Deepak Bhatt, MD, MPH: Need for In-Hospital Initiation, Uptitration of GDMT in Acute Heart Failure

For years, many in the heart failure community were banging the drum that in-hospital initiation and rapid uptitration of guideline-directed medical therapy should not just be encouraged, but become the standard for the field.

Still, without a randomized controlled trial, concerns surrounding adverse events, such as hemodynamic instability or other tolerance issues, have led to delays in initiation among patients hospitalized being commonplace, which contributes to negative outcomes.

The community received the news it had been waiting for and they confirmed what many had already suspected: in-hospital initiation of GDMT is not only safe, but was also associated with reduced symptoms, improved quality of life, and reduced risk of 180-day all-cause death or heart failure readmission. Presented at the European Society of Cardiology 2023 Congress, STRONG-HF served as a landmark win for the community and offers an evidence base for this practice.

In late 2023, a posthoc analysis of the trial offered further insight into the benefits of in-hospital initiation and uptitration of the 3 pillars of GDMT included in the trial. When assessed as a continuous time-dependent covariate, results indicated an increase of 10% in the average percentage optimal dose was associated with a reduction in 180-day heart failure readmission or all-cause death (adjusted hazard ratio [aHR], 0.89; 95% Confidence Interval, 0.81-0.98; P=.01) as well as a reduction in 180-day all-cause mortality (aHR, 0.84; 95% CI, 0.73-0.95; P=.007).

In addition to STRONG-HF and subsequent analyses of the trial, data from the SOLOIST-WHF trial expands the evidence base supporting use of in-hospital GDMT initiation to include SGLT2 inhibitors. In the trial, which assessed use of sotagliflozin (Inpefa) in patients hospitalized with acute heart failure, in-hospital initiation contributed to a statistically significant reduction total number of deaths from cardiovascular causes and hospitalizations and urgent visits for heart failure (HR, 0.67; 95% CI, 0.52 to 0.85; P <.001).

Still, even with the benefit illustrated in randomized controlled trials, data suggests the community is far from being able to rest on its laurels, with issues surrounding adherence, which are not unique to heart failure, holding back optimal management of the disease. For more perspective on the push for greater initiation and rapid uptitration of GDMT in heart failure, we sat down with the editorial’s senior author Deepak Bhatt, MD, MPH, director of Mount Sinai Heart. That conversation is the subject of the video found below.

Relevant disclosures for Bhatt include Amarin, AstraZeneca, Sanofi, Pfizer, Roche, Amgen, and Eli Lilly and Company, among others.

References:

1. Cotter G, Davison BA, Adams KF Jr, et al. Effective medications can work only in patients who take them: Implications for post-acute heart failure care. Eur J Heart Fail. Published online December 20, 2023. doi:10.1002/ejhf.3109
2. Mebazaa A, Davison B, Chioncel O, 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(10367):1938-1952. doi:10.1016/S0140-6736(22)02076-1
3. Bhatt DL, Szarek M, Steg PG, et al. Sotagliflozin in Patients with Diabetes and Recent Worsening Heart Failure. N Engl J Med. 2021;384(2):117-128. doi:10.1056/NEJMoa2030183
4. Campbell P. Strong-HF analysis: More rapid uptitration of heart failure therapies confers greater benefit. HCP Live. January 1, 2024. Accessed February 8, 2024. https://www.hcplive.com/view/strong-hf-more-rapid-uptitration-of-heart-failure-therapies-confers-greater-benefit.