Safety, tolerability and efficacy of up‐titration of guideline‐directed medical therapies for acute heart failure in elderly patients: A sub‐analysis of the STRONG‐HF randomized clinical trial

Abstract

AimsSTRONG‐HF examined a high‐intensity care (HIC) strategy of rapid up‐titration of guideline‐directed medical therapy (GDMT) and close follow‐up after acute heart failure (AHF) admission. We assess the role of age on efficacy and safety of HIC.Methods and resultsHospitalized AHF patients, not treated with optimal GDMT were randomized to HIC or usual care. The primary endpoint of 180‐day death or HF readmission occurred equally in older (>65 years, n = 493, 74 ± 5 years) and younger patients (53 ± 11 years, adjusted hazard ratio [aHR] 1.02, 95% confidence interval [CI] 0.73–1.43, p = 0.89). Older patients received slightly lower GDMT to day 21, but same doses at day 90 and 180. The effect of HIC on the primary endpoint was numerically higher in younger (aHR 0.51, 95% CI 0.32–0.82) than older patients (aHR 0.73, 95% CI 0.46–1.15, adjusted interaction p = 0.30), partially related to COVID‐19 deaths. After exclusion of COVID‐19 deaths, the effect of HIC was similar in younger (aHR 0.51, 95% CI 0.32–0.82) and older patients (aHR 0.63, 95% CI 0.32–1.02, adjusted interaction p = 0.56), with no treatment‐by‐age interaction (interaction p = 0.57). HIC induced larger improvements in quality of life to day 90 in younger (EQ‐VAS adjusted‐mean difference 5.51, 95% CI 3.20–7.82) than in older patients (1.77, 95% CI −0.75 to 4.29, interaction p = 0.032). HIC was associated with similar rates of adverse events in older and younger patients.ConclusionHigh‐intensity care after AHF was safe and resulted in a significant reduction of all‐cause death or HF readmission at 180 days across the study age spectrum. Older patients have smaller benefits in terms of quality of life.

Non‐cardiac comorbidities and intensive up‐titration of oral treatment in patients recently hospitalized for heart failure: Insights from the STRONG‐HF trial

“…Similar to other STRONG‐HF sub‐analyses, 9,10 variables used for covariate adjustment were selected from those most highly associated with each endpoint in the UC group of STRONG‐HF using backwards selection in the Cox regression model.…”

“…6 The STRONG-HF (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-ProBNP Testing, of Heart Failure Therapies) trial demonstrated that a high-intensity care (HIC) treatment strategy, characterized by rapid up-titration of oral medications for HF and close follow-up with multiple early ambulatory visits after an admission for AHF, improves quality of life and reduces the risk of 180-day all-cause death or HF rehospitalization, compared with usual care (UC). 8 This strategy was both safe and effective regardless of age, 9 sex, 10 left ventricular ejection fraction (LVEF) 11 or baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. 12 In clinical trial settings, there are relatively limited data to describe the impact of comorbidities on optimization of HF medical therapies and relationship between comorbidity burden and post-discharge clinical outcomes.…”

July 2023 at a glance: heart failure with preserved ejection fraction and comorbidities

“…In a secondary analysis of the STRONG-HF trial, the high-intensity care (HIC) strategy was safe and significantly reduced all-cause mortality and HF readmission at 180 days compared to usual care without a significant interaction of age and sex. 40,41 However, older patients had smaller benefits in terms of quality of life. 40 The detection of B-lines through lung ultrasound (LUS) is of utmost importance for the diagnosis of congested acute HF.…”

“…40,41 However, older patients had smaller benefits in terms of quality of life. 40 The detection of B-lines through lung ultrasound (LUS) is of utmost importance for the diagnosis of congested acute HF. A secondary analysis of the BLUSHED-AHF trial, designed to investigate the effect of LUS-guided therapy in patients with acute HF, tested the use of artificial intelligence/machine learning (AI/ML)-based automated guidance systems in order to detect lung congestion.…”

September 2023 at a glance: focus on acute heart failure and health status

“…These data confirm the prognostic value of guideline-directed medical therapy optimization in patients hospitalized for HF. [30][31][32][33][34] Figure 1 Variability in decongestive strategies among physicians. ADHF, acute decompensated heart failure; SBP, systolic blood pressure.…”