May 29, 2023European Journal of Heart Failure40 citationsOpen Access
View Full PaperSafety, Tolerability and Efficacy of Up-Titration of Guideline-Directed Medical Therapies for Acute Heart Failure in Elderly Patients: A Sub-Analysis of the STRONG-HF Randomized Clinical Trial
Key Result
High-intensity care with rapid up-titration of GDMT after acute heart failure reduced 180-day death or readmission similarly in younger (aHR 0.51) and older patients (aHR 0.73; interaction P=0.30).
Study Design
Type
RCT
Randomization
randomized
Structured PICO
Does a high-intensity care strategy of rapid up-titration of GDMT reduce 180-day death or HF readmission in older versus younger patients hospitalized for acute heart failure?
P
Population
Hospitalized acute heart failure (AHF) patients not treated with optimal guideline-directed medical therapy (GDMT), stratified into older (>65 years, n=493, mean age 74 ± 5 years) and younger (mean age 53 ± 11 years) cohorts.
I
Intervention
High-intensity care (HIC) strategy of rapid up-titration of guideline-directed medical therapy (GDMT) and close follow-up after acute heart failure admission.
C
Comparator
Usual care.
O
Outcome
Composite of all-cause death or heart failure readmission at 180 days.composite
Rapid up-titration of guideline-directed medical therapy after acute heart failure is safe and reduces death or HF readmission at 180 days regardless of age, though younger patients experience greater quality of life improvements.
Main Result
Effect estimate: aHR 0.51 (younger), aHR 0.73 (older) (95% CI 0.32-0.82 (younger), 0.46-1.15 (older))
p-value: p=0.30
Abstract
AIMS: STRONG-HF examined a high-intensity care (HIC) strategy of rapid up-titration of guideline-directed medical therapy (GDMT) and close follow-up after acute heart failure (AHF) admission. We assess the role of age on efficacy and safety of HIC. METHODS AND RESULTS: Hospitalized AHF patients, not treated with optimal GDMT were randomized to HIC or usual care. The primary endpoint of 180-day death or HF readmission occurred equally in older (>65 years, n = 493, 74 ± 5 years) and younger patients (53 ± 11 years, adjusted hazard ratio aHR 1.02, 95% confidence interval CI 0.73-1.43, p = 0.89). Older patients received slightly lower GDMT to day 21, but same doses at day 90 and 180. The effect of HIC on the primary endpoint was numerically higher in younger (aHR 0.51, 95% CI 0.32-0.82) than older patients (aHR 0.73, 95% CI 0.46-1.15, adjusted interaction p = 0.30), partially related to COVID-19 deaths. After exclusion of COVID-19 deaths, the effect of HIC was similar in younger (aHR 0.51, 95% CI 0.32-0.82) and older patients (aHR 0.63, 95% CI 0.32-1.02, adjusted interaction p = 0.56), with no treatment-by-age interaction (interaction p = 0.57). HIC induced larger improvements in quality of life to day 90 in younger (EQ-VAS adjusted-mean difference 5.51, 95% CI 3.20-7.82) than in older patients (1.77, 95% CI -0.75 to 4.29, interaction p = 0.032). HIC was associated with similar rates of adverse events in older and younger patients. CONCLUSION: High-intensity care after AHF was safe and resulted in a significant reduction of all-cause death or HF readmission at 180 days across the study age spectrum. Older patients have smaller benefits in terms of quality of life.