Journal of CardioVascular Insights

Abstract

The transition phase after hospital discharge for acute heart failure represents a vulnerable period that requires careful management to optimize guideline-directed medical therapy (GDMT) and reduce the risk of early adverse events. For this reason, we planned a 30-day post-discharge follow-up including weekly tele-visits and the assessment of biohumoral and heart–lung ultrasound parameters at discharge (T1) and after 4 weeks of post-hospitalization (T5).

The Kansas City Cardiomyopathy Questionnaire (KCCQ), a structured clinical monitoring form, a heart-lung point-of-care ultrasound (HLPOCUs) diagram, and a dedicated database were used to support therapy titration and to record prognostic parameters.

Four weeks after discharge, the proportion of patients receiving GDMT increased (T0 vs T5: ARNI 22 vs 80%, beta-blockers 63 vs 92%, MRA 40 vs 96%, SGLT2i 24 vs 100%). Clinical signs of heart failure resolved, and echocardiographic parameters of systolic and diastolic function as well as pulmonary congestion showed consistent improvement (T0 vs T5: EF 32 vs 47%, p=0.000; E/e’ 21 vs 14, p=0.013; indexed LA volume 56 vs 45 ml/m², p=0.008; PAPS 39 vs 25 mmHg, p=0.001; IVC diameter 17 vs 11 mm, p=0.000; B-lines/8 zones 17 vs 4, p=0.000). Biohumoral markers also decreased (BNP 1141 vs 420 pg/ml, p=0.009; CA-125 101 vs 15 U/ml, p=0.012). Quality of life improved as assessed by the KCCQ score (55 vs 86, p=0.000). A reduction in emergency department visits and hospitalizations for heart failure was observed during short-term follow-up. In conclusion, a structured telemedicine-supported transitional care pathway appears feasible in the post-hospitalization phase after acute heart failure and may support optimization of therapy and short-term clinical stability.