Optimizing Pre-to-Post Discharge Transition of Care in Patients Hospitalized for Heart Failure - Part 3 of the International Expert Opinion Series on Acute Heart Failure Management.
Written by: Husam M SalahAndrew P AmbrosyJan BiegusEdimar A BocchiJaved ButlerOvidiu ChioncelGad CotterBeth DavisonAnastase DzudieYonathan FreundSivadasanpillai HarikrishnanIvna G C V LimaAlexandre MebazaaRobert J MentzÒscar MiróAnika S NaiduSiti E NauliMatteo PagnesiMauro RiccardiNaoki SatoGianluigi SavareseKaren Sliwa-HahnleYuhui ZhangJingmin ZhouMarat Fudim
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HS
Dr. Husam Salah
Interventional Cardiology · Duke University
RM
Dr. Robert Mentz
Advanced Heart Failure · Duke University
Summary
Hospitalization for heart failure (HF) represents a pivotal event in the disease course, often signaling decompensation and an elevated risk of readmission, mortality, and functional decline. Despite advances in inpatient management, the transition from hospital to home remains a vulnerable period characterized by residual congestion, incomplete implementation of guideline-directed medical therapy (GDMT), unmanaged comorbidities, and fragmented care coordination. This expert consensus provides a comprehensive, evidence-based framework to optimize the pre-to-post discharge transition in patients hospitalized with HF. Key priorities include confirmation of decongestion using biomarkers, lung ultrasound, and validated risk scores; in-hospital initiation and up-titration of foundational GDMT; and identification of reversible etiologies such as ischemic heart disease. Early evaluation for device therapy, arrhythmia management, including anticoagulation and rhythm control in atrial fibrillation, and structured management of comorbidities such as chronic kidney disease, diabetes, COPD, iron deficiency, frailty, and depression are emphasized. Multidisciplinary collaboration across pharmacy, rehabilitation, mental health, and social services is essential to support safe discharge and continuity of care. Proactive strategies such as medication reconciliation, simplified dosing regimens, caregiver engagement, and attention to social determinants of health are critical to improving adherence and preventing avoidable readmissions. Early post-discharge follow-up (ideally within 7 days), remote monitoring, and ongoing GDMT optimization are central to management during the high-risk vulnerable phase. Cardiac rehabilitation, timely evaluation for advanced therapies, and integration of palliative care complete the continuum of care. This consensus proposes a structured, patient-centered approach that bridges inpatient stabilization with longitudinal outpatient management to reduce rehospitalizations, improve clinical outcomes, and enhance quality of life for patients living with HF.
