Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age

Abstract

This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.

Keywords: comorbidity; elderly; geriatric; readmissions; translating guidelines; translational research.

Figure 1.

Natural history of heart failure (HF). Diagram demonstrates a 3-phase process once HF is diagnosed. The natural history of HF is chronological progression of left ventricular remodeling, manifesting with symptoms, physical morbidity, and early death. HF readmissions, presenting as acute decompensation, have greatest risks in the transition and palliative phases. The transition forward to more advanced phases is influenced by rate of recovery and normalization of LV function in correlation to the starting point of prior screening (black arrow), early treatment (blue arrow), and through its natural history (read arrow), and the type of cardiomyopathy, energetic defects > toxins > inflammatory causes. The slope of the arrows highlights the trajectory and prolongations toward death. Terminology: (1) Normalization of LV function, defined as an EF ⩾50%; (2) recovery of LV function, defined as an improvement in LF ejection fraction from 5% to 15 %; normalization occurs less frequently than recovery of LV function. Image modified from Fonarow et al.^,,

Figure 2.

Models for closing the gap. To address an outcome measure such as readmission requires arms of the health systems, which are often compartmentalized into silos, to overlap with common purpose. In answering, 5 key areas should be addressed: (1) defining the health jurisdiction from which most of the clients reside, (2) engagement of that community and its primary health infrastructure, (3) investing in technology to bring the gaps and address resource issues, (4) equipped for internal audits and aligning with partners to engage novel research, and (5) delivering these services at an acceptable cost.