Rapid uptitration of oral HF therapies after HF hospitalization was safe, effective across LVEF categories
A high-intensity care strategy was associated with a reduced risk of death or heart failure (HF) readmission at 180 days in patients hospitalized for acute HF, regardless of left ventricular ejection fraction (LVEF), a prespecified analysis of a randomized trial found.
After hospitalization for acute heart failure (HF), rapid uptitration of oral HF therapies within a few weeks after discharge, performed under close follow-up and monitoring, was associated with improved outcomes independent of left ventricular ejection fraction (LVEF), a recent study found.
The STRONG-HF (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-ProBNP Testing, of HF Therapies) trial showed that compared with usual care, a high-intensity care strategy improved quality of life and reduced the risk of 180-day all-cause death or HF rehospitalization in patients with any LVEF. The strategy included rapid uptitration of oral medications for HF and close follow-up with multiple early ambulatory visits after an admission for acute HF. In the current study, researchers assessed whether a high-intensity care strategy with rapid uptitration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors; beta-blockers; and mineralocorticoid receptor agonists is safe and effective across different LVEF categories in patients with acute HF enrolled in the STRONG-HF trial. The primary end point was the composite of first HF rehospitalization or all-cause death at day 180. Results were published in the June 6 Journal of the American College of Cardiology.
Of 1,078 patients randomized in the trial, 731 (68%) had an LVEF of 40% or less and 347 (32%) had an LVEF greater than 40%. Among those with an LVEF of 40% or less, the primary end point occurred in 57 (17.4%) of 346 patients in the high-intensity care group and in 74 (23.7%) of 346 patients in the usual care group (risk difference, 6.3%; 95% CI, −0.2% to 12.9%). Among the patients with an LVEF greater than 40%, the primary end point occurred in 17 (10.7%) of 160 patients in the high-intensity care group and in 35 (23.3%) of 156 patients in the usual care group (risk difference, 12.5%; 95% CI, 3.7% to 23.1%). There was no significant interaction between an LVEF of 40% or less versus greater than 40% and high-intensity care versus usual care regarding the primary end point (P=0.268 for interaction). Among those with an LVEF of 40% or less, adverse events up to day 90 were observed in 148 (40.5%) of 365 patients in the high-intensity care group and in 102 (27.9%) of 366 patients in the usual care group. Among those with an LVEF greater than 40%, adverse events up to day 90 were observed in 75 (42.4%) of 177 patients in the high-intensity care group and in 56 (32.9%) of 170 patients in the usual care group. Of note, bradycardias occurred in fewer than 1.5% of patients, regardless of LVEF and treatment arm, and the overall incidence of serious adverse events was similar between treatment arms in both LVEF groups.
Limitations of the analysis include the fact that quantification of LVEF was performed at local study sites and was therefore investigator reported, rather than core laboratory reported, the authors noted. “Future studies are needed to confirm these findings and further explore the implications of rapid uptitration of oral treatment in HF patients with different LVEF values,” they wrote.
The findings re-emphasize the message that instilling urgency within HF care and rapidly optimizing therapy can improve patient outcomes, an accompanying editorial noted. “This sense of urgency should apply to both inpatients and outpatients, recognizing that every encounter with a HF patient (whether in-person or remote) is a critical opportunity to augment disease-modifying therapy as tolerated,” the editorialists wrote.