STRONG-HF and NT-proBNP: stronger together against acute heart failure

As the NHS continues to face challenges with rising hospital admissions and extensive waiting lists, I reflect on the particular challenges faced by people with heart failure.??

Acute heart failure is the leading cause of hospital admission in people 65 years or older in the UK.1? With nearly a fifth of patients being readmitted back to hospital within a month of being discharged,2 could many of these readmissions be avoided??

Today I would like to share with you the results and reasoning for the early termination of STRONG-HF, a recent landmark trial that shows how an intensive therapeutic strategy guided by biomarker testing, can significantly reduce the risk of readmission in patients hospitalised with acute heart failure.?

Post-acute HF vulnerable phase1?2?

The period starting with acute HF hospitalisation and the couple of months following, often called the vulnerable period, is a time of increased risk of morbidity and mortality for patients with HF.1?

In the 30 days after hospital discharge, 18% of heart failure patients are readmitted and 5% of patients die.3?

Optimisation of treatment is essential following acute heart failure, but many patients never receive full treatment optimisation: in the UK approximately 1 in 3 patients are on >50% of the guideline-recommended dose for ACE-i/ARB or BBs 12 months after their diagnosis.??

The STRONG-HF, biomarker led therapeutic strategy offers clinicians guidance on rapid initiation and optimisation of guideline-directed medical therapy (GDMT) during the vulnerable period before and after discharge, thereby supporting healthcare professionals in providing optimal treatment when it is needed most.1?

What is STRONG-HF??

The STRONG-HF study was a multinational, open-label, randomised clinical trial, designed to assess the safety and efficacy of rapid up-titration of treatments, through the use of biomarkers including NT-proBNP, after acute heart failure, as compared to usual care.1?

After enrolling more than 1000 patients, the data and safety monitoring board of the study recommended early termination of the study because the efficacy of the biomarker-guided treatment strategy meant it was no longer ethical to randomly assign and treat patients in the usual care group.?

The STRONG-HF study design

Frequent visits coupled with safety monitoring guided the rapid up-titration of GDMT in the first 30 days?

With NT-proBNP testing you can practice precision medicine and strike a balance between being too aggressive or too cautious with HF management.1???? The following table outlines the steps involved in initiating the safe up-titration of treatment.?

Reassure your patients with the proven benefits of rapid, high intensity care?

You can now implement the STRONG-HF biomarker-led therapeutic strategy in your own practice and drive the same positive results for your patients with acute heart failure.1

Reduced risk of all-cause death or heart failure readmission by Day 180?

34% RRR - Adjusted risk ratio = 0.66 (95% CI: 0.50-0.86; p=0.0021)?

8.1% ARR - Adjusted treatment effect = 8.1% (95% CI: 2.9 - 13.2: p=0.0021)?

Improved quality of life?

3.49 - (95% CI: 1.74-5.24; p<0.0001)?

Adjusted mean change from baseline to Day 90 in EQ-5D VAS = 3.49?

No increased risk of serious adverse events?

Consistent results across all subgroups?

Such as age, gender, baseline, LVEF, baseline NT-proBNP and history of atrial fibrillation or flutter.

NT-proBNP offers clinicians precision guidance1???

The STRONG-HF study demonstrated the strength of combining an intensive treatment protocol with the guardrails of frequent monitoring and biomarker testing. Monitoring biomarker levels, in particular NT-proBNP, you can strike a balance between being too aggressive or too cautious with your treatment optimisation.1???

The decision to up titrate is based on tangible results.1???

NT-proBNP testing is a key component of the STRONG-HF treatment strategy and enables the safe up-titration of GDMT, but also for aiding you in making informed dosing decisions and monitoring prognosis.1???

Guided optimisation of GDMT using blood pressure, heart rate and biomarkers including NT-proBNP significantly contributed to reducing mortality or hospital readmission at 180 days, without increasing the risk of serious adverse events.1?

How could the STRONG-HF pathway transform HF care in your network?

1. Rapid initiation of treatment within the post-acute vulnerable phase1?

With the STRONG-HF biomarker-led therapeutic strategy, patients with acute heart failure can be quickly up-titrated within weeks of discharge to maximally tolerated doses of GDMT.1?

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2. Tailored high-intensity care enabled by baseline stratification??

Gradation of patients based on changes in biomarkers including NT-proBNP measurements can guide the optimisation of different GDMT treatments as well as the dose adjustments of diuretics, helping you fine-tune and tailor therapy for individual patients.???

Thus, NT-proBNP testing within the STRONG-HF treatment strategy allows for personalised care based on each individual patient’s clinical characteristics.??

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3. Safety monitoring guided by NT-proBNP and other biomarkers??

The safety of rapid optimisation was guided by frequent monitoring including NT-proBNP measurement. 41% of patients had an NT-proBNP >10% compared to pre-discharge levels and this was the most commonly reported safety indicator informing clinical decision making.??

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4. Frequent follow-up now = reduced risk of readmission later1?

Rapid up-titration of GDMT supported by frequent follow-up and biomarker monitoring in the first few weeks of discharge can significantly reduce the risk of hospital readmission and therefore potentially reduce pressures on emergency care departments.1?

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5. Optimising treatment for as many eligible patients as possible1?

The STRONG-HF study demonstrated that rapid up-titration was tolerated and led to consistent benefits across sub-groups including age and LVEF category.1?

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Click here and get in touch to learn more about how Roche and STRONG-HF are supporting HCPs to optimise acute HF care. ?

Abbreviations:?

HF – heart failure; ACEi – angiotensin-converting enzyme inhibitor; ARB – angiotensin-2 receptor blockers; BB – beta blockers; GDMT – guideline directed medical therapy; ARNi - angiotensin receptor/neprilysin inhibitor; MRA - mineralocorticoid receptor antagonists; SGLT2i - sodium-glucose co-transporter-2 inhibitors; HGB – haemoglobin; RRR - Relative risk reduction; CI – confidence interval; ARR – absolute risk reduction; LVEF - left ventricular ejection fraction; HR – heart rate; bpm – beats per minutes; eGFR – estimated glomerular filtration rate; SBP – systolic blood pressure; mmHg – millimetres of mercury; mmol/L – millimoles per litre; mL/min – millilitres per minute??

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References:?

1.??????? Mebazaa A, et al. Safety, tolerability and efficacy of up-titration of guideline directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet. 2022;400:1938-52.?

2.??????? Khan MS, et al. Trends in 30- and 90-day readmission rates for heart failure. Circ Heart Fail. 2021;14:e008335.?

3.??????? Lawson C, et al. Trends in 30-day readmissions following hospitalisation for heart failure by sex, socioeconomic status and ethnicity. EClinicalMedicine. 2021 Jul 14;38:101008. doi: 10.1016/j.eclinm.2021.101008. PMID: 34308315; PMCID: PMC8283308?

4.??????? Conrad N, et al. 2019. PLOS Medicine 16(5): e1002805?

5.??????? Richards M. Troughton RW. NT-proBNP in heart failure: therapy decisions and monitoring. Eur J Heart Fail. 2004;6:35 1-4?

6.??????? Adamo M, et al. NT-proBNP and high-intensity care for acute heart failure: the STRONG-HF trial. Eur Heart J. 2023;doi:10.1093/eurheartj/ehad335.?

7.??????? Greene SJ, et al. In-hospital initiation of quadruple medical therapy for heart failure: making the post-discharge vulnerable phase far less vulnerable. Eur J Heart Fail. 2022;24:227-9.??

8.??????? Kimmoun A, et al. Safety, tolerability and efficacy of rapid optimization, helped by NT-proBNP and GDF-15, of Heart Failure therapies (STRONG-HF): rationale and design for a multicentre, randomized, parallel-group study. Eur J Heart Fail. 2019;21:1459-67.?

9.??????? Tomasoni D, et al. Safety indicators in patients receiving high-intensity care after hospital admission for acute heart failure: the STRONG-HF trial. J Card Fail. 2023 Sep 29:S1071-9164(23)00342-1. doi: 10.1016/j.cardfail.2023.09.002. Epub ahead of print. PMID: 37820896.?

10.???????NICE [CG187] 'Acute heart failure: diagnosis and management' Accessed August 2024.?