Prevention of readmission in the acute setting for heart failure patients: an adapted protocol of levosimendan infusion in inpatient high-intensity cardiac rehabilitation

Abstract Introduction Heart failure is a systemic disorder often endemic in older and frail patients, associated with increased long-term mortality, reduced health-related quality of life and greater likelihood of hospital readmission. Intensive care stay worsens the risk of cognitive dysfunction, depressive and anxiety symptoms and pressure injuries and lead to an increased risk of critical illness myopathy and polyneuropathy. Derangement of thyroid homeostasis, sexual function and difficulty with feeding and nutrition are common among patients hospitalized for heart failure in the acute setting. High intensity cardiac rehabilitation can be the ideal setting to stabilize heart failure patients early discharged from the acute setting, avoiding a "come-back" phenomenon and providing an integrated support of advanced medical care, physiotherapist support, psychological counselling, nutritional tailored prescription and nurse assistance. Purpose To provide a pilot adapted protocol of levosimendan infusion in patients with heart failure early admitted to a high intensity cardiac rehabilitation setting. Methods Six patients early discharged from the acute setting after a hospitalization for acute heart failure and admitted to an intensity cardiac rehabilitation were treated with an adapted protocol of levosimendan infusion. All patients were in a SCAI B class according to the updated Society for Cardiovascular Angiography and Intervention classification; two patients were on dopamine continuous infusion. A midline catheter was placed before the infusion was started. Levosimendan was administrated starting at 0.02 mcg/Kg/min and titrated at 0.04 mcg/Kg/min over 5-6 days. During the levosimendan infusion, the patients were managed with continuous positive airway pressure (CPAP) with careful mask fitting. An interval training excercise adapted to the hemodynamic status was performed. Results All the patients were weaned from the inotropic support and started titration of medical treatment for heart failure. One patient was discharged with a palliative support. Nutritional and psychological counselling were constantly delivered. All patients were assessed for long-term CPAP prescription. Readmission in the acute setting was avoided in all except one patient; patient’s empowerment, education and self-confidence were the major achievements measured by the psychological assessment, along with caregiver awareness. Conclusions The care continuum is the key of the heart failure patient’s trajectory. In this perspective, an adapted protocol of levosimendan infusion in a high-intensity cardiac rehabilitation may be effective and safe. Nevertheless, inadequate national reimbursement practices and policy frameworks based on different quality indicators among the acute and post-acute setting are the major limitations to improve the patient’s outcome. A call to action is required to improve the heart failure patient’s trajectory across Europe.