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Rapid Up-Titration of Guideline-Directed Medical Therapies for Acute Heart Failure

STRONG-HF investigators report that patients readily accepted “an intensive treatment strategy of up-titration of guideline-directed medication and close follow-up after an acute heart failure admission” because “it reduced symptoms, improved quality of life, and reduced the risk of 180-day all-cause death or heart failure readmission compared with usual care.”

A total of 1,078 adults participated in the multinational, open-label, randomized, parallel-group trial. All had been hospitalized with acute heart failure and not treated with full doses of guideline-directed drug treatment at 87 hospitals in 14 countries. Participants were categorized by left ventricular ejection fraction (≤40% or >40%) to usual local practice or high-intensity care with up-titration of treatments to 100% of recommended doses within 2 weeks of discharge and 4 scheduled outpatient visits over the 2 months after discharge.

The primary endpoint of 180-day readmission to the hospital due to heart failure or all-cause death showed the following: “Mean age was 63.0 years (SD 13.6), 416 (39%) of 1078 patients were female, 662 (61%) were male, 832 (77%) were White or Caucasian, 230 (21%) were Black, 12 (1%) were other races, one (<1%) was Native American, and one (<1%) was Pacific Islander (two [<1%] had missing data on race). The study was stopped early per the data and safety monitoring board’s recommendation because of greater than expected between-group differences. As of data cutoff (Oct 13, 2022), by day 90, a higher proportion of patients in the high-intensity care group had been up-titrated to full doses of prescribed drugs (renin-angiotensin blockers 278 [55%] of 505 vs 11 [2%] of 497; β blockers 249 [49%] vs 20 [4%]; and mineralocorticoid receptor antagonists 423 [84%] vs 231 [46%]). By day 90, blood pressure, pulse, New York Heart Association class, body weight, and NT-proBNP concentration had decreased more in the high-intensity care group than in the usual care group. Heart failure readmission or all-cause death up to day 180 occurred in 74 (15.2% down-weighted adjusted Kaplan-Meier estimate) of 506 patients in the high-intensity care group and 109 (23.3%) of 502 patients in the usual care group (adjusted risk difference 8.1% [95% CI 2.9–13.2]; P = 0.0021; risk ratio 0.66 [95% CI 0.50–0.86]). More adverse events by 90 days occurred in the high-intensity care group (223 [41%] of 542) than in the usual care group (158 [29%] of 536) but similar incidences of serious adverse events (88 [16%] vs 92 [17%]) and fatal adverse events (25 [5%] vs 32 [6%]) were reported in each group.”

Source: Lancet