Rapid uptitration of HF medication with close follow-up benefits hospitalized AHF patients
STRONG-HF: Successful Post-Discharge Management of Heart Failure
Presented at the AHA Scientific Sessions 2022 by: Alexandre Mebazaa, MD- Paris, France
Introduction and methods
After discharge following hospital admission for acute HF (AHF), patients should be followed up within 1–4 weeks, as recommended by the 2021 ESC Guidelines and 2022 ACC/AHA/HFSA guidelines. However, only few AHF patients are monitored or treated with full doses of HF medications. In the STRONG-HF (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) study, the efficacy and safety of rapid uptitration of oral HF therapies were therefore assessed.
In this RCT, 1800 AHF patients who were ready to be discharged from the hospital were scheduled for randomization to high-intensity care after discharge or usual care. Inclusion criteria were no or suboptimal doses of HF therapies and predischarge NT-proBNP >1500 pg/mL. Before discharge, patients in the high-intensity care arm received half of the optimal doses of 3 HF therapies (i.e., ACEi/ARB/ARNI plus beta-blocker plus MRA). At weeks 1, 2, 3, and 6, safety was assessed by clinical exam and laboratory testing (including NT-proBNP) in the high-intensity arm only. If there were no safety concerns at week 2, all 3 HF medications were uptitrated to the full optimal dose.
The primary endpoint was a composite outcome of HF hospital readmission or all-cause mortality after 180 days. The main secondary endpoint was patient’s quality of life as assessed with the EuroQol-5D (EQ-5D) visual analog scale (VAS). To evaluate safety, the incidence of treatment-emergent adverse events at day 90 was assessed.
On September 23, 2022, the study was terminated early by the Data and Safety Monitoring Board (at that time, 1069 patients were included) because of a larger than expected difference in the primary endpoint in favor of the high-intensity care group.
- At days 90 and 180, ~50% of the patients in the high-intensity care group were taking a full dose of an ACEi/ARB/ARNI, 50% were taking a full dose of a beta-blocker and >80% were on a full MRA dose, while a low percentage (<10%) of patients in usual care were taking full doses of ACEi/ARB/ARNI, a low percentage was taking a full dose of a beta-blocker and ~50-60% were on full dose of MRA.
- All parameters of congestion were improved in the high-intensity group at day 90 compared with the usual care group, for example body weight (adjusted treatment effect: –1.36; 95%CI: –1.91 to 0.80; P<0.0001), NYHA class (adjusted treatment effect: 1.36; 95%CI: 1.22–1.53; P<0.0001), grade of peripheral edema (adjusted treatment effect: 1.30; 95%CI: 1.17–1.44; P=0.0002), and NT-proBNP level (adjusted treatment effect: 0.77; 95%CI: 0.67–0.89; P=0.0003).
- In the high-intensity care group, there was a lower event rate of the primary endpoint (i.e., 180-day HF hospital readmission or all-cause mortality) compared with the usual care group (treatment effect for probability of event-free survival: 8.1%; 95%CI: 2.9–13.2; P=0.021).
- Stratification by subgroups (f.e., age, LVEF category, or baseline NT-proBNP level) showed primary endpoint results that were also mostly in favor of high-intensity care.
- The EQ-5D VAS score was higher in the high-intensity care group than in the usual care group (treatment effect: 3.5; 95%CI: 1.7–5.2; P<0.0001).
- The incidence rate of any adverse event was higher in the high-intensity arm than in the usual care arm (41.1% vs. 29.5%) , but the rates of any serious adverse event and any fatal serious adverse event were similar.
In the STRONG-HF trial, rapid uptitration of HF therapies with close follow-up of hospitalized AHF patients who were ready to be discharged was associated with a reduction of HF hospital readmission or all-cause mortality with usual care. This form of high-intensity care was safe and also improved patient’s quality of life.
- Our reporting is based on the information provided at the AHA Scientific Sessions -