Getting to Dry

Abstract

Article, see p 1671 Heart failure (HF) hospitalization presents a substantial burden to patients, hospitals, and payors. Hospitals face competing incentives from government payors because prolonged lengths of stay risk unreimbursed costs beyond the fixed reimbursement, whereas premature discharge increases the risk of 30-day readmission, for which hospitals can be penalized on a much broader scale. Clinicians have struggled to define the objective criteria regarding readiness for discharge from a HF hospitalization, which should address not only relief of congestion, but also evaluation of etiology, enhancement of guideline-directed therapies, review of disease trajectory, and consolidation of outpatient management. Once gaps in the transition process have been closed, the major cause of readmission is recurrent congestion. Regardless of how congestion is documented,1–3 patients who go home “wet” are likely to return “wetter”. Quality improvement and cost containment efforts are converging to design care pathways that begin early during hospitalization to ensure adequate decongestion by discharge. Employment of brain natriuretic peptide (BNP) levels as targets for therapy arose naturally from the robust predictive value of BNP levels and changes in levels, further supported by their close relationship with elevated cardiac filling pressures4,5 and recognized as a hemodynamic determinant of outcomes. Utility of a biomarker as a target for therapy requires not only clinical relevance, but also timely responsiveness to the therapy titration, and unique information beyond usual clinical assessments. Multiple trials have used natriuretic peptides as targets for adjustment of chronic outpatient therapy with neurohormonal antagonists6–10 (Figure). When uptitration was aggressive in response to persistently high levels of natriuretic peptides, outcomes were better than without such uptitration.9 However, when the design encouraged vigorous …