Early, rapid uptitration of HF therapies after discharge reduces death, readmission risk
Key takeaways:
- Initiating and uptitrating HF medications within a few weeks of hospital discharge reduces risk for death or HF readmission at 180 days.
- Improvements were seen across the spectrum of ejection fraction.
Rapid uptitration of medical therapy early after hospitalization for acute HF improves prognosis independent of left ventricular ejection fraction, according to a prespecified analysis of the STRONG-HF trial.
“A high-intensity care strategy characterized by rapid uptitration of therapy and close follow-up is beneficial across the entire spectrum of left ventricular EF,” Matteo Pagnesi, MD, cardiologist with ASST Spedali Civili di Brescia, Italy, told Healio. “Current guidelines provide different recommendations regarding medical treatment of patients with chronic HF and either reduced, mildly reduced or preserved EF; however, this analysis of STRONG-HF demonstrated that rapid uptitration of neurohormonal modulators is uniformly beneficial across the spectrum of EF, thus suggesting that this strategy may be implemented in clinical practice in patients with acute HF and any EF.”
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Study data
Pagnesi and colleagues analyzed data from 1,078 participants enrolled in STRONG-HF who were hospitalized for acute HF with any LVEF and not treated with full doses of renin-angiotensin inhibitors, beta-blockers and mineralocorticoid receptor antagonists (MRAs). Researchers randomly assigned participants to high-intensity care with uptitration of oral medications including beta-blockers, ACE inhibitors, angiotensin receptor/neprilysin inhibitors (ARNIs) or MRAs, or to usual care, independent of participant LVEF. Participants in the high-intensity care group were treated according to an algorithm combining rapid optimization of renin-angiotensin system modulators, beta-blockers and MRAs and had visits at 1, 2, 3 and 6 weeks after randomization. The primary endpoint was the composite of first HF rehospitalization or all-cause death at 180 days. Secondary endpoints were change in EQ-5D visual analog scale (VAS) from baseline to 90 days, all-cause death at 180 days and a composite of first HF rehospitalization or all-cause death at 90 days.
The findings were published in the Journal of the American College of Cardiology.
Within the cohort, 68% had an LVEF of 40% or less and 32% had an LVEF of more than 40%.
Researchers found that the treatment benefit of high-intensity care vs. usual care on the primary endpoint was consistent across the LVEF spectrum (interaction P with LVEF as a continuous variable = .372). The mean difference in the EQ-5D VAS change from baseline to 90 days between treatment arms was slightly greater at higher LVEF values; however, there was no interaction between LVEF as a continuous variable and the treatment strategy (interaction P = .358).
Serious adverse events were also independent from LVEF, according to the researchers.
“The mechanisms by which rapid uptitration of medical therapy is beneficial independently from left ventricular EF, including patients with preserved EF, require further investigation,” Pagnesi told Healio.
Moving away from ‘culture of therapeutic hesitancy’
In a related editorial, Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of the UCLA Preventive Cardiology Program, co-chief of the division of cardiology at UCLA and the Eliot Corday Chair in Cardiovascular Medicine and Science, and Stephen J. Greene, MD, assistant professor of medicine at Duke Clinical Research Institute and Duke University School of Medicine, wrote that, in contrast with a culture of therapeutic urgency toward cancer, HF has a culture of therapeutic hesitancy where risks of omitting or delaying therapy are routinely underestimated or ignored.
“Despite the availability of multiple medications proven to substantially extend survival and improve symptoms, most patients with HF will have their disease progress and many will ultimately die without ever receiving all of these therapies, despite being eligible,” Fonarow and Greene wrote.
Data from STRONG-HF plus other evidence supports the benefits of rapid and intensive optimization of guideline-directed medical therapies for HF and the substantial harms associated with delaying therapy, Fonarow and Greene wrote.
“For patients with HFrEF, this approach starts with simultaneous or rapid sequence initiation of four therapies (ARNI, beta-blocker, MRA and SGLT2 inhibitor) among eligible patients at the time of HF diagnosis,” Fonarow and Greene wrote. “For patients with HFpEF, the foundation is immediate initiation of SGLT2 inhibitor therapy, with additional consideration of ARNI and MRA. 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.”
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For more information:
Matteo Pagnesi, MD, can be reached at m.pagnesi@gmail.com.
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