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Into the Dark HF Homepage
Into the Dark HF Homepage
Into the Dark HF Homepage
Into the Dark HF Homepage


FOR heart failure patients
post discharge1,2

Though clinical focus can stress the importance of the vulnerable period 90 days post discharge for heart failure (HF), the first 30 days is a critical time1,3,4

During this period, patients with HF face a journey fraught with risks.1,2 From high mortality and rehospitalization rates, to gaps in timely guideline-directed medical therapy (GDMT) initiation, and subpar transition of care, it is a time filled with dangerous uncertainty and darkness.1,2,5-9

Test your knowledge of the 30 days of risk

Unpack the first 30 days of risk1,2

And the risks continue to 90 days, and beyond3,15

Your patients
are at risk for

Some more than others16

Factors that

People with the greatest risk for readmissions for HF, including those readmitted within the first critical 30 days post discharge, often are16,17:

with multiple

(diabetes mellitus, chronic kidney disease [CKD], peripheral vascular disease, stroke)


From lower

Comorbidities can leave
patients at an even higher risk16

Patients with HF and comorbidities, such as type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), are at significantly higher risk of being rehospitalized during the critical 30 days post discharge when compared to patients with HF alone.16‑18

Type 2 diabetes mellitus

Compared to patients without T2DM, patients with both HF and T2DM had a significantly higher risk of being rehospitalized for HF or myocardial infarction at 30 days and 90 days post discharge.19

Chronic kidney disease

By the onset of stage 3, CKD is a significant contributor to poor prognosis in patients with HF, leading to significantly higher rates of hospitalization, 30-day readmissions, and mortality.20

See latest Guidelines to help keep your
patients out of the hospital6,21

The underuse of GDMT

Did you know GDMT is often not initiated early enough for many patients?6,9

The AHA/ACC/HFSA Joint Guidelines recommend initiating GDMT during hospitalization for patients with HF once hemodynamically stable.6

Additionally, the ESC recommends administering optimal medical therapy pre discharge for patients
with HF.4

Although initiation of therapy before discharge is critical to reduce risk of rehospitalization, more than 40% of patients do not receive GDMT even within 30 days after discharge.6,9

Help Keep your patients
out of the hospital longer6,21



The AHA/ACC/HFSA Joint Guidelines and the ESC Guidelines were updated to include SGLT inhibitors along with beta-blockers, MRAs, and ARNIs in the treatment
of HF.4,6

Early initiation of appropriate therapy was recommended across both guidelines.4,6

The AHA/ACC/HFSA Joint Guidelines advise in-hospital initiation of GDMT for HFrEF patients.6

The ESC Guidelines recommend administering optimal medical therapy prior to discharge.4

Get more familiar
with the current
HF guidelines


Both the AHA/ACC/HFSA Joint Guidelines and the ESC Guidelines

recommend the following for the treatment of HF4,6:

  • ACE=angiotensin-converting enzyme;
  • AHA/ACC/HFSA=American Heart Association/American College of Cardiology/Heart Failure Society of America;
  • ARB=angiotensin receptor blocker;
  • ESC=European Society of Cardiology;
  • ARNI=angiotensin receptor-neprilysin inhibitor;
  • SGLT=sodium-glucose cotransporter;
  • MRA=aldosterone receptor antagonist


  • Updated to recommend the use of SGLT inhibitors, regardless of ejection fraction, along with beta-blockers, MRAs, and ARNIs for patients with HF6
  • Recommended for initiation during hospitalization after clinical stability is achieved in patients with HFrEF6
  • Can be initiated simultaneously, or sequentially over several months, at initial recommended doses for patients with HFrEF6,27
  • Should reflect a clear plan for optimization—a key component of transitional care before discharge6
  • Can be beneficial in decreasing HF hospitalizations and CV death for patients with HF6

ARNI=angiotensin receptor-neprilysin inhibitor; CV=cardiovascular; GDMT=guideline-directed medical therapy; HF=heart failure; MRA=aldosterone receptor antagonist; SGLT=sodium-glucose cotransporter.

Test your knowledge of the 30-day Danger Zone post discharge


Tap into helpful resources regarding the 30-day danger zone post discharge and the treatment of HF

1. Khan MS, Sreenivasan J, Lateef N, et al. Trends in 30- and 90-day readmission rates for heart failure. Circ Heart Fail. 2021;14(4):450-458. doi: 10.1161/CIRCHEARTFAILURE.121.008335 2. Lin AH, Chin JC, Sicignano NM, Evans AM. Repeat hospitalizations predict mortality in patients with heart failure. Mil Med. 2017;182(9):e1932-e1937. doi: 10.7205/MILMED-D-17-00017 3. Greene SJ, Fonarow GC, Vaduganathan M, Khan SS, Butler J, Gheorghiade M. The vulnerable phase after hospitalization for heart failure. Nat Rev Cardiol. 2015;12(4):220-229. doi: 4. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2022;24(1):3599-3726. doi: 10.1093/eurheartj/ehab368 5. Bhagat AA, Greene SJ, Vaduganathan M, Fonarow GC, Butler J. Initiation, continuation, switching, and withdrawal of heart failure medical therapies during hospitalization. JACC Heart Fail. 2019;7(1):1-12. doi: 10.1016/j.jchf.2018.06.011 6. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines [published correction appears in Circulation. 2022 May 3;145(18):e1033]. Circulation. 2022;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063 7. Albert NM, Barnason S, Deswal A, et al. Transitions of care in heart failure: a scientific statement from the American Heart Association. Circ Heart Fail. 2015;8(2):384-409. doi: 10.1161/HHF.0000000000000006 8. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716-1722. doi: 10.1001/jama.2010.533 9. Deschaseaux C, McSharry M, Hudson E, Agrawal R, Turner SJ. Treatment initiation patterns, modifications, and medication adherence among newly diagnosed heart failure patients: a retrospective claims database analysis. J Manag Care Spec Pharm. 2016;22(5):561-571. doi:10.18553/jmcp.2016.22.5.561 10. DeVore AD, Hammill BG, Sharma PP, et al. In-hospital worsening heart failure and associations with mortality, readmission, and healthcare utilization. J Am Heart Assoc. 2014;3(4):1-11. doi: 10.1161/JAHA.114.001088 11. Patel J. Heart failure population health considerations. Am J Manag Care. 2021;27(9 Suppl):S191-S195. doi: 10.37765/ajmc.2021.88673 12. Warraich HJ, Kitzman DW, Whellan DJ, et al. Physical function, frailty, cognition, depression, and quality of life in hospitalized adults ≥60 years with acute decompensated heart failure with preserved versus reduced ejection fraction. Circ Heart Fail. 2018;11(11):1-11. doi: 10.1161/CIRCHEARTFAILURE.118.005254 13. Pastva AM, Hugenschmidt CE, Kitzman DW, et al. Cognition, physical function, and quality of life in older patients with acute decompensated heart failure. J Card Fail. 2021;27(3):286-294. doi: 10.1016/j.cardfail.2020.09.007 14. Fuentes-Abolafio IJ, Stubbs B, Pérez-Belmonte LM, Bernal-López MR, Gómez-Huelgas R, Cuesta-Vargas AI. Physical functional performance and prognosis in patients with heart failure: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2020;20(1):1-23. doi: 15. McCullough PA, Mehta HS, Barker CM, et al. Mortality and guideline-directed medical therapy in real-world heart failure patients with reduced ejection fraction. Clin Cardiol. 2021;44(9):1192-1198. doi: 10.1002/clc.23664 16. Chamberlain RS, Sond J, Mahendraraj K, Lau CS, Siracuse BL. Determining 30-day readmission risk for heart failure patients: the Readmission After Heart Failure scale. Int J Gen Med. 2018;11:127-141. doi: 1.2147/IJGM.S150676 17. Bansal N, Zelnick L, Bhat Z, et al. Burden and outcomes of heart failure hospitalizations in adults with chronic kidney disease. J Am Coll Cardiol. 2019;73(21):2691-2700. doi: 18. Enomoto LM, Shrestha DP, Rosenthal MB, Hollenbeak CS, Gabbay RA. Risk factors associated with 30-day readmission and length of stay in patients with type 2 diabetes. J Diabetes Complications. 2017;31(1):122-127. doi: 19. Thyagaturu HS, Bolton AR, Li S, Kumar A, Shah KR, Katz D. Effect of diabetes mellitus on 30 and 90-day readmissions of patients with heart failure. Am J Cardiol. 2021;155:78-85. doi: 20. Hakopian NN, Gharibian D, Nashed MM. Prognostic impact of chronic kidney disease in patients with heart failure. Perm J. 2019;23(4):1-7. doi: 21. Alsamman M, Zayas Zuazaga D, Komanduri K, Prashad R, Cintron C, Vickery KNP. Factors influencing thirty-day readmission rate in patients with heart failure exacerbation. Cardiol Res. 2022;13(4):206-217. doi: 22. Vaduganathan M, Claggett BL, Jhund PS, et al. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: a comparative analysis of three randomized controlled trials. Lancet. 2020;396(10244):121-128. doi: 23. Fonarow GC, Abraham WT, Albert NM, et al. Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program. J Am Coll Cardiol. 2008;52(3):190-199. doi:10.1016/j.jacc.2008.03.048 24. Curtis LH, Mi X, Qualls LG, et al. Transitional adherence and persistence in the use of aldosterone antagonist therapy in patients with heart failure. Am Heart J. 2013;165(6):979-986. doi:10.1016/j.ahj.2013.03.007 25. Cornelio C, Di Palo K. Guideline-directed medical therapy in hospitalized heart failure patients: still underprescribed despite updated guidelines and over 20 years of evidence. J Card Fail. 2018;24(8S):S100. doi: 26. Fitchett D, Butler J, van de Borne P, et al. Effects of empagliflozin on risk for cardiovascular death and heart failure hospitalization across the spectrum of heart failure risk in the EMPA-REG OUTCOME® trial. Eur Heart J. 2018;39(5):363-370. doi: 10.1093/eurheartj/ehx519 27. Khan MS, Butler J, Greene SJ. Simultaneous or rapid sequence initiation of medical therapies for heart failure: seeking to avoid the case of 'too little, too late'. Eur J Heart Fail. 2021;23(9):1514-1517. doi: 10.1002/ejhf.2311