Non‐cardiac comorbidities and intensive up‐titration of oral treatment in patients recently hospitalized for heart failure: Insights from the STRONG‐HF trial

Abstract

AimsTo assess the potential interaction between noncardiac comorbidities (NCCs) and the efficacy and safety of high intensity care (HIC) versus usual care (UC) in STRONG‐HF trial, including stable patients with improved but still elevated NPsMethods and ResultsIn the trial, 8 NCCs were reported: anemia, diabetes, renal dysfunction, severe liver disease, COPD/asthma, stroke/TIA, psychiatric/neurological disorders, and malignancies. Patients were classified by NCC number (0, 1, 2 and ≥3). The treatment effect of HIC versus UC on the primary endpoint, 180‐day death or HF‐rehospitalization, was compared by NCC number and by each individual comorbidity.Among the 1078 patients, the prevalence of 0, 1, 2 and ≥3 NCCs was 24.3%, 39.8%, 24.5% and 11.3%. Achievement of full doses of HF‐therapies at 90‐ and 180‐days in the HIC was similar irrespective of NCCs number.In the HIC, the primary endpoint occurred in 10.0%, 16,6%, 13,6% and 26,2%, in those with 0, 1, 2 and ≥3 NCCs, as compared to 19,1%, 25,4%, 23,3% and 26,2% in UC (interaction‐p=0.80). The treatment benefit of HIC vs. UC on the primary endpoint didn't differ significantly by each individual comorbidity. There was no significant treatment interaction by NCC number in quality‐of‐life improvement (p=0.98) or the incidence of serious adverse events (p=0.11).ConclusionsIn the STRONG‐HF trial, non‐cardiac comorbidities neither limited the rapid up‐titration of HF‐therapies, nor attenuated the benefit of HIC on primary endpoint. In the context of a clinical trial, the benefit‐risk ratio favors the rapid up‐titration of HF‐therapies even in patients with multiple NCCsThis article is protected by copyright. All rights reserved.

Guideline‐directed medical therapy in severe heart failure with reduced ejection fraction: An analysis from the HELP‐HF registry

“…26 Although the implementation of GDMT during a hospitalization for acute HF is strongly recommended, [27][28][29][30] it may be more challenging due to critical conditions, frailty and/or comorbidities. [31][32][33][34] Hypotension and renal dysfunction were among the main reported causes of GDMT underprescription/underdosing. 33 Patients with advanced HF may be less likely to tolerate GDMT because of low cardiac output, hypotension, and severe kidney dysfunction.…”

“…Although the implementation of GDMT during a hospitalization for acute HF is strongly recommended, 27–30 it may be more challenging due to critical conditions, frailty and/or comorbidities 31–34 . Hypotension and renal dysfunction were among the main reported causes of GDMT underprescription/underdosing 33 .…”

The role of multimorbidity in patients with heart failure across the left ventricular ejection fraction spectrum: Data from the Swedish Heart Failure Registry

“…1,9 Several studies explored the prevalence of CV and non-CV comorbidities and their association with outcomes and health status using data from major randomized clinical trials. 7,8,10 However, patients with comorbidities are often under-represented in clinical trials due to enrolment criteria, safety aspects, e.g. severe kidney disease, and to magnify the observed effects of the studied treatment, limiting the generalizability of multimorbidity assessment.…”

Digital consults to optimize guideline‐directed therapy: design of a pragmatic multicenter randomized controlled trial

“… 5 It is advised to set up GDMT with rapid sequencing and avoid delays. 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 Nonetheless, there is a substantial proportion of GDMT underuse where slow optimization, low target dose achievement, and/or discontinuation have been reported. 1 , 15 , 16 Furthermore, race/ethnicity, gender, and socio‐economic status also impact GDMT use.…”