Intensive treatment strategy after discharge for HF reduces death, readmission at 180 days
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CHICAGO — In patients hospitalized for acute HF, an intensive treatment strategy of rapid uptitration of appropriate medications and close follow-up reduced death and readmission at 180 days compared with usual care, researchers reported.
For the STRONG-HF trial, presented at the American Heart Association Scientific Sessions and simultaneously published in The Lancet, researchers randomly assigned 1,078 patients (mean age, 63 years; 39% women; 21% Black) admitted with acute HF regardless of ejection fraction (67% with reduced EF) who had not been treated with full doses of guideline-directed medical therapy (GDMT) and had residual congestion (high N-terminal pro-B-type natriuretic peptide levels at discharge) to receive the usual care or a high-intensity care intervention after discharge.
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“After acute heart failure, very few patients are monitored after discharge or get the full dose of heart failure therapies,” Alexandre Mebazaa, MD, professor of anesthesia and critical care at Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, said during a press conference. “Guidelines from both Europe and the U.S. recommend to do follow-up within 1 to 4 weeks after discharge, but the level of evidence was very low. STRONG-HF was designed to assess the safety and efficacy of rapid uptitration of heart failure therapies [in conjunction with] very close follow-up.”
The high-intensity care intervention involved the introduction of half-doses of GDMT at discharge, a safety visit at 1 week, a safety visit at 2 weeks — in which full doses of GDMT were initiated if safe — a safety visit at 3 weeks and a safety visit at 6 weeks, Mebazaa said during the press conference, noting that patients in both groups had a 90-day follow-up visit and were contacted at 180 days to confirm if death or HF readmission had occurred.
The safety visits included monitoring of clinical status, obtaining of laboratory values and measuring N-terminal pro-B-type natriuretic peptide concentrations, according to the researchers.
GDMT included a renin-angiotensin blocker (which could include an angiotensin receptor/neprilysin inhibitor), a beta-blocker and a mineralocorticoid receptor antagonist (MRA), Mebazaa said, noting that when the study was initiated, SGLT2 inhibitors were not recommended in HF, but the investigators were asked to prescribe as locally recommended; similar advice was given for iron supplementation.
The primary endpoint was all-cause death or readmission for HF at 180 days.
The study was stopped in September, well short of the planned enrollment of 1,800 patients, because of greater-than-expected differences between the groups in the primary endpoint, making it unethical to keep patients in the usual care group, Mebazaa said during the press conference.
At 90 days, compared with the usual care group, more patients in the high-intensity group had been uptitrated to full doses of renin-angiotensin blockers (55% vs. 2%), beta-blockers (49% vs. 4%) and MRAs (84% vs. 46%), according to the researchers.
The high-intensity group had greater improvement than the usual care group at 90 days in all parameters of congestion, including weight (P < .0001), respiratory rate (P = .0028), peripheral edema (P = .0002), jugular venous pressure (P = .015), NYHA class (P < .0001) and NT-proBNP (P = .0003), Mebazaa said.
In a down-weighted adjusted Kaplan-Meier estimate, at 180 days, the primary endpoint occurred in 15.2% of the high-intensity group and 23.3% of the usual care group (adjusted risk difference, 8.1 percentage points; 95% CI, 2.9-13.2; P = .0021; RR = 0.66; 95% CI, 0.5-0.86), the researchers found.
Quality of life metrics favored the high-intensity group, according to the researchers.
The results did not vary by subgroup, including EF. “Probably for the first time, we could show that patients with a preserved ejection fraction have very positive benefits from high-intensity care,” Mebazaa said.
The high-intensity group had more adverse events than the usual care group at 90 days (41% vs. 29%), but there was no difference in serious adverse events or fatal adverse events, Mebazaa said during the press conference.
“The next challenge is to implement this technique, including rapid education, into daily practice,” he said.
Reference:
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The investigators behind the STRONG-HF study should be commended on conducting a study focused on strategy. Medical therapy for HF across the range of EF has evolved dramatically, yet we know implementation is sorely lacking. The population was more diverse than other studies at least with respect to race and gender, and two-thirds had EF less than or equal to 40%.
Patients in the high-intensity care group (with uptitration of medical therapy within 6 weeks after discharge) experienced lower rates of readmission for HF or mortality at 180 days as well as improvement in quality of life as measured by the EQ-VAS score (a more generalized [quality of life] instrument than the Kansas City Cardiomyopathy Questionnaire, which is HF-specific) and measurements of congestion including weight loss, improvement in NYHA class, jugular venous pressure, edema and natriuretic peptide levels.
The trial was stopped early due to clinical benefit seen across subgroups including EF and renal function.
This study adds undeniable evidence showing us the time is now to implement the therapies discovered to benefit our patients. This means improving equitable access to care and creating workflows to allow for the close and frequent follow-up needed following hospital discharge for HF.
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Mebazaa A, et al. FS.04: Emerging Heart Failure Science. Presented at: American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
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