Optimizing Pre- to Postdischarge Transition of Care in Patients Hospitalized for Heart Failure: Part 3 of the International Expert Opinion Series on Acute Heart Failure Management.

Hospitalization for heart failure (HF) represents a pivotal event in the disease course, often signaling decompensation and an elevated risk of readmission, mortality, and functional decline. Despite advances in inpatient management, the transition from hospital to home remains a vulnerable period characterized by residual congestion, incomplete implementation of guideline-directed medical therapy (GDMT), unmanaged comorbidities, and fragmented care coordination. This expert consensus provides a comprehensive, evidence-based framework to optimize the pre- to postdischarge transition in patients hospitalized with HF. Key priorities include confirmation of decongestion using biomarkers, lung ultrasound examination, and validated risk scores; in-hospital initiation and up-titration of foundational GDMT; and identification of reversible etiologies such as ischemic heart disease. Early evaluation for device therapy, arrhythmia management, including anticoagulation and rhythm control in atrial fibrillation, and structured management of comorbidities such as chronic kidney disease, diabetes, chronic obstructive pulmonary disease, iron deficiency, frailty, and depression are emphasized. Multidisciplinary collaboration across pharmacy, rehabilitation, mental health, and social services is essential to support safe discharge and continuity of care. Proactive strategies such as medication reconciliation, simplified dosing regimens, caregiver engagement, and attention to social determinants of health are critical to improving adherence and preventing avoidable readmissions. Early postdischarge follow-up (ideally within 7 days), remote monitoring, and ongoing GDMT optimization are central to management during the high-risk vulnerable phase. Cardiac rehabilitation, timely evaluation for advanced therapies, and integration of palliative care complete the continuum of care. This consensus proposes a structured, patient-centered approach that bridges inpatient stabilization with longitudinal outpatient management to decrease rehospitalizations, improve clinical outcomes, and enhance quality of life for patients living with HF.• Enhancing early outcomes: this document outlines practical strategies to ensure patients hospitalized with heart failure are discharged with appropriate therapy, clear instructions, and timely follow-up, thus reducing early readmission risk and improving recovery trajectories.• Addressing health equity: by recognizing the impact of social determinants and advocating for team-based, community-adaptable transitional care models, this framework aims to improve access and adherence among underserved and high-risk populations.• Sustaining guideline-directed therapy: emphasis on in-hospital initiation and structured outpatient follow-up supports long-term persistence with life-saving therapies and reinforces a continuity-of-care approach across health care settings.