Journal of the American College of Cardiology (JACC)Rapid Uptitration of GDMT and HF Outcomes

Rapid GDMT Uptitration Post-Discharge: A Promising Strategy for Sustained HF Decongestion

This post hoc analysis of the STRONG-HF trial reveals significant benefits of intensive guideline-directed medical therapy (GDMT) uptitration in heart failure (HF) patients following hospitalization. The study demonstrates that rapid GDMT optimization during early post-discharge outpatient visits correlates with improved decongestion outcomes and reduced mortality and rehospitalization rates, highlighting a potential shift in post-discharge HF management strategies.

Key Points:

• Study design: Post hoc analysis of STRONG-HF trial, including 1,078 adults hospitalized with HF
• Randomization: Routine care vs. high-intensity care (HIC) with rapid GDMT uptitration
• HIC protocol: Post-discharge visits at 1, 2, 3, and 6 weeks, and 90 days
• GDMT titration in HIC arm: One-half optimal dose at randomization, full optimal doses by week 2
• Primary outcomes: Symptoms and signs of congestion at 90 days
• Pre-randomization: 47% of patients had successful decongestion, equally distributed in both arms
• Day 90 results:
  • Higher proportion of HIC patients achieved successful decongestion (75% vs. 68%)
  • Improvement seen regardless of pre-randomization congestion status
  • Lower NT-proBNP, weight reduction, and orthopnea severity in HIC arm
  • Higher use of all GDMT components in HIC arm
  • Higher percentage of target GDMT dose correlated with lower congestion score
  • Lower mean daily loop diuretic dose in HIC arm (difference not sustained to day 180)
• 180-day outcomes: Lower all-cause mortality and first HF rehospitalization in HIC arm, irrespective of pre-randomization congestion status
• Clinical implications:
  • Rapid GDMT uptitration may provide effective, sustained decongestion strategy
  • Post-discharge visits should prioritize aggressive GDMT uptitration
  • Current focus on weight and symptom monitoring with diuretic titration may be insufficient
• Study limitations:
  • Inclusion of patients who responded to initial treatment limits generalizability
  • Usual care arm not monitored as frequently for congestion as HIC arm

HCN Medical Memo
This study emphasizes the potential benefits of rapid GDMT uptitration in post-discharge HF management. Physicians should consider implementing more aggressive GDMT optimization strategies during early follow-up visits to improve long-term outcomes in HF patients.

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