Lower achieved doses after rapid uptitration of HF medication with early eGFR decline

Renal function in STRONG-HF

Presented at the ESC Heart Failure 2023 by: Jozine Ter Maaten, MD, PhD - Groningen, The Netherlands

Introduction and methods

Recently, it was shown in STRONG-HF that an intensive treatment strategy of rapid uptitration of guideline-directed medical therapy (GDMT) together with close follow-up was safe and led to fewer HF hospital readmissions or death in hospitalized patients with acute HF compared with usual care. It remains unknown what the effects are of this intensive treatment strategy on renal function and outcomes.

STRONG-HF was a multicenter, open-label, randomized study with 1078 patients who were hospitalized for acute HF. Patients were randomized before discharge in a 1:1 ratio to early and rapid uptitration of GDMT or usual care. Patients were eligible for enrolment if they were: adults <85 years of age; admitted to the hospital 72h before screening; NT-proBNP > 1500 ng/L; not treated with optimal doses of GDMT.

In this subanalysis, patients from the high intensity care arm (n=542) were included. Renal function was assessed at baseline and during follow-up at week 1, 2, 3, and 6. The association between clinical characteristics and outcomes of an early decrease in eGFR at week 1 (defined as decrease >15% from baseline) was studied. 421 patients had an early decrease in eGFR during rapid uptitration of GDMT, whereas this was not observed in 77 patients.

Main results

• The beneficial effect of high intensity care on HF hospitalization or all-cause mortality at 180 days was independent of baseline renal function (P for interaction=0.4809).
• Patients who had an early decrease in eGFR had increased NT-proBNP levels at week 1 compared to patients without an early decrease in eGFR (mean difference: 1.58; 95%CI: 1.24-2.02; P=0.0003).
• Patients who had an early decrease in eGFR more often had signs of congestion.
• Patients who had an early decrease in eGFR were treated during follow-up with lower optimal doses of GDMT (mean difference: 4.91; SE: 2.20; P=0.0257).
• There was no association between an early decrease in eGFR with the rate of HF readmission or all-cause mortality at 180 days compared to no early eGFR decrease (18.5% vs. 12.3%, respectively; P=0.2335). However, the rate of HF readmissions was higher in the group with an early eGFR decrease compared to the group with no early eGFR decrease (P=0.0496).

Conclusion

In this subanalysis of STRONG-HF, high intensity care had beneficial effects on HF hospitalization or all-cause mortality at 180 days regardless of baseline eGFR. An early decrease in eGFR during rapid uptitration of GDMT was associated with more evidence of congestion and lower treatment doses during follow-up.

‘Our findings suggest that an early decrease in eGFR in the context of rapid uptitration should be evaluated carefully especially with respect to the congestion status of the patient, yet should not necessarily lead to discontinuation of guideline-directed medical therapy’ said the presenter Jozine Ter Maarten.

-Our reporting is based on the information provided at ESC Heart Failure 2023 –