Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts

Abstract

Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.

Keywords: acute; decompensation; heart failure; treatment; vulnerable period.

Figure 1

Evaluation of congestive symptoms. HF, heart failure.

Figure 2

Diuretic adjustment during acute HF episode.^{a a}The use of loop diuretics should be limited to the control of congestion. ^bIf the patient is already taking mineralocorticoid receptor antagonists (MRAs) and no marked deterioration of renal function or hyperkalaemia is observed, maintain MRA treatment. ^cConsider the introduction of MRAs in case of naive patients (or uptitration of MRA dosage if already taking) to increase diuresis. ^dConsider the introduction of MRAs in case of naive patients when reduction of loop diuretics dose starts, in patients without marked deterioration of renal function or hyperkalaemia.

Figure 3

Checklist in pre-discharge and early follow-up of patients with HF. ACEI, angiotensin-converting enzyme inhibitors; ARNI, angiotensin receptor-neprilysin inhibitor; BB, beta-blocker; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium–glucose cotransporter 2 inhibitors.

Figure 4

Comprehensive strategy for evaluation and management of patients with heart failure during the vulnerable period. CCT, cardiac computed tomography; CV, cardiovascular; DMHFD, disease-modifying HF drugs; EQ-5D, EuroQol-5D; HF, heart failure; KCCQ, Kansas City Cardiomyopathy Questionnaire; MLHFQ, Minnesota Living-With-Heart-Failure Questionnaire; MRI, magnetic resonance imaging; NM, nuclear medicine.