Higher rates of successful decongestion with rapid up-titration of neurohormonal blockade in acute HF

Rapid up-titration of comprehensive neurohormonal blockade after heart failure hospitalization: Effects on decongestion and outcomes – An analysis of the STRONG-HF trial

Presented at the ESC Congress 2023 by: Piotr Ponikowski, MD, PhD - Wroclaw, Poland

Introduction and methods

The STRONG-HF trial previously showed that rapid uptitration of HF therapies with close follow-up of hospitalized acute HF patients who were ready to be discharged was associated with a reduction of HF hospital readmission or all-cause mortality, compared with usual care. The current analysis of the STRONG-HF trial investigated the relationship between intensive up-titration of neurohormonal blockade with beta-blockers, ACEi/ARB/ARNI and MRA, during early post-discharge on decongestion outcomes. SGLTi were not yet part of the standard treatment of HF at the time the study was designed and were therefore not included in the study protocol.

STRONG-HF included patients with acute HF ready to be discharged, with a pre-discharge NT-proBNP >1500 pg/ml and no or suboptimal dose of HF therapies. A total of 1800 patients were randomized in a 1:1 ratio to receive high intensity care or usual care. Patients in the high intensity care arm received half of optimal doses of HF therapy before discharge. Doses were uptitrated to full optimal doses in week 2. Safety visits took place in week 1, 2, 3 and 6.

Congestion was assessed using a congestion score, consisting of the sum of points gained for presence (1) or absence (0) of oedema, presence (1) or absence (0) of pulmonary rales, and jugular venous pressure <6 cm (0) or >6 cm (1). A score of 0 points was considered successful decongestion.

Main results

• 75% of patients in the high intensity care arm achieved successful decongestion at day 90 compared with 68% of patients in the usual care arm (P=0.0001).
• The benefits of the high intensity care strategy were apparent in all three component of congestion score.
• Patients in the high intensity care arm achieved a mean weight reduction of -1.36 kg (95%CI -1.92 to -0.79 kg).
• The mean daily doses of loop diuretics at day 90 was lower in the high intensity care group compared to the usual care group (mean [SD]: 52.8 [45.89] vs. 59.4 [56.07], P=0.038).
• NTproBNP change at day 90 was in favor of the high intensity care arm (usual care arm as reference, LS Mean difference in the high intensity care arm was 0.77, 95%CI 0.67-0.89, P=0.0003).
• The average percentage of optimal neurohormonal blockade dose at day 90 was inversely related to the congestion score at day 90. The higher the average percentage optimal dose, the lower (an thus the better) the congestion score.
• Compared to unsuccessful decongestion, successful decongestion was associated with a lower risk of 180-day HF readmission or death (aHR 0.40, 95%CI 0.27-0.59, P<0.0001), 180-day all-cause death (aHR 0.36, 95%CI 0.22-0.59, P<0.0001) and 180-day HF readmission (aHR 0.34, 95%CI 0.21-0.54, P<0.0001).

Conclusion

This analysis of the STRONG-HF trial showed that rapid up-titration of neurohormonal blockade (beta-blockers, ACEi/ARB/ARNI and MRA) was associated with higher rates of successful decongestion at day 90 compared with usual care. This was achieved despite lower daily doses of loop diuretics in the high intensity care group. Successful decongestion was associated with reduced risk of HF readmission and death compared with unsuccessful decongestion. “This is the first evidence that in patients with worsening HF, an intensive and comprehensive up-titration of neurohormonal blockade in the peri-discharge phase facilitates effective decongestion which may translate into better outcomes” said Piotr Ponikowski.

• Our reporting is based on the information provided at the ESC Congress 2023 -