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diastolic pressure and pulmonary congestion. In these cases, LV unloading is mandatory and can be achieved by means of transeptal/ ventricular apex vent or adding an unloading device such as the Impella device.510,511

11.3.11 Pre-discharge assessment and post-discharge management planning A significant proportion of patients with AHF are discharged with minimal or no weight loss and, more importantly, persistent congestion.427,472 Persistent congestion before discharge is associated with a higher risk of readmission and mortality.426,472 Treatment, including diuretic dose, should therefore be optimized in order to keep the patient free of congestion. In those admitted with ADHF, oral OMT should be continued, except for possible dose reduction or withdrawal if there is haemodynamic instability (symptomatic hypotension), severely impaired renal function or hyperkalaemia. Once haemodynamic stabilization is achieved with i.v. therapy, treatment should be optimized before discharge.467 Treatment optimization has three major aims. First, to relieve congestion. Second, to treat comorbidities, such as iron deficiency, that have an impact on post-discharge outcome.512 Third, to initiate, or restart oral, OMT with beneficial effects on outcome. Doses may be uptitrated before discharge and/or in the early postdischarge phase. Studies have shown that such optimization of medical treatment is associated with a lower risk of 30-day readmission, although prospective randomized trials have not been performed, to date.103,467,513 Retrospective analyses show that discontinuation or dose reduction of beta-blocker therapy during an AHF hospitalization is associated with worse outcomes.514 Initiation of ARNI in recently hospitalized stable patients with HFrEF, including those who are ACE-I/ARB naı ̈ve, is safe and may be considered in this setting.106,107 Safety and better outcome have also been recently shown in a prospective randomized trial with sotagliflozin in diabetic patients hospitalized for HF, irrespective of their LVEF.136 It is recommended to have one follow-up visit within 1 to 2 weeks after discharge.515,516 Components of this follow-up visit should include monitoring of signs and symptoms of HF, assessment of volume status, BP, heart rate, and laboratory measurements including renal function, electrolytes, and possibly NPs. Iron status and hepatic function should also be assessed when not done before discharge. Based on clinical evaluation and laboratory exams, further optimization and/or initiation of disease-modifying treatment for HFrEF should occur. Retrospective studies show that such an approach is associated with lower 30-day readmission rates although prospective randomized trials have not been performed, to date.513,516518

12 Cardiovascular comorbidities

12.1 Arrhythmias and conduction

disturbances 12.1.1 Atrial fibrillation AF and HF frequently coexist.519,520 They can cause or exacerbate each other through mechanisms such as structural cardiac remodelling, activation of neurohormonal systems, and rate-related LV impairment.519523 The proportion of patients with HF who develop AF increases with age and HF severity. When AF causes HF the clinical course seems more favourable than with other causes of HF (so called tachycardiomyopathy).524 In contrast, development of AF in patients with chronic HF is associated with worse prognosis, including stroke and increased mortality.525,526

The management of patients with concomitant HF and AF is summarized in Figure 14.7,521 It includes:

(1) Identification and treatment of possible causes or triggers of AF (2) Management of HF (3) Prevention of embolic events (4) Rate control (5) Rhythm control

Identification of triggers and management of heart failure Potential causes or precipitating factors such as hyperthyroidism, electrolyte disorders, uncontrolled hypertension, mitral valve disease, and infection should be identified and corrected. Worsening congestion due to AF should be managed with diuretics. Congestion relief may reduce sympathetic drive and ventricular rate and increase the chance of spontaneous return to SR. The presence of AF may reduce or abolish the prognostic benefits of beta-blockers and renders ivabradine ineffective.12,125 Some treatments for HF decrease the risk of developing AF, including ACE-I, slightly, and CRT, probably.7,527

Prevention of embolic events Unless contraindicated, an oral, long-term anticoagulant is recommended in all patients with HF and paroxysmal, persistent, or permanent AF. Direct-acting oral anticoagulants (DOACs) are preferred

Recommendations for pre-discharge and early post-discharge follow-up of patients hospitalized for acute heart failure

Recommendations Classa Levelb

It is recommended that patients hospitalized for HF be carefully evaluated to exclude persistent signs of congestion before discharge and to optimize oral treatment.427,472 I C It is recommended that evidence-based oral medical treatment be administered before discharge.103,513 I C An early follow-up visit is recommended at 12 weeks after discharge to assess signs of congestion, drug tolerance and start and/or uptitrate evidence-based therapy.517,518 I C Ferric carboxymaltose should be considered for iron deficiency, defined as serum ferritin <100 ng/mL or serum ferritin 100299 ng/mL with TSAT <20%, to improve symptoms and reduce rehospitalizations.512 IIa B

HR = heart failure; TSAT = transferrin saturation. aClass of recommendation. bLevel of evidence. ESC 2021

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