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  • Review Article
  • Published:

The vulnerable phase after hospitalization for heart failure

Nature Reviews Cardiology volume 12, pages 220–229 (2015)Cite this article

Subjects

This article has been updated

Key Points

  • The early postdischarge phase after hospitalization for heart failure (HF) carries particularly high risk of poor outcomes and has been termed the vulnerable phase

  • Limited evidence suggests that patients hospitalized with HF, with or without early postdischarge adverse events, have distinct clinical profiles

  • No treatment has definitively reduced rates of early death and rehospitalization other than optimizing guideline-directed chronic HF therapies

  • Despite provision of all available therapy, many patients remain at substantial risk of poor postdischarge outcome

  • The current emphasis on generic transitional care hospital strategies to reduce readmissions is disproportionate to the quality of the supporting evidence and the cost that can be incurred

  • In addition to optimizing chronic HF therapies, a progressive management strategy includes aggressive treatment of congestion, treatment with digoxin, prioritizing postdischarge resources for high-risk patients, and optimal treatment of comorbidities

Abstract

Despite available therapy, mortality and readmission rates within 60–90 days of discharge for patients hospitalized with heart failure (HF) approach 15% and 30%, respectively. This early postdischarge period has been termed the 'vulnerable phase' and accounts for a disproportionate amount of the >US$30 billion spent annually on HF care in the USA. The pathophysiology underlying these early adverse events is likely associated with persistently elevated filling pressures at time of discharge and subsequent acute or subacute worsening of postdischarge haemodynamics. Despite limited proven strategies to reduce early adverse events, hospitals in the USA face penalties for 30-day readmission rates that exceed current expectations, and an urgent need exists for novel approaches to improve early postdischarge outcomes. The objective of this Review is to describe the early postdischarge problem among patients hospitalized for HF, the associated patient profile and pathophysiology, and the limitations of current postdischarge treatment strategies. We also identify therapeutic targets and outline a progressive management approach that should be considered by clinicians for reducing early postdischarge morbidity and mortality. Although these strategies require prospective validation, they are practical, affordable, and have the potential to improve patient outcomes substantially after HF hospitalization.

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Figure 1: Rehospitalization risk among patients hospitalized for heart failure.
Figure 2: Survival and hospitalization status from the EVEREST trial.
Figure 3: A mechanistic approach to treating patients hospitalized for heart failure.
Figure 4: Clinical trials to investigate therapies for HF.

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Change history

  • 18 February 2015

    In the version of this article initially published online, 'Rehospitalization' was misspelled in the title of Figure 1. The error has been corrected for the print, HTML, and PDF versions of the article.

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Authors and Affiliations

  1. Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 201 East Huron Street, Galter 3-150, Chicago, 60611, IL, USA

    Stephen J. Greene & Mihai Gheorghiade

  2. Ahmanson–UCLA Cardiomyopathy Center, Ronald Reagan–UCLA Medical Center, 10833 LeConte Avenue, Room 47-123 CHS, Los Angeles, 90095, CA, USA

    Gregg C. Fonarow

  3. Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 740, Boston, 02114, MA, USA

    Muthiah Vaduganathan

  4. Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 600, Chicago, 60611, IL, USA

    Sadiya S. Khan

  5. Division of Cardiology, Stony Brook University, 100 Nicolls Road, HSC T-16, Room 080, Stony Brook, 11794, NY, USA

    Javed Butler

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S.J.G. wrote the manuscript. All the authors researched data for the article, made substantial contribution to discussion of the content, reviewed, and edited the manuscript before submission.

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Correspondence to Mihai Gheorghiade.

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Competing interests

G.C.F. declares research support from the Agency for Healthcare Research and Quality and has been a consultant for Gambro, Medtronic, and Novartis. J.B. has received research support from the NIH, European Union, and Health Resources Service Administration, and is or has been a consultant for Amgen, Bayer, BG Medicine, Cardiocell, Celladon, Gambro, GE Healthcare, Medtronic, Novartis, Ono Pharma, Takeda, Trevena, and Zensun. M.G. is a consultant for Abbott Laboratories, Astellas, AstraZeneca, Bayer Schering Pharma AG, Cardiorentis, CorThera, Cytokinetics, CytoPherx Inc, DebioPharm SA, Errekappa Terapeutici, GlaxoSmithKline, Ikaria, Intersection Medical Inc, Johnson & Johnson, Medtronic, Merck, Novartis Pharma AG, Ono Pharmaceuticals USA, Otsuka Pharmaceuticals, Palatin Technologies, Pericor Therapeutics, Protein Design Laboratories, Sanofi-Aventis, Sigma Tau, Solvay Pharmaceuticals, Sticares InterACT, Takeda Pharmaceuticals North America, and Trevena Therapeutics. The other authors declare no competing interests.

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Greene, S., Fonarow, G., Vaduganathan, M. et al. The vulnerable phase after hospitalization for heart failure. Nat Rev Cardiol 12, 220–229 (2015). https://doi.org/10.1038/nrcardio.2015.14

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