[Rapid up-titration of guide-directed medical therapy after a heart failure hospitalisation]

Introduction: The European Society of Cardiology focused update of the heart failure guidelines recommends the rapid up-titration of the guideline-directed medical therapy in all heart failure patients after a heart failure hospitalisation, to improve the outcomes based on the STRONG-HF trial. However, the trial had strict randomisation criteria; hence in everyday clinical practice we do not have available data regarding its feasibility. Objective and method: We report the retrospective pilot study of nine consecutive cases of patients with heart failure with reduced ejection fraction, who had a heart failure hospitalisation at our Institute’s Heart Failure Unit, followed by rapid up-titration of guideline-directed medical therapy at our Heart Failure Outpatient Clinic during six weeks of follow-up. The STRONG-HF trial’s essential randomisation criteria were applied to determine the eligibility for rapid up-titration (systolic blood pressure ≥100 mmHg, heart rate ≥60 min–1, serum potassium ≤5 mmol/L, eGFR (estimated glomerular filtration rate) ≥30 mL/min/1.73 m2). Results: At admission, median NT-proBNP was 4786 (1670–13283) pg/mL, eGFR: 92 (58–101) mL/min/1.73 m2, serum potassium: 3.9 (3.6–4.3) mmol/L, systolic blood pressure: 134 (115–136) mmHg, heart rate 113 (96–134) min–1, left ventricular ejection fraction: 23 (20–34)%. One patient received quadruple therapy and one received triple therapy below target doses, while seven patients were treated with ≤2 strategic drug classes. At discharge, quadruple therapy was initiated in eight patients: mean dose of RASi (renin-angiotensin system inhibitor) was 61% of the target dose, 26% of βB (beta-blocker), and 97% of MRA (mineralocorticoid receptor antagonist); eight patients received SGLT2i (sodium glucose co-transporter 2 inhibitor). No severe adverse events were observed. After the rapid up-titration period, 94% of target doses was reached in the case of RASi, 93% of βB, 100% of MRA and SGLT2i. Six patients received quadruple therapy at target doses; in three cases, hypotension and/or bradycardia limited the rapid up-titration of RASi and βB. According to the patients’ feedback, rapid up-titration did not cause an increased burden to them, but it enhanced their satisfaction and sense of safety. Conclusion: According to our cases, the rapid up-titration of guideline-directed medical therapy after heart failure hospitalisation was feasible and safe, high doses of quadruple therapy were achievable, although it needed an intensive effort from both the clinician and the patients. Orv Hetil. 2024; 165(31): 1197–1205.