Comparison of the effect of the rapid up-titration programme and the standard care on therapy optimisation at a heart failure outpatient clinic in real-world clinical practice

Background The 2023 Focused Update of the 2021 ESC Heart Failure (HF) Guidelines (GLs) gives a class I recommendation for the rapid up-titration (RT) of GL-directed medical therapy (GDMT) in 6 weeks after a HF hospitalisation (HFH). Data on comparing RT programme (RTP) and standard care (SC) in everyday practice are scare. Purpose To evaluate the effect of RTP compared to SC at our HF Outpatient Clinic (HFOC) on GDMT and the achieved target doses (TDs). Methods A retrospective observational study was performed in a real-world cohort of patients (pts) hospitalised for HF at the HF Unit of our tertiary cardiac centre and then were taken into care at our HFOC. After the publication of the 2023 ESC GLs, pts were consecutively selected for RT based on the main discharge randomisation criteria of the STRONG-HF trial (systolic blood pressure≥100 mmHg, heart rate≥60 min-1, serum potassium≤5 mmol/L, eGFR≥30 mL/min/1.73m2). A 6-week RTP was performed at our HFOC with weekly visits. As historical control, a consecutive group of pts with SC was formed who had been hospitalised after the release of the 2021- and before the 2023 ESC HF GLs, who were followed-up (FUP) with individualised visits at 1-3 months. The RTP and SC pts were propensity-score-matched (PSM) with 1:1 ratio. GDMT and TDs achieved at the end of the 6-month FUP in both groups before and after PSM were compared. Results The total cohort of 93 pts (RTP: 48 pts, SC: 45 pts) were analysed (at baseline: male: 80%, age: 55 [47-63] years, eGFR<60 mL/min/1.73m2: 34%, LVEF: 25 [20-34] %, NT-proBNP at discharge: 1900 [723-3074] pg/mL, HFrEF: 91%). At hospital discharge, a remarkable ratio of pts received GDMT, however TDs were rarely achieved (RASi: 99%, TD RASi: 23%; βB: 96%, TD βB: 1%; MRA: 98%, TD MRA: 74%; SGLT2i: 86%, TD SGLT2i: 86%; triple therapy [TT: RASi+βB+MRA]: 94%, TD TT: 0%; quadruple therapy [QT:TT+SGTL2i]: 82%, TD QT: 0%). RTP pts had median 8 [7-8] visits compared to 3 [2-4] visits of the SC group during the 6-month FUP. At the end of the FUP, without serious adverse events, the use of GDMT remained high in both groups (RASi: 100% vs 98%, p=0.30; βB: 98% vs 98%, p=0.96; MRA: 98% vs 96%, p=0.52; SGLT2i: 98% vs 78%, p<0.05; TT: 96% vs 91%, p=0.354; QT: 96% vs 73%, p<0.05; RTP vs SC). After the RTP, up-titration to TDs was more successful (RASi: 73% vs 51%; βB: 50% vs 13%; MRA: 98% vs 71%; SGLT2i: 98% vs 78%; TT: 42% vs 7%; QT: 40% vs 7%; RTP vs SC; p<0.05) compared to SC. After PSM, no differences (p>0.05) were seen in the TD use of RASi and SGLT2i therapy, while TDs of βBs (50% vs 18%), MRAs (95% vs 59%), TT (45% vs 5%) and QT (45% vs 5%) were applied more frequently with RTP. Conclusions After a HFH, RTP was feasible in a group of appropriately selected HF pts. According to our analysis pts with RTP at 6-month FUP, compared to a historical consecutive cohort of pts with SC, with moderately increased number of FUP visits, achieved TDs of TT and QT at remarkably higher rates.