The session “Bless Your Heart—Update in Heart Failure” provided a high-yield, evidence-based review of recent trials and evolving strategies in the management of heart failure (HF), with a focus on practical applications for hospitalists. The presentation emphasized optimizing inpatient care, refining procedural decision making, and leveraging newer pharmacologic and preventive strategies to improve outcomes.
One of the first topics addressed was the role of thoracentesis in patients with heart failure and pleural effusions. The TAP-IT trial evaluated whether routine thoracentesis for non-negligible pleural effusions improves clinical outcomes. While thoracentesis has traditionally been used both diagnostically and therapeutically, this randomized controlled trial demonstrated that routine use did not improve key outcomes, including days alive outside the hospital over 90 days, length of stay, or all-cause mortality. Importantly, the procedure was shown to be safe, but without a clear benefit in routine cases. For hospitalists, this reinforces a more selective approach—reserving thoracentesis for diagnostic uncertainty or for cases where symptoms are clearly attributable to large effusions, rather than using it as a standard adjunct to decongestion.
The session then explored an emerging strategy to enhance diuresis: the use of hypertonic saline in combination with loop diuretics. This approach is based on the concept of “priming” the kidneys to improve diuretic responsiveness, particularly in patients with diuretic resistance. A meta-analysis involving approximately 3,500 patients across Veterans Affairs hospitals compared loop diuretics alone versus diuretics plus hypertonic saline. Results suggested that combination therapy improved renal function (as evidenced by lower creatinine), reduced B-type natriuretic peptide levels, promoted greater weight loss, and shortened hospital length of stay. However, the analysis was limited by significant heterogeneity and a lack of standardized dosing protocols. Additionally, benefits were not observed immediately and often required four to six days to become evident. There was also no clear evidence for reductions in mortality or readmissions. While promising, this strategy remains practice-dependent and highlights the need for further prospective trials before widespread adoption.
A major pharmacologic update focused on the use of mineralocorticoid receptor antagonists, specifically finerenone, in patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF). The FINEARTS-HF trial examined the timing of finerenone initiation relative to recent worsening heart failure (WHF) events. These events included hospitalizations, urgent visits, or outpatient intensification of diuretics. The study demonstrated that patients who were started on finerenone within three months of a WHF event experienced a greater reduction in subsequent HF events and cardiovascular death compared to those with delayed initiation. Notably, patients with recent WHF represent a high-risk population with increased rates of hospitalization and mortality, yet they also derive the greatest benefit from early intervention. These findings support early initiation of finerenone in appropriate patients, particularly in the post-decompensation period, as part of a comprehensive HF management strategy.
Another critical area discussed was the optimization of guideline-directed medical therapy (GDMT) during hospitalization for acute decompensated heart failure. The STRONG-HF trial provided compelling evidence for a “high-intensity, rapid initiation” approach to GDMT. Traditionally, clinicians have taken a more gradual approach to initiating and uptitrating HF medications. However, this trial demonstrated that starting all four pillars of HF therapy—angiotensin receptor-neprilysin inhibitor, or ARNI, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor—prior to discharge, followed by rapid uptitration to target doses within two weeks, resulted in significantly improved outcomes. Patients in the high-intensity care group had better decongestion, lower N-terminal pro-B-type natriuretic peptide levels, and reduced rates of HF readmission and all-cause mortality at 180 days.
An important nuance from the STRONG-HF trial is the central role of effective decongestion. Regardless of treatment strategy, patients who achieved successful decongestion at 90 days had better outcomes overall. However, even among those with incomplete decongestion, the high-intensity GDMT group still performed better than the usual care group. This suggests that aggressive neurohormonal blockade provides benefit beyond volume management alone. For hospitalists, this reinforces the importance of initiating and titrating GDMT early during hospitalization rather than deferring to outpatient follow-up.
The final topic addressed preventive care, specifically the role of influenza vaccination in patients hospitalized with heart failure. The PANDA II trial evaluated whether administering the flu vaccine prior to discharge improves outcomes compared to advising patients to obtain vaccination in the community. The results were striking: In patients with more advanced HF (NYHA class III–IV), in-hospital vaccination was associated with a significant reduction in all-cause mortality at 12 months, with a number needed to treat of 17. Additionally, vaccination reduced the likelihood of readmission and was associated with fewer adverse events. Despite these benefits, vaccination rates in this population remain suboptimal. This study highlights a simple, low-cost intervention that can be readily implemented during hospitalization to improve long-term outcomes.
Overall, this session emphasized a shift toward more intentional, evidence-driven inpatient management of heart failure. Key themes included avoiding low-value interventions, such as routine thoracentesis; exploring novel adjunctive therapies like hypertonic saline; initiating disease-modifying therapies earlier and more aggressively; and capitalizing on hospitalization as an opportunity for preventive care. For hospitalists, these updates underscore the importance of integrating new evidence into clinical workflows to optimize both short- and long-term outcomes for patients with heart failure.
Dr. Beshay
Dr. Beshay is an assistant professor of medicine and assistant director of education at Emory St. Joseph’s Hospital in Atlanta.