Anemia prevalence and effects of rapid GDMT uptitration in acute HF

A STRONG-HF analysis showed 27% of the acute HF patients had anemia at hospital admission. Still, the presence of anemia at baseline did not affect the efficacy and safety of high-intensity HF therapy post-discharge.

This summary is based on the publication of Čelutkienė J, Čerlinskaitė-Bajorė K, Cotter G, et al. - Insights on prevalence and incidence of anemia and rapid up-titration of oral heart failure treatment from the STRONG-HF study. Clin Res Cardiol. 2024 Nov;113(11):1589-1603. doi: 10.1007/s00392-024-02518-y

Introduction and methods

Background

In patients hospitalized for acute HF (AHF), rapid uptitration of GDMTs with close follow-up reduced all-cause mortality or hospital readmission for HF and improved quality of life compared with usual care, as was recently shown in the STRONG-HF (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) study [1]. However, anemia is a common comorbidity in HF patients [2], and neurohormonal blockers can alter hemoglobin levels [3-5].

Aim of the study

In an analysis of the STRONG-HF study, the authors assessed the prevalence of anemia and changes therein, the association of anemia with clinical outcomes, and the possible interaction between anemia and the efficacy and safety of high-intensity HF therapy.

Methods

The STRONG-HF trial was an international, multicenter, open-label, parallel-group RCT in which 1078 patients admitted to the hospital for AHF were randomized ≤2 days before the anticipated discharge to high-intensity care (HIC) or usual care. The HIC strategy comprised uptitration of oral HF medications (RAASi (ACEi/ARB/ARNI), beta-blocker, and MRA) to half optimal doses at randomization and to full doses at 2 weeks. In addition, these patients had follow-up visits with comprehensive evaluation at 1, 2, 3, and 6 weeks post-discharge. The current analysis comprised 1077 patients. Anemia was defined as baseline hemoglobin <120 g/L in women and <130 g/L in men.

Outcomes

The study’s primary endpoint was a composite outcome of HF hospital readmission or all-cause mortality at 180 days. Secondary endpoints were all-cause mortality at 180 days; a composite outcome of HF hospital readmission or all-cause mortality at 90 days; and change in quality of life as assessed with the EuroQol-5D visual analog scale (EQ-VAS) score from baseline to 90 days.

Main results

Anemia at baseline and association with clinical outcomes

• At enrollment, 27.2% of the study participants had anemia, whereas the prevalence at 90 days was 32.1%.
• In the total study population, the primary composite endpoint occurred in 18.2% of the patients with no anemia at baseline (n=737) and 22.5% of those who did have baseline anemia (n=270) (unadjusted HR: 1.27; 95%CI: 0.90–1.80; P=0.1737).
• After adjustment for diastolic blood pressure, ischemic heart disease, edema severity, and NT-proBNP levels at baseline, the incidence of the primary composite endpoint still did not differ between the 2 treatment groups (adjusted HR: 1.22; 95%CI: 0.86–1.72; P=0.2757).
• Patients with baseline anemia showed significantly less improvement in the EQ-VAS score from baseline to 90 days than those with no anemia (adjusted least-squares mean difference: –2.34; 95%CI: –4.37 to –0.31; P=0.024).

Anemia during follow-up

• At 90 days, 19.4% of the patients in the HIC group developed anemia, compared with 14.6% in the usual-care group (P>0.05).
• In contrast, recovery of anemia occurred in 27.6% and 28.8% of the patients in the HIC and usual-care groups, respectively (P=0.1379).
• Predictors of incident anemia at 90 days were male sex, geographical region other than Europe, ischemic etiology, higher glucose levels, and elevated uric acid levels at baseline but not randomization to the HIC strategy.

Interaction between anemia and efficacy and safety of high-intensity HF therapy

• In the HIC group, the proportions of patients reaching optimal doses of RAASis, beta-blockers, and MRAs at 90 or 180 days did not differ between patients with and those with no anemia at baseline.
• The HIC strategy reduced the rate of the primary composite endpoint compared with usual care regardless of baseline hemoglobin levels (P for interaction=0.5323).
• There were also no significant interactions between the presence of anemia at baseline and the effects of the HIC strategy versus usual care on all-cause mortality at 180 days, the change in the EQ-VAS score, or the frequencies of adverse and serious adverse events (all P for interaction>0.05).

Conclusion

This STRONG-HF study analysis among AHF patients showed 27% had anemia at hospital admission. In the 90 days after discharge, 17% developed anemia, whereas recovery of anemia was observed in 28%. The presence of anemia at baseline did not affect the efficacy and safety of high-intensity HF therapy versus usual care after discharge. Although anemic patients experienced less improvement in quality of life over the first 90 days, there was no significant interaction between baseline anemia and the effect of the HIC strategy versus usual care on the change in the EQ-VAS score.

Find this article online at Clin Res Cardiol.

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