LandmarkRCT

STRONG-HF

Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure

Lancet, 2022 · Multinational open-label randomized trial (n=1078)

Clinical question

After an acute heart-failure admission, does high-intensity rapid optimization of recommended oral HF therapy with close follow-up improve 180-day outcomes?

Population: Patients hospitalized for acute heart failure who were clinically stable before discharge and eligible for oral HF therapy optimization.
Intervention: High-intensity strategy with rapid up-titration of recommended HF therapies to 100% of guideline-recommended doses within 2 weeks after discharge plus frequent follow-up.
Comparator: Usual care.
Primary outcome: 180-day heart-failure readmission or all-cause death.
Result: The primary composite occurred in 15.2% with high-intensity care versus 23.3% with usual care (adjusted risk ratio 0.66; 95% CI 0.50-0.86; P=0.0021). Adverse events were more frequent with high-intensity care, while serious and fatal adverse events were similar.

What the trial found

Rapid post-discharge optimization of recommended HF therapy with close follow-up reduced the composite of HF readmission or all-cause death at 180 days.

Clinical interpretation

Supports structured, closely monitored rapid optimization after stabilization; it does not prove that every patient should receive immediate four-drug therapy or that mortality alone was reduced by each component.

High certainty

Clinical Context & Relevant Topics (1)

Disease Reference

Acute Heart Failure & Cardiogenic Congestion

Hemodynamic phenotypes (SCAPE vs ADHF vs Cardiogenic Shock), non-invasive positive pressure ventilation, high-dose vasodilator algorithms, loop diuretics, and sequential nephron blockade.

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