Physicians' Academy for Cardiovascular Education

NT-proBNP does not influence beneficial effects of high-intensity care in hospitalized acute HF patients

NT-proBNP and high-intensity care for acute heart failure: the STRONG-HF trial

Literature - Adamo M, Pagnesi M, Mebazaa A, et al. - Eur Heart J. 2023 May 22;ehad335 [Online ahead of print]. doi: 10.1093/eurheartj/ehad335


The recently conducted STRONG-HF trial showed that a high-intensity care (HIC) strategy, consisting of rapid uptitration of guideline-recommended medical therapy (GRMT) and close follow-up, was associated with better outcomes after hospital admission for acute HF (AHF) compared with usual care [1-3]. In the prespecified subgroup analysis, there was a trend towards a larger benefit of HIC over usual care in patients with NT-proBNP levels above the median, although there was no significant interaction [1 ].

Aim of the study

Using data from the STRONG-HF trial, the authors examined the relation of baseline NT-proBNP levels with the efficacy of HIC versus usual care in hospitalized AHF patients and the prognostic significance of changes in NT-proBNP levels during follow-up in the HIC group.


The STRONG-HF (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) trial was a multicenter, open-label RCT in which 1078 patients hospitalized for AHF were enrolled who showed high NT-proBNP levels (>2500 pg/mL) at screening and a >10% decrease between screening and randomization (with NT-proBNP >1500 pg/mL before discharge). Within 2 days before the anticipated discharge date, participants were randomized to HIC or usual care.

Patients in the HIC group had follow-up visits at 1, 2, 3, and 6 weeks after randomization. In this group, oral doses of ACEi/ARB/ARNI, beta-blocker, and MRA were rapidly uptitrated to full optimal doses at week 2 if measures, including an NT-proBNP change, indicated it was safe to do so. In patients with an NT-proBNP increase >10% relative to the predischarge level, physicians were advised to consider increasing loop diuretic doses and not uptitrating beta-blockers. Baseline NT-proBNP concentrations were available for 1077 patients and follow-up data for 1007.


The primary endpoint was a composite outcome of all-cause mortality or first HF rehospitalization at 180 days. Secondary endpoints included, among others, all-cause mortality at 180 days.

Main results

Baseline NT-proBNP

Change in NT-proBNP during follow-up


In this analysis of the STRONG-HF trial, HIC reduced the rate of all-cause mortality or HF rehospitalization at 180 days (i.e., primary endpoint) in AHF patients compared with usual care, regardless of baseline NT-proBNP levels. In the HIC group, patients who showed increased NT-proBNP levels between randomization and 1 week thereafter were less likely to receive >50% GRMT target doses and were on higher loop diuretic doses compared with those with an NT-proBNP decrease. The early postdischarge NT-proBNP change was associated with a poorer outcome up at 60 and 90 days but not at 180 days.

The authors state the following: “Our analysis suggest[s] a new role for NT-proBNP measurements in the context of rapid uptitration of GRMT as they can alert the physician that the patient has persistent congestion and is not tolerating rapid GRMT uptitration [well], so that beta-blocker titration must be slowed or interrupted and/or higher diuretic doses must be administered.”


Show references

Find this article online at Eur Heart J.

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