1. Post-discharge is a vulnerable phase for heart failure patients

2. “Hospitalized heart failure is associated with unacceptable high post-discharge mortality and rehospitalization rate” 1 REFERENCES------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1-Gheorghiade M, Shah AN, Vaduganathan M, et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes academics’, clinicians’, industry’s, regulators’, and payers’ perspectives. Heart Failure Clin. 2013;9:285-290. 2-Joynt KE, Jha AK. Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circ Cardiovasc Qual Outcomes. 2011;4:53-59. 3-Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS. Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circ Heart Fail. May 2, 2012. doi 10.1161/ CIRCHEARTFAILURE.111.964791. http://circheartfailure.ahajournals.org. Accessed April 19, 2012. 4-Krumholz HM. Post-hospital syndrome – an acquired, transient condition of generalized risk. N Engl J Med. 2013;368;100-102. 5-Marti CN, Fonarow GC, Gheorghiade M, Butler J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101.  Several recent publications 1-5 discuss important issues on hospitalized heart failure patients who have unacceptably high post-discharge mortality and rehospitalization rates. A high event rate despite all available therapies makes this topic a health care priority in terms of patient well-being and expenditure.  With the aging of the population and an ever-increasing burden of disease, the cumulative incidence and prevalence of heart failure requiring hospitalization have evolved into epidemic proportions. The costs associated with hospitalized heart failure have added demands from society, government, and payers to improve outcomes.

3. Mortality is particularly high in the early phase after hospitalization ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1-Marti NC, Fonarow GC, Gheorghiade M, Bulter J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail 2013;6:1095-1101 All-cause mortality after discharge for HF is high at the 1 st month 1 Changes in risk profile after hospitalization. Hasard ratio of all-cause mortality after discharge from hospital for first hospitalization for heart failure

4. Rehospitalization is particularly high in the early phase after hospitalization 1 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1-Gheorghiade M, Shah AN, Vaduganathan M, et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes academics’, clinicians’, industry’s, regulators’, and payers’ perspectives. Heart Failure Clin. 2013;9:285-290. 2-Marti NC, Fonarow GC, Gheorghiade M, Butler J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101. 3-Joynt KE, Jha AK. Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circ Cardiovasc Qual Outcomes. 2011;4:53-59. 4-Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS. Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circ Heart Fail. May 2, 2012. doi 10.1161/ CIRCHEARTFAILURE.111.964791. http://circheartfailure.ahajournals.org. Accessed April 19, 2012. 30 days from discharge 1 1 patient out of 4 is readmitted 1-2 1 1 patient out of 2 is readmitted 3-4 6 months from discharge

5. Weeks to months post-discharge at high risk may be viewed as a “vulnerable phase” 1,2 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1-Krumholz HM. Post-hospital syndrome – an acquired, transient condition of generalized risk. N Engl J Med. 2013;368;100-102. 2-Marti NC, Fonarow GC, Gheorghiade M, Butler J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101.  The post-discharge period is described as an “acquired, transient condition of generalized risk” or “a period of vulnerability”. 1  Comprehensive strategies should focus on factors during hospitalization and also during the early recovery period soon after discharge to target stressors that probably contribute to the vulnerability of patients. 1,2

6. Initiating therapy during hospitalization is suggested to reduce the risk of adverse outcomes 1-2  At discharge, patients can be considered to be in a stable chronic heart failure state at high risk for adverse outcomes. 1 -2   “Initiating therapies in patients who are stabilized in the hospital and continued long-term provides a potent option to improve long-term clinical outcomes.” 1   “Delaying initiation of potentially effective therapies for weeks to months post discharge risks unabated high risk for adverse events in the meantime.” 1 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1-Gheorghiade M, Shah AN, Vaduganathan M, et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes academics’, clinicians’, industry’s, regulators’, and payers’ perspectives. Heart Failure Clin. 2013;9:285-290. 2-Marti NC, Fonarow GC, Gheorghiade M, Butler J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101.