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Review article: Biomedical intelligence

Vol. 150 No. 0506 (2020)

Roadmap for the treatment of heart failure patients after hospital discharge: an interdisciplinary consensus paper

  • Christian Mueller
  • Klaus Bally
  • Marc Buser
  • Andreas J. Flammer
  • Jean-Michel Gaspoz
  • François Mach
  • Giorgio Moschovitis
  • Matthias Paul
  • Andreas Zeller
  • Ellen Heitlinger
  • Bianca Fay
  • Thomas Rosemann
Cite this as:
Swiss Med Wkly. 2020;150:w20159


The transition period from the hospital to the outpatient setting is a critical phase when managing heart failure. A well-structured transition is paramount and helps to ensure a tight follow-up schedule for the heart failure patient, thereby improving treatment outcomes. This article aims to provide guidance for the first three follow-up visits after hospital discharge, with a focus on monitoring heart failure patients and up-titrating their medication in primary care.


  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al.; ESC Scientific Document Group. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(27):2129–200. doi:.
  2. Stewart S, Ekman I, Ekman T, Odén A, Rosengren A. Population impact of heart failure and the most common forms of cancer. Circ Cardiovasc Qual Outcomes. 2010;3(6):573–80. doi:.
  3. Muzzarelli S, Leibundgut G, Maeder MT, Rickli H, Handschin R, Gutmann M, et al.; TIME-CHF Investigators. Predictors of early readmission or death in elderly patients with heart failure. Am Heart J. 2010;160(2):308–14. doi:.
  4. Garnier A, Rouiller N, Gachoud D, Nachar C, Voirol P, Griesser AC, et al. Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: a before-and-after study. ESC Heart Fail. 2018;5(4):657–67. doi:.
  5. Ritter M, Laule-Kilian K, Klima T, Christ A, Christ M, Perruchoud A, et al. Gender differences in acute congestive heart failure. Swiss Med Wkly. 2006;136(19-20):311–7.
  6. Metra M, Gheorghiade M, Bonow RO, Dei Cas L. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation. 2010;122(18):1782–5. doi:.
  7. McDonagh TA, Blue L, Clark AL, Dahlström U, Ekman I, Lainscak M, et al.; European Society of Cardiology Heart Failure Association Committee on Patient Care. European Society of Cardiology Heart Failure Association Standards for delivering heart failure care. Eur J Heart Fail. 2011;13(3):235–41. doi:.
  8. Lee DS, Stukel TA, Austin PC, Alter DA, Schull MJ, You JJ, et al. Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation. 2010;122(18):1806–14. doi:.
  9. Coleman EA, Williams MV. Executing high-quality care transitions: a call to do it right. J Hosp Med. 2007;2(5):287–90. doi:.
  10. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–23. doi:.
  11. Workshop zum Spitalaustrittsmanagement des herzinsuffizienten Patienten (Organisation: Novartis). Luzern; 5 December 2018.
  12. Herzstiftung S. Internetplattform Schweizerische Herzstiftung 2019; Accessed 27 September 2019.
  13. Schweizerische Herzstiftung. Herztagebuch. Available at:[action]=detail&tx_nezzoshop_detail[categoryId]=62&tx_nezzoshop_detail[controller]=Product&tx_nezzoshop_detail[productId]=93&cHash=2cf3ca7e874b9d18e55758122bf971e6. Accessed February 2019.
  14. Stocker R, Close H, Hancock H, Hungin APS. Should heart failure be regarded as a terminal illness requiring palliative care? A study of heart failure patients’, carers’ and clinicians’ understanding of heart failure prognosis and its management. BMJ Support Palliat Care. 2017;7(4):464–9. doi:.
  15. Heart Failure Policy Network. The handbook of multidisciplinary and integrated heart failure care. 2018; Accessed 18 December 2018.
  16. Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). DEGAM Leitlinie Nr. 9. Herzinsuffizienz - Teil 1, no. 9. 2006; Accessed 18 December 2018.
  17. Coleman E. The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions. California Health Care Foundation. 2010. Available at: Accessed 18 December 2018.
  18. Santitätsbetrieb S. Klinischer Betreuungspfad für den Patienten mit Herzinsuffizienz. Available at: Accessed 18 December 2018.
  19. Nationale VersorgungsLeitlinie. Chronische Herzinsuffizienz Kurzfassung. 2013; Accessed 18 December 2018.
  20. Angermann CE, Störk S, Gelbrich G, Faller H, Jahns R, Frantz S, et al.; Competence Network Heart Failure. Mode of action and effects of standardized collaborative disease management on mortality and morbidity in patients with systolic heart failure: the Interdisciplinary Network for Heart Failure (INH) study. Circ Heart Fail. 2012;5(1):25–35. doi:.
  21. Güder G, Störk S, Gelbrich G, Brenner S, Deubner N, Morbach C, et al. Nurse-coordinated collaborative disease management improves the quality of guideline-recommended heart failure therapy, patient-reported outcomes, and left ventricular remodelling. Eur J Heart Fail. 2015;17(4):442–52. doi:.
  22. BAG CK. Referenzrahmen Selbstmanagement-Förderung bei chronischen Krankheiten und Sucht. Konzeptionelle Klärung, Umsetzungsbeispiel und strategische Emfpfehlungen 2018, Available at: Accessed 23 July 2019.
  23. Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010;8:CD007228. doi:.
  24. Rosemann A. Guidelines Herzinsuffizienz. Available at: Accessed 18 December 2018. 2014.
  25. Nicholls MG, Richards AM ; Christchurch Cardioendocrine Research Group. Disease monitoring of patients with chronic heart failure. Heart. 2007;93(4):519–23. doi:.
  26. Dunlay SM, Gheorghiade M, Reid KJ, Allen LA, Chan PS, Hauptman PJ, et al. Critical elements of clinical follow-up after hospital discharge for heart failure: insights from the EVEREST trial. Eur J Heart Fail. 2010;12(4):367–74. doi:.
  27. Arulnathan A, Vaaheesan S, Denecke K. A mobile application for self-monitoring for patients with heart failure. Healthcare of the Future. 2019:113–7.
  28. Maggioni AP, Anker SD, Dahlström U, Filippatos G, Ponikowski P, Zannad F, et al.; Heart Failure Association of the ESC. Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2013;15(10):1173–84. doi:.
  29. Martens P, Verbrugge FH, Boonen L, Nijst P, Dupont M, Mullens W. Value of routine investigations to predict loop diuretic down-titration success in stable heart failure. Int J Cardiol. 2018;250:171–5. doi:.
  30. Canadian Cardiovascular Society. Heart Failure Medication Initiation and Titration. Available at: Accessed 18 December 2018.
  31. Enalapril Helvepharm® Swiss Prescribing Information (Status April 2016). Available at: Acessed 23 January 2019.
  32. Lisinopril Axapharm® Swiss Prescribing Information (Status June2018). Available at: Acessed 18 December 2018.
  33. Ramipril® Swiss Prescribing Information (Status September 2016). Available at: Acessed 23 January 2019.
  34. Candesartan Sandoz® Swiss Prescribing Information (Status December 2015) Available at: Acessed 23 January 2019.
  35. Losartan Sandoz® Swiss Prescribing Information (Status June 2015). Available at: Acessed 23 January 2019.
  36. Diovan® Swiss Prescribing Information (Status September 2015). Available at: Acessed 23 January 2019.
  37. Entresto® Swiss Prescribing Information (Status April 2018). Available at: Acessed 23 January 2019.
  38. Concor® Swiss Prescribing Information (Status August 2018). Available at: Acessed 23 January 2019.
  39. Dilatrend® Swiss Prescribing Information (Status March 2015). Available at: Acessed 23 January 2019.
  40. Beloc Zok® Swiss Prescribing Information (Status March 2015). Available at: Acessed 23 January 2019.
  41. Nebilet® Swiss Prescribing Information (Status March 2015). Available at: Acessed 23 January 2019.
  42. Aldactone® Swiss Prescribing Information (Status December 2018). Available at: Acessed 23 January 2019.
  43. Inspra® Swiss Prescribing Information (Status October 2016). Available at: Acessed 23 January 2019.
  44. Coversum® Swiss Prescribing Information (Status March 2018). Available at: Acessed 24 January 2019.
  45. Hickey A, Suna J, Marquart L, Denaro C, Javorsky G, Munns A, et al. Improving medication titration in heart failure by embedding a structured medication titration plan. Int J Cardiol. 2016;224:99–106. doi:.
  46. Wagner EH, Groves T. Care for chronic diseases. BMJ. 2002;325(7370):913–4. doi:.
  47. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr, Colvin MM, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776–803. doi:.
  48. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr, Drazner MH, et al.; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147–239. doi:.

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