Rapid Uptitration of Guideline-Directed Medical Therapies in Acute Heart Failure With and Without Atrial Fibrillation.

Background: Rapid uptitration of guideline-directed medical therapy (GDMT) before and after discharge in hospitalized heart failure (HF) patients is feasible, is safe, and improves outcomes; whether this is also true in patients with coexistent atrial fibrillation/flutter (AF/AFL) is not known.
Objectives: This study sought to investigate whether rapid GDMT uptitration before and after discharge for HF is feasible, safe and beneficial in patients with and without AF/AFL.
Methods: In this secondary analysis of the STRONG-HF (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) trial, GDMT uptitration and patient outcomes were analyzed by AF/AFL status and type (permanent, persistent, paroxysmal).
Results: Among 1,078 patients enrolled in STRONG-HF, 496 (46%) had a history of AF, including 238 assigned to high-intensity care (HIC) and 258 to usual care (UC), and 581 did not have a history of AF/AFL, including 304 assigned to HIC and 277 to UC. By day 90, the average percent optimal dose of neurohormonal inhibitors achieved in the HIC arm was similar in patients with and without AF/AFL, reaching approximately 80% of the optimal dose (average absolute difference between AF/AFL and non-AF/AFL groups: -0.81%; 95% CI: -3.51 to 1.89). All-cause death or HF readmission by day 180 occurred less frequently in the HIC than the UC arm, both in patients with and without AF (adjusted HR: 0.75 [95% CI: 0.48-1.19] in AF vs adjusted HR: 0.50 [95% CI: 0.31-0.79] in non-AF/AFL patients; P for interaction = 0.2107). Adverse event rates were similar in patients with and without AF/AFL. AF/AFL type did not affect either uptitration or patient outcomes.
Conclusions: Nearly half of acute HF patients have AF/AFL history. Rapid GDMT uptitration before and early after discharge is feasible, is safe, and may improve outcomes regardless of AF presence or type. (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies [STRONG-HF]; NCT03412201).
Competing Interests: Funding Support and Author Disclosures Dr Farmakis has received lecture honoraria or consulting or Advisory Board fees and/or grants from AstraZeneca, Bayer, Boehringer Ingelheim, Leo, Myocardial Solutions, Novartis, Remedica, Roche Diagnostics, and Viatris, all outside the present work. Dr Davison is an employee of Momentum Research, which has received grants for research from Abbott Laboratories, Amgen, Celyad, Cirius Therapeutics, Corteria Pharmaceuticals, Heart Initiative, Sanofi, Windtree Therapeutics, and XyloCor Therapeutics and is the director of Heart Initiative, a nonprofit organization. Dr Fountoulaki has received honoraria for lectures from Boehringer Ingelheim and AstraZeneca. Dr Chioncel has received support from Servier for the European Society of Cardiology Congress. Dr Metra has received personal fees from Actelion, Amgen, Livanova, and Vifor Pharma as a member of Executive or Data Monitoring Committees of sponsored clinical trials and from AstraZeneca, Bayer, Boehringer Ingelheim, Edwards Lifesciences, and Roche Diagnostics for participation to Advisory Boards or for speaking at sponsored meetings. Dr Celutkiene has received support from Novartis for New York Cardiovascular Seminars and speaker fees from AstraZeneca, Boehringer Ingelheim, Bayer, and Grindex. Dr Cohen-Solal has received honoraria for lectures or consultancy from AstraZeneca, Novartis, Vifor, Bayer, Merck, Sanofi, Abbott, and Boehringer Ingelheim. Dr Damasceno is an employee of the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique, which has received research grants from the Heart Initiative for its participation in this study. Dr Diaz has received supporting fees for the coordination of STRONG-HF trial activities. Dr Edwards is an employee of Momentum Research, which has received grants for research from Abbott Laboratories, Amgen, Celyad, Cirius Therapeutics, Corteria Pharmaceuticals, Heart Initiative, Sanofi, Windtree Therapeutics, and XyloCor Therapeutics. Dr Novosadova is an employee of Momentum Research, which has received grants for research from Abbott Laboratories, Amgen, Celyad, Cirius Therapeutics, Corteria Pharmaceuticals, Heart Initiative, Sanofi, Windtree Therapeutics, and XyloCor Therapeutics. Dr Bistola has received honoraria for lectures or Advisory Boards from AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Pfizer, and Roche Diagnostics. Dr Pang has served as a consultant for Heart Initiative (Data and Safety Monitorin Board), Roche Diagnostics, Eagle Pharmaceuticals, and Kowa Pharmaceuticals; has served as a former or current investigator for industry studies funded by Abbott, Beckman Coulter, OrthoDiagnostics, and Siemens; and is a 5% owner in the HeartCourse, a Continuing Medical Education course. Dr Saidu has received grants from Medtronic, Servier, and Amylam and honoraria from Merck Sharp & Dohme, Novartis, and Sanofi. Dr Takagi is an employee of Momentum Research, which has received grants for research from Abbott Laboratories, Amgen, Celyad, Cirius Therapeutics, Corteria Pharmaceuticals, Heart Initiative, Sanofi, Windtree Therapeutics, and XyloCor Therapeutics. Dr Voors has received consultancy fees and or research support paid to his employer from AstraZeneca, Anacardio, BMS, Bayer, Boehringer Ingelheim, Corteria, Cytokinetics, Eli Lilly, Merck, Moderna, Novartis, Novo Nordisk, and Roche Diagnostics. Dr Mebazaa has received grants from Roche Diagnostics, Abbott Laboratories, 4TEEN4, and Windtree Therapeutics and honoraria for lectures from Roche Diagnostics, Bayer, and Merck Sharp & Dohme; has served as a consultant for Corteria Pharmaceuticals, S-form Pharma, FIRE-1, Implicity, 4TEEN4, and Adrenomed; and is the coinventor of a patent on combination therapy for patients having acute or persistent dyspnea. Dr Cotter is an employee of Momentum Research, which has received grants for research from Abbott Laboratories, Amgen, Celyad, Cirius Therapeutics, Corteria Pharmaceuticals, Heart Initiative, Sanofi, Windtree Therapeutics, and XyloCor Therapeutics, and is director of Heart Initiative, a nonprofit organization. Dr Filippatos has received research support from the European Union and has received lecture fees from, served on the Advisory Board of, and/or made committee member contributions in clinical trials sponsored by Bayer, Medtronic, Vifor, Servier, Novartis, Impulse Dynamics, Novo Nordisk, and Boehringer Ingelheim. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)