Clinical question: Does rapid up-titration of guideline-directed medical therapies (GDMT) following admission for acute heart failure improve patient outcomes?
Background: GDMT provides evidence-based practice guidance to clinicians in the treatment of heart failure. Evidence was scarce regarding proper dosing and stepwise approach to GDMT intensification following acute heart failure admissions, as well as lack of consensus on the frequency of patient monitoring following medication optimization. This study reviewed the intensification of GDMT and follow-up guidelines over 180 days to determine the impact of these interventions in morbidity and mortality.
Study design: The STRONG-HF trial was an open-label, international, randomized controlled trial
Setting: The trial recruited adults between the ages of 18 and 85 years, admitted within the 72 hours before screening for heart failure. Patients selected were followed in 87 inpatient hospitals spanning 14 countries across four continents between May 2018 and September 2022.
Synopsis: 1,085 adult patients enrolled (mean age, 63; 61% male; 77% Caucasian; average left ventricular ejection fraction, 36%) with 542 patients assigned to the high-intensity care group, and 536 patients assigned to the usual-care cohort. The usual-care group received treatment as per the local overseeing clinician. The high-intensity group received the first dose two days before discharge, and up-titration of GDMT to 100% of recommended therapies within two weeks, monitored through biweekly visits.
By 90 days, the high-intensity group had greater incidence of up-titration to full doses of renin-angiotensin system inhibitors, beta-blockers, and/or mineralocorticoid inhibitors (ranging from 49% to 84%) when compared to the usual group (2% to 46%). The high-intensity group had 4.8 clinic visits, compared to one visit in the usual-care group. Results showed that NT-proBNP, New York Heart Association classification, BP, and pulse had significantly decreased in the high-intensity group. Also, 15% of patients in the high-intensity group were readmitted, compared to 23% of those given usual care.
Limitations of this study included early termination of the usual-care pathway, as it was deemed unethical to withhold high-intensity treatment from this cohort, and omission of sodium-glucose transport protein 2 inhibitors, due to their approval following initiation of the study.
Bottom line: Rapid up-titration of GDMT following initial admission and close follow-up following discharge was shown to reduce symptoms, heart failure readmissions, and risk of death within 180 days. Patients also reported improved quality of life when compared to usual-care practices.
Citation: Mebazaa A, Davison B, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet. 2022;400(10367):1938-52.
Ms. Oro
Ms. Oro is a nurse practitioner in the department of heart transplant and mechanical circulatory support at Stanford Health Care in Palo Alto, Calif.