Heart Failure is a complex clinical syndrome with recurrent readmissions. target Vulnerable patients at right time to prevent recurrent admissions

1. Heart Failure Admission and
Readmission Syndromes
Dr Asadullah Khan Soomro
Adult Cardiologist
Awwad albishri hospital Holy Makkah
Email, hssbasadsoomro@gmail.com
“ Vulnerable Phase in Heart Failure
Syndromes ”

3. Introduction
Heart failure is a complex clinical syndrome.
Acute heart failure ( AHF ) represents a serious health problem with
significant mortality and morbidity in-hospital despite contemporary therapy.
Postdischarge outcomes of patients with acute heart failure remain
unacceptably high .
About 50% patients with acute heart failure are readmitted with in one year
of discharge and about 20% die in the following year.
Survival of the patients with chronic compensated heart failure has improved
by multidisciplinary programme over time.

4. What & when is Vulnerable
Phase in HF
The “ Vulnerable phase “ as typically defined for patients with acute heart failure (
AHF ) ,is a period during which microenviromental changes occur in heart after an
episode of acute heart failure .
Patient is at increased risk for adverse or might experience unexpected outcomes
“Death or re-hospitalization for HF ”
This vulnerability is typically observed during periacute HF period, which extends
from initiation of an index acute HF event leading to admission, through a
peridischarge and up to 6 months after discharge.
It can occur with every episode ,weather index event is first or not. Patients who
overcome this period successfully may transition into long-term stable phase.

5. Classification of Vulnerable
Phase ( 1 to 3 ) in HF
Very Early
Vulnerable phase
Early
Vulnerable phase
Late
Vulnerable phase
Index event
AHF episode
Repeat event
Worsening HF
15
%
Discharge Phase
Heterogeneous Period
In-hospital Worsening HF is associated
with adverse Outcomes.
After discharge up to 6 months
After discharge up to 60
days ( 30% readmission )
Vulnerability Begets
Vulnerability
Crucial Phase
“ Target
Vulnerable Patients at
right time “
Acute MI complicated by in-hospital Heart Failure
1
2
3

6. Very Early Vulnerable
Phase in AHF
After discharge from hospital to home, this transitional phase require meticulous
follow up by HF multidisciplinary team.
As per recent ACCF/AHA Guide line recommends early telephonic follow up within 3
days of discharge and an early HF clinic follow-up visit within 2 weeks.
Guidelines are printed but not implemented even in tertiary care institutions ,because
most of the hospitals have no MDHFP/ HF clinic .
Our current payment system is also fee for service based, which is uncoordinated,
fragmented and low-quality care ,yet no concept of value based payment .
All these problems encourage HF patients to visit Emergency and patients are
readmitted without justification.

7. Very Early Vulnerable
Phase in AHF
It extends from index episode of acute heart failure up to few days post
discharge .
“Episode of acute heart failure itself is a Vulnerable period “.
15% experience in-hospital worsening of HF symptoms, require extra
intervention.
Mean duration of this phase is around 4-5 days, which is too short to
relieve congestion before discharge.
Over all there is lack of in-hospital clinical pathways with no admission
and discharge criteria , and most of the HF are treated symptomatically .

8. Very Early Vulnerable
Phase in AHF
System induced pressure encourages physicians to discharge patients as early
as possible ,which leads to the common practice to use high doses of
diuretics to achieve rapid decongestion in short period ,but there is
subclinical residual congestion and major organ dysfunction( Over-looked
renal and liver injury ).
Precipitating factors, like ischemia, anemia and infections are also
neglected.
Long term GDMT are not easy to initiate within short hospitalization
phase , therefore re-hospitalization and high mortality after discharge.

9. Early Vulnerable
Phase in HF ( post discharge )
The early vulnerable phase typically begins after the discharge ,following an episode
of acute heart failure ( AHF ).
Hospitalization duration is typically 8-10 days , which is usually sufficient for
adequate decongestion , dry weight and BNP reduction.
Unfortunately most patients do not fulfill discharge criteria and prematurely
discharged, with subclinical congestion & incomplete HF education .
No or inadequate post-discharge early follow-up for dose titration / reduction due
to major organ dysfunction & comorbidities.
No heart failure cardiac rehabilitation referral criteria .
Both these factors are important determinants of stability after AHF
“ Honey-moon Period “

10. Early Vulnerable
Phase in HF ( post discharge )
This phase of vulnerability is potentially secondary to patients attitude ie,
restricting lifestyle modifications following discharge
“ Honey-moon Period “
However ,most of the vulnerability is thought be related to hospital based
problems ( lack of MDHFP ,no post discharge early follow-up/ appointment ) and
accompanying comorbidities/ potentially exacerbating factors.
Incomplete /poor targets of revascularization keep precipitating ischemic episodes
and heart failure. Repeated ischemic episodes , persistently raised BNP and
troponin are important contributors to vulnerability and readmissions.
30% of all readmissions occur within the first 60 days of hospital discharge.
Less than 50% patients are prescribed /tolerate GDMT at time of discharge.

11. Early Vulnerable
Phase in HF ( post discharge )
Patients should be discharged on GDMT ( beta blockers, ACE, ARB /ARNI and MRA )
Patients who are decongested , discharged on GDMT and have post-discharge follow-up , have significantly better
outcomes than those discharged without .
Unfortunately there is significant heterogeneity in the organization of heart failure
management with multiple communication gaps amongst HF stakeholders.
Transition from inpatient to outpatient care can be very difficult in vulnerable
period due to complexity & dynamic nature of disease state itself, accompanying
comorbidities and long-term expensive medications / device therapies.
Despite our patients are younger than western counterpart ,yet HF readmission
rate are similar to elderly patients. Therefore require clinical follow-up typically
within 1-2 weeks.

12. Late Vulnerable
Phase in HF( post discharge )
Late vulnerable phase of heart failure typically extends up to
6 months after discharge.
HF related re-hospitalizations are typically preceded by a gradual
rise in ventricular filling pressures more than 2 weeks before
clinical HF.
This phase can be prevented by adherence and up-titration of
GDMT including residual revascularization ,and device therapy
if indicated.

13. Identification of Vulnerable HF
Patients for Re-hospitalization
Patients hospitalized first time, is vulnerable for re-hospitalization, with in 30-60 days ,especially with
1 or more, following complex features.
1) Non adherence to therapeutic regimens .
2) Renal insufficiency
3) Low cardiac out-output states
4) Uncontrolled diabetes
5) Chronic obstructive pulmonary disease ( COPD )
6) Persistent symptoms FC III,IV & Premature discharge
7) Frequent non HF hospitalizations
8) Multiple active comorbidities
9) History of depression
10) Poor HF education
11) Inadequate social support

14. Conclusion
A vulnerable phase lasting up to 6 months following an episode of acute
heart failure exist and is a critical determinant of prognosis.
In order to avoid the poor outcomes related to this vulnerable phase
,patient should be discharged when they fulfill discharge criteria
( hemodynamically stable for atleast 24-48 hours, euvolemic ( dry weight BNP come down)
Stable major organ function ( renal & liver ) and on GDMT oral medications .
Last not the least ,It appears that best management of the vulnerable phase requires a
collaborative and multistep approach.

15. THANK YOU