/ triggering factors to cause decompensation , on the
other hand advanced heart failure is rare ,progressive and refractory to conventional HF
treatment ,they carry worse prognosis despite advanced therapies in right patients at
right time .
3) In between two phases ( stage C to D ) is a transitional phase ,which is bit difficult to
predict but must be recognized before advanced therapies ( LVAD,MV clip and
transplantation).
4) Our patients are 10-15 years younger then Europe and USA, therefore natural history and
response to guide line directed medical therapies with appropriate dose titration is
different .
5) Diagnostic tools and criteria, in advanced HF must be applied along with optimal guide line
directed medical therapies , before considering and implanting devices and advanced
therapies to avoid iatrogenic complications of devices.

DEC
2016
JUNE
2018
6.11. 2019 25 .1. 2020 16.2 2020 18.3 2020 26 .5 .20 14 JULY 2020 3 .8.20to
6.8.20
SEPT
2020
OCTOBER
2020
NOVEMBER –
DECEMBER 2020
Ist post discharge HF
Review on 9.8.20 last on
24.11.20 ( 7 OPD + Virtual )
Started sacubitri 50 mg titrated
to 200 mg .then reduce to 100 mg
because of renal injury creatinine
2.4 ,K ok,
Ist Ant STEMI
4.12.2016
Normal coronaries
( ? Coronary spasm)
EF 10-15%. LV thrombus
Twice NSTEMI
With symptoms of heart
failure and admissions at
KAMC. 2018 and Nov
2019
For HF following at local
hospital .
Heart Failure journey of a patient, with in transitional phase of ambulatory advanced HF syndrome.
3 mahroon circles on left side , ist big, admitted with Ant wall STEMI in 2016, then two small for NSTEMI admissions.
From 2016 to Nov 2019 had symptoms of heart failure but were controlled on medications, following at local hospital.
Yellow small dips are fist 3 visits to KAMC ER. Red bigger dips are HF hospital admission and readmissions.
Last admitted on 3rd August 2020, 7 Green star are OPD visits , big star is first post discharge heart failure clinic review.
Post discharge first 3 months no readmissions. Visited twice to ER for I/V furosemide. He is in ambulatory advanced heart
failure stage D. After being rejected for device therapy , started on sacubitril with close follow up, is better after sacubitril.
Readmitted with
recractory HF
Twice ,on 10th
March 21 CRTD
implantation.
Last in June 2021
with ADCHF due
to non
compliance of
medications .

0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
JUL-19 17/2/20 15/3/20 18/3/20 19/3/20 13/7/20 19/7/20 3/8/2020 9/8/2020 16/8/20 22/9/20 1/10/2020 24/11/20
BNP Level Column1
BNP level from November 2019 to November 2020.
Ist BNP was on 7.11.2019 ( 503 ) at time of NSTEMI ,while troponin was 4.2. We did not had the base line BNP and dry weight. It gradually started to rise in Feb
and in March at time of ist ADCHF ( 1796) .Subsequently from July to November 2020 remain persistently high ( 2855 to 4475 average BNP is 2266 ) .this is
one of the typical sign of chronic Advanced heart failure syndrome .These are the patients to pick up early for advanced heart failure therapies.

0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
troponin T
Troponin T
troponin T
Troponin Tests graph.
Troponin levels were done for 17 times 5 times in November 2019 during NSTEMI highest was 4.2,
then 12 times were done during January 2020 to November 2020. All were less than 1.0 . Every test costs money ,its free for
patients but ministry/organization is paying the cost.Therefore clinical judgement is important before ordering troponin.

Heart Failure
39 year male divorced ,living in family ,unemployed ( but was driver for 16 years )
living 300 Km away from heart failure clinic facility.
Hypertensive for 12 years on irregular treatment ,non diabetic ,smoker and multi drug
abuser for 16 -17 years ( mainly amphetamine & captagon) .
First time admitted at local hospital on 13th December 2016 with acute
extensive anterior wall ST elevation myocardial infarction ,was
thrombolysd at local hospital remain uncomplicated and referred for coronary
angiogram, done and showed normal coronaries .
First Echo on 14th December 2016 showed severely dilated LV with severe global LV
systolic dysfunction EF 10-15%.Normal right side heart mild MR ,normal RVSP. Large
apical thrombus

Heart Failure
In March 2017 was first time admitted with de - novo heart failure
,stablized on medical treatment .
June 2018 admitted with NSTEMI ,raised troponin ,CT coronaries was normal
Severe LV systolic dysfunction EF 10-15%. Persistent LV apical thrombus on
anticoagulants.
In November 2019 readmitted with NSTEMI ,( troponin 4.2, BNP 503
creatnine 1.7) was evaluated by heart failure team and at that time considered
unsuitable for sacubitril, due to multiple reasons.
Since January 2020 developed progressive worsening of symptoms of heart
failure FC 111 1V visited multiple times in ER at local hospital and KAMC.

Heart Failure
Readmitted in March 2020 with acute decompensated heart failure ,persistently raised BNP ( 1796 )
Cardiac MRI showed laminated LV thrombus ,Dilated LV EF 15%, RV dysfunction EF 24%, LAD, RCA, LCX
territaries all viable.
Discussed in combined meeting and was considered not a candidate of device therapy
( LVAD & ICD ) and Heart transplant ( Because non compliant to offending amphetamine and HF
medications ) was COVID negative indeed .
Since then recurrent ER visits and recurrent hospitalization at local hospital and KAMC.
Last re-admission on 3rd August 2020 with ADCHF syndrome was evaluated by psychiatrist bit
depressed and was fade up from life, and seriously decided to stop offending abuse of drugs and
adhere to doctors advise.
After 9 months of terrible HF journey , ( ER & hospitals ) first time visited, on Sunday 9th August at
1.30pm to post discharge non Heart failure out patient clinic ( thanks to Dr Ghada & Abdul Rehman
and security people to control his aggressive attitude) .

Heart Failure
Heart failure team was contacted during COVID vacation , looking at his vulnerability for
readmissions and transitional phase of ambulatory advanced heart failure travelled all along
300 km .
He was re-assesed after a long gap while in patient in November 2019 and 9th August
2020 by heart failure team , was in FC 111,1V in respiratory distress JVP raised beyond angle
of mandible ,parasternal heave was palpable with displaced sustained apex beat S1 S2
S3 gallop no murmur.
Chest bilateral basal crepts , peripheral pulses were palpabe with ankle edema.
EKG sinus rhythm and incomplete LBBB.
( BNP 3405 ,2171, Creat 1.1, K 3.7, Na 131, Tbil 1.9 ,uric acid 6.8, HB% 10.6, WBC 7.0,
Plt 217 )
He was on Lisinopril, Spironolactone, Carvediolol, Isosorbide dinitrate, Metolazone , Apixban,
Allopurinol and from psychiatry mirtazipine.

Heart Failure
After all complex situation , we decided to switch him on sacubitril .
He and his accompanying brother was given full HF education and
awareness about his condition and bad prognosis , ( rejected for device and
transplant ) it’s a last hope , so he promised to comply, we offered him admission
to relieve congestion before sacubitril but he refused to go to even ER for fear of
admission and COVID test , there was no arrangement of I/V furosemide in OPD .
Finally we arranged his sacubitril from pharmacy , and gave him 80 mg
furosemide orally and observed him in OPD ,and he decided to go home, and will
arrange to communicate with local physician ,which he did ,physician was
co operative , knew the nature of patients and course of disease ,he kept him on
furosemide to relieve congestion and after 36 hours of ACE wash out
started sacubitril ( 11.8.20) “ there is a will there is a way” things are difficult
but not impossible .

Heart Failure
We maintain telephonic contact twice a day until discharged from local hospital
,then daily basis telephonic contact ( whats up).
After two weeks on sacubitril 50 mg ,he did not visited ER even once, so
develop confidence and we reviewed him on 20th August , on Thursday
clinic . Gave him free will to call and come on any day .
He was compensated in FC 11 after long time, hemodynamically stable renal
function and K was OK so titrated to 100 mg for 4 weeks.
Since then whole September remained in close contact & compensated with out
ER visit and no readmission.
Reviewed him in regular heart failure clinic on Tuesday afternoon 24 September
2020 ,Clinically Compensated ,titrated to full target dose 200 mg for next 2
months.

Heart Failure
Lab Results came late ,when he already left for home, creatnine
increased from 1.2 to 1.9 and GFR was 43, so we continued the
sacubitril full dose ,with repeat labs at local hospital, creatnine came
down to 1.6. no worsening of HF symptoms no readmission. but
remain in close contact.
He was again seen on 2nd october 2020, clinically bit upset creatnine
first time raised to 2.4,GFR 33, Na, K OK .
Sacubitril was stopped for 3 days ,creatnine came to 1.7 GFR 49 ,
so sacubitril restarted and reduced to 100 mg .

Heart Failure
He was again seen in OPD on 24.11.20 weight increased from 74
to 79 KG ,BNP 3140,K 3.9, Creatnine 1.7 GFR 49,T bil 2.8. Refused
to go to ER so increased the dose of furosemide with close contact
, His BNP and weight made me upset .
On 30th mid night he called for PND. Advised him to go to local
ER ,he followed instruction given I/V furosemide and kept him
under observation. At morning came to KAMC ER for possible
admission but after Troponin ( 0.764 ) & Creatnine 1.8 .
disposed to go home.

Heart Failure
Symptoms fluctuating and last re visited KAMC ER on
Tuesday 15.12.20 , evening time saying ER was busy so gave
him frusemide ,no new Labs ,and disposed to home.
Called him to increase the dose of oral furosemide .Last
called him today Friday 18th december 2020 at 5.20 pm he is
fine his voice tone was changed ,no PND no visit to ER for 3
days , and will come next week to review medications after
new Lab work.
“ Those who read full story will agree that heart failure is a science and Art indeed “

Heart Failure
Readmitted on 18.2.2021 with ADCHF ,his BNP raised from 688 to 3190
with passive liver congestion Tbil 3.4 Dbil 1.1,creat 1.2 ,trop 0.029,K 5.1
and Na 137.CRTD was deferred because of previous drug abuse history.
In March 2021 Visited ER many times, despite persistently raised BNP
( 8254,6332,5801 & 5503) denied admission and CRTD.
We reviewed him in OPD on 4.3.21 ,his BNP was 8254 with major organ
dysfunction, shifted to ER for admission until bed is available. Case re-
discussed with EP colleague and was finally accepted for CRTD, which
was implanted on 10.3.21.clinically improved and post discharged
reassesed in HF clinic on 21.3.21 .BNP came down to 844, on sacubitril
100 mg. In june did not received medications via post so non compliant
to drugs for two weeks, re-admitted in June 2021 with ADCHF .Last
contacted him on phone on 22nd june 21,and remained compensated
after treatment.

EKG of 36 year male , on 13th December 2016 had Ant wall ST Elevation Myocardial Infarction , was thrombolysed
at local hospital . Normal coronaries in December 2016 ,& Normal CT coronaries 2018 .

X –Ray Chest P/A & Lat April 2020
During recurrent acute decompensated Phase

Non Dilated Non Ischemic ( Idiopathic ) Reversible Heart Failure Syndromes
Non Dilated
Acute
Malignant
Heart
Failure
Syndromes
Big ,chronic compensated
Non Ischemic Heart Failure Syndromes
Soomro’s Heart Failure Prognostic zones Red, yellow and Green
Thank
You

Post discharge HF Care

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