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Eligibility for Rapid Up-Titration of Guideline-Directed Medical Therapy of Real-World Patients Hospitalised for
Fanni Bánfi-Bacsárdi, Zsolt Forrai1,2, Ádám Kazay1
1Department of Adult Cardiology, Gottsegen National Cardiovascular Center, Budapest, Hungary.
Insights
Only 34-60% of hospitalized heart failure patients meet criteria for rapid up-titration of guideline-directed medical therapy. Careful patient selection is crucial for effective treatment initiation post-discharge.
Area of Science:
- Cardiology
- Clinical Medicine
- Pharmacology
Background:
- The 2023 ESC Heart Failure Guidelines advocate rapid up-titration (RT) of guideline-directed medical therapy (GDMT) for hospitalized patients.
- The STRONG-HF trial demonstrated improved prognosis with RT, but its real-world application requires careful patient selection due to strict trial criteria.
Purpose of the Study:
- To determine the proportion of hospitalized heart failure patients eligible for rapid up-titration (RT) of GDMT after discharge.
- To assess the feasibility of implementing RT based on STRONG-HF trial criteria in a real-world clinical setting.
Main Methods:
- A consecutive cohort of 408 hospitalized heart failure patients were evaluated between April 2021 and December 2023.
- Eligibility for RT was assessed using STRONG-HF trial criteria: systolic blood pressure (SBP) ≥100 mm Hg, heart rate (HR) ≥60 min-1, serum potassium ≤5 mmol/L, estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2, and discharge N-terminal pro-B type natriuretic peptide (NT-proBNP) >1,500 pg/mL.
Main Results:
- A significant majority met individual criteria: 78% for SBP, 93% for HR, 89% for potassium, and 91% for eGFR.
- Combined assessment of hemodynamic and renal parameters indicated 60% eligibility for RT.
- When including the NT-proBNP criterion, only 34% of the cohort were eligible for RT.
Conclusions:
- The proportion of hospitalized heart failure patients eligible for rapid up-titration of GDMT, based on STRONG-HF criteria, ranges from 34% to 60%.
- These findings underscore the necessity for strategic and careful patient selection to successfully implement rapid up-titration protocols in clinical practice.
Introduction And Aims:
The 2023 Focused Update of the 2021 ESC Heart Failure (HF) Guidelines recommends the rapid up-titration (RT) of guideline-directed medical therapy (GDMT) for all patients hospitalised for HF to improve prognosis in light of the STRONG-HF trial. However, the real-world feasibility of RT and the optimal selection of suitable patients may cause difficulties as the STRONG-HF trial applied strict randomisation criteria. We aimed to assess the proportion of hospitalised HF patients suitable for RT after discharge.
Methods:
The proportion of patients eligible for RT based on the basic inclusion and exclusion criteria of the STRONG-HF trial (systolic blood pressure [SBP] ≥100 mm Hg, heart rate [HR] ≥60 min-1, serum potassium ≤5 mmol/L, estimated glomerular filtration rate [eGFR] ≥30 mL/min/1.73 m2, discharge N-terminal pro-B type natriuretic peptide [NT-proBNP] >1,500 pg/mL) was assessed in a consecutive patient cohort at a tertiary referral centre between April 01, 2021, and December 31, 2023.
Results:
Data from 408 consecutive patients were analysed (male: 71%; age: 62 [51-72] years; left ventricular ejection fraction: 27 [20-35]%; HF with reduced ejection fraction: 82%; hypertension: 67%; diabetes: 36%; atrial fibrillation: 47%). 78% of the patients were suitable for RT based on the SBP criterion, 93% on HR, 89% on serum potassium, and 91% on eGFR values. Thus, 60% were eligible for RT using the combined assessment of these parameters. When including the NT-proBNP value as well (60%), 34% of the cohort were eligible for RT.
Conclusions:
Based on our study, the proportion of patients suitable for RT of GDMT ranged from 34% to 60% based on the basic eligibility indicators of the STRONG-HF trial. Our results highlight the strategic importance of careful selection of patients eligible for RT.
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