Secondary analysis of STRONG-HF trial data highlighted the benefits of quickly bringing heart failure patients up to full guideline-directed medical therapy (GDMT), showing that rapid uptitration to optimal doses of at least three classes of guideline-directed meds reduces readmissions and mortality, while improving quality of life.
The analysis included 515 acute HF patients who weren’t taking optimal GDMT doses before discharge, and were randomly assigned to be uptitrated within 2 weeks.
- 39 patients achieved “low” doses (<50% of max GDMT), 254 patients achieved “medium” doses (≥50% to <90% of max GDMT), and 222 patients achieved “high” doses (≥90% of GDMT) two weeks after discharge.
In general, higher doses meant better outcomes…
- Each 10% average optimal dose increase translated into an 11% reduction in HF readmissions and a 16% decrease in all-cause mortality at 180 days.
- Quality of Life EQ-5D scores improved by more in patients in the high (from −1.98 to 8.24 points) and medium GDMT group (from −4.88 to 5.07) compared to the low dose group at 90 days.
- Adverse events through 90 days were less common at higher GDMT doses, although that was related to more stable patients receiving higher doses.
Despite this evidence that rapid GDMT uptitration had an outsized impact on HF outcomes, only 43% of the patients reached “high” dosage.
- However, 90% of patients were able to achieve at least “medium” GDMT doses, suggesting that “a lot” of the GDMT adherence challenges in the real world are due to therapeutic inertia.
- With that in mind, the authors emphasized that “all efforts should be made to rapidly uptitrate” the three or four GDMT medications to optimal doses in all HF patients that can tolerate them.
The Takeaway
The original STRONG-HF trial results already showed that rapid uptitration improved HF patients’ outcomes and quality of life, and these new results add more evidence that clinicians can (and often should) quickly increase many of their HF patients’ GDMT doses.
