Up-titration of HF therapies following HF discharge saves lives

The STRONG-HF trial demonstrated that rapid up-titration of heart failure (HF) therapies under close follow-up is safe, decreases mortality and HF readmissions, and improves the quality of life (QoL) of patients with HF. According to the authors, the next step is to educate physicians to implement the procedure of STRONG-HF in daily clinical practice.

“Very few patients with acute HF are closely monitored or treated with the full doses of HF therapies,” claimed Prof. Alexandre Mebazaa (Université Paris Cité, France) [1]. The multicentre, randomised STRONG-HF trial (NCT03412201) investigated the safety and efficacy of rapid up-titration of HF therapies and close follow-up of patients with an episode of acute HF once discharged from the hospital.

The trial randomised 1,800 participants with acute HF and ready to be discharged from hospital to standard care or up-titration HF therapies. In the up-titration arm, participants received half of the optimal doses of HF therapies before discharge and up-titration to full optimal doses of HF therapies at week 2. They underwent safety checks at weeks 1, 3, and 6 post-discharge. Full optimal doses or half-to-full optimal doses of HF therapies were less frequently prescribed in the standard-care arm (assessed at 90 days and 180 days post-discharge). The primary endpoint was a composite of HF readmission and all-cause mortality on day 180. Notably, it was recommended by the Data and Safety Monitoring Board to terminate the study prematurely because the difference between the 2 experimental arms on the primary endpoint was larger than expected and it was deemed unethical to retain participants at standard care. The authors acted on this recommendation and terminated the study with 1,069 included patients.

The participants in the up-titration arm showed a decreased risk of HF readmission or all-cause mortality on day 180 compared with the standard-care arm (absolute risk difference 8.1%; 95% CI 2.9–13.2; P=0.0021; see Figure). The 90-day EQ-5D VAS scores reflected greater improvements in QoL in the up-titration than in the standard-care arm (change from baseline 10.7 vs 7.2; P<0.0001). Haemodynamic and congestion parameters were also significantly improved in the up-titration compared with the standard-care arm. Although the adverse event (AE) rate was numerically higher in the up-titration arm (41.1% vs 29.5%), there was no difference in the rate of serious AEs (16.2% vs 17.2%) or fatal AEs (4.6% vs 6.0%) between the 2 study groups.

Figure: Probability of event-free survival over time upon up-titration versus standard care [1]



“Post-discharge rapid up-titration of HF therapies under close monitoring is safe and effective in patients with acute HF,” concluded Prof. Mebazaa.

1. 
   
   1. Mebazaa A, et al. Successful post-discharge management of heart failure. Emerging Heart Failure Science, AHA Scientific Sessions 2022, 05–07 November, Chicago, USA.

 

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Posted on 11 January 2023