Thread by @NealDixit

A 🧵on STRONG-HF 💪🏾🫀

⭐️The first randomized trial to show the immense benefits of a comprehensive high-intensity med-titration program with #HF GDMT

❓How did the investigators achieve an 8.1% ARR in HFH/mortality at 6 months❓

Let’s see what we can learn 👇🏾🧵

First let’s take a look at the inclusion and exclusion criteria.

You’ll note:
👉🏾must have SBP > 100, HR >60, K <5.0, GFR > 30
-this eliminates many patients unlikely to tolerate aggressive titration

At baseline still a sick cohort:
-66% NYHA 3 or more
-avg NT-proBNP 7110

Next we see what they aimed for

✌🏽Half doses at discharge

✊🏽Full doses by week 2

And these were high guideline directed target doses e.g.:
-Carvedilol 50 BID
-Spironolactone 50 qd
-Enalapril 20 BID (👀)
-S/V 97/103 BID

Could it have just been the effect of close monitoring with loop diuretic adjustment?

🛑🛑🛑

Nope! As we can see, loop diuretic dose was lower in high-intensity arm!

(Source: appendix)

So what was their strategy and what did they achieve? Look at these four slides based off appendix data.

You’ll note:

1. Many more pts at half dose at discharge
2. And more at full dose by wk 2
3. Meds pts are on at dc-wk 3 are the meds at 6 months in both arms

Concerns:

-side effects were remarkably low. Only 5% with hypotension. In contrast to 14% in PARADIGM-HF. Believable?
-AKI 0.6%, hyperkalemia 3.3%. Perhaps we are over-concerned in clinical practice but again seems low
-MRA use in both cohorts is very high? Conflicts prior data

Despite this, STRONG-HF is still a huge success.

How can we implement its lessons into practice?

One thing to do differently would be to introduce GDMT earlier in the 🏥

But the main message is to be aggressive 💪🏾

This is how I would do it — let me know what you think 👇🏾