Heart failure early post-discharge appointment: a 1.5-year single-centre experience
Authors: Fialho I , Passos M , Gerardo F , Mateus C , Lima-Lopes J , Miranda I , Oliveira-Soares A , Morais C , Roque D 
Published: November 2023

Abstract

Background
According to Heart Failure (HF) guidelines, a follow-up visit should be conducted within 1 to 2 weeks after hospital discharge to monitor signs and symptoms of HF, optimize therapy, and evaluate treatment side effects. Retrospective studies have shown that this approach is associated with lower 30-day readmission rates.

Purpose
Our aim is to describe the role of early post-discharge appointment in the management of HF patients and to evaluate prognostic factors after HF hospitalization.

Methods
We conducted a single-centre prospective registry of consecutive patients evaluated in the early post-discharge appointment at our centre, from March 2021 to September 2022. HF symptoms, vital signs, blood test results, treatment decision, and 90-day HF events were recorded.

Results
Overall, 153 patients were included (mean age 65.7 ± 13.0 years, 63.4% male). The mean time from hospital discharge to post-discharge appointment was 13.4 ± 5.7 days. Left ventricle ejection fraction was reduced in 83.6% (n = 127) of patients. Guideline-directed medical treatment prescribed at discharge, as well as up-titration and withdrawal patterns at the post-discharge appointment, are presented in Table 1. At the post-discharge appointment, 34.3% of patients (n = 35) presented with drug adverse effects, most often including hyperkalemia (17.5%, n = 22), acute kidney injury (9.9%, n = 12), and hypotension (3.9%, n = 6). Of those evaluated at the post-discharge appointment, 11.2% (n = 17) were scheduled to another appointment one week later, for early re-evaluation, 90.1% (n = 137) were followed-up in the standard HF ambulatory program, and 2.6% (n = 4) were hospitalized. The serum creatinine (1.10 [0.87 – 1.36] mg/dL vs 1.40 [1.09 – 1.95] mg/dL, p&lt;0.001), the serum C cystatin (1.50 [1.25 – 1.98] mg/dL vs 1.97 [1.54 – 2.46] mg/dL, p = 0.007) and the NT-proBNP levels (1859 [977 – 4877] mg/dL vs 5928 [2817 – 11957] mg/dL, p = 0.013), measured at the time of the post-discharge appointment, were found to be associated with HF events within 90 days (urgent HF visit or HF hospitalization). An NT-proBNP level above 2400 pg/mL adjusted to C cystatin was found to be a strong predictor of 90-day HF events (OR 9.855, 95% CI 2.657 – 36.550, p = 0.001). This model yielded a good prognostic performance (AUC 0.790, CI 95% 0.689-0.890, p&lt;0.001).

Conclusions
Early evaluation of HF patients after hospital discharge allows for guideline-directed medical therapy up-titration and early detection of drug adverse effects. The NTproBNP level and kidney function, assessed early after discharge, have been found to be strong predictors of 90-day HF events, indicating which patients would benefit most from a stricter follow-up program.
Table 1 – Guideline-directed medical therapy patterns of prescription both at hospital discharge and during the early post-discharge appointment. ACE, angiotensin converting enzyme; ARA, aldosterone receptor antagonist, MRA, mineralocorticoid receptor antagonist.