Refining early post-discharge management in acute heart failure using an international delphi consensus

Abstract

Early intensive optimisation of guideline-directed medical therapy after hospitalisation for acute heart failure (HF) reduces morbidity and mortality. However, real-world implementation remains heterogeneous, particularly in complex or under-represented patient groups. Uncertainty persists regarding treatment sequencing, safety limits, and follow-up intensity after discharge.

To quantify international expert consensus on early post-discharge management of acute HF and identify areas of agreement and uncertainty across complex clinical scenarios.

A multinational Delphi consensus process was conducted between December 2024 and August 2025, involving 45 HF specialists from 32 countries. Eighteen representative acute heart failure cases were developed reflecting diverse phenotypes, comorbidities, and risk profiles. Experts anonymously reassessed predefined clinical scenarios across three iterative rounds, focusing on treatment initiation, up-titration, or withholding at discharge and 2-week follow-up. Consensus was predefined as strong (≥75%), moderate (59–74%), or none (<59%). Only strong consensus findings were reported. Patient archetypes were clustered according to guideline recommendations, prescribing information, and protocol adherence, and compared using established risk and comorbidity scores.

Across all scenarios, strong consensus supported systematic reassessment of clinical status and laboratory parameters before discharge and at 2 weeks. Biomarker-guided evaluation informed treatment decisions in more than 95% of cases. At each timepoint, patients were classified into four implementation clusters: full optimisation, near-complete optimisation, minimal optimisation, and misuse. At discharge, one-third of cases achieved full optimisation, while misuse remained frequent, mainly driven by haemodynamic constraints or dosing errors. At 2 weeks, overall optimisation improved, with nearly two-thirds of cases reaching full or near-complete implementation. Misuse declined, and treatment intensification progressed alongside uniform adoption of sodium–glucose cotransporter inhibition. Among evaluated risk tools, comorbidity- and prognosis-based scores best discriminated between implementation clusters. Of 144 decision points, most achieved strong consensus. Moderate consensus primarily involved treatment choices in patients with multiple comorbidities or borderline haemodynamics. No dissensus was observed at discharge, and limited dissensus at follow-up reflected differing safety perceptions rather than disagreement with treatment principles.

This international Delphi consensus demonstrates that early post-discharge optimisation of HF therapy is considered feasible and safe across diverse real-world scenarios. Variability persists in complex subgroups. The identified implementation archetypes provide a pragmatic framework to support individualised care and inform future implementation strategies bridging evidence and clinical practice.