# Start and step up heart-failure medicines quickly after a hospital stay

Idea · id `cardio:idea-rapid-hf-medicine-uptitration` · Cardiovascular Atlas · release `f6f6f1b6f50379ed` (public)

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Also called: STRONG-HF approach; Rapid up-titration of heart-failure medicines

Browse, organ or system: Heart  
Browse, condition area: Heart failure  

## In plain language

The idea is to aim to raise heart-failure medicines to full recommended doses within about 2 weeks of leaving hospital, with several close follow-up visits, instead of leaving it to usual practice. STRONG-HF, a trial of 1078 people admitted with acute heart failure, found fewer 180-day readmissions or deaths with this approach, although by day 90 not everyone had reached full doses. More adverse events were reported with it. The approach needs scheduled visits and laboratory tests.

## Technical summary

Hypothesis page with maturity set to tested, from one trial. STRONG-HF was open-label, was stopped early on the monitoring board's recommendation, and down-weighted patients enrolled before a protocol amendment to the primary endpoint. It was funded by Roche Diagnostics according to the abstract; the registry lists Heart Initiative as lead sponsor and Roche Diagnostics GmbH as a collaborator. The registry still shows an unknown status and an estimated enrollment of 1800, which does not match the paper. Only the abstract and the registry record were read.

## Claims, with the population each applies to

## Context: Adults aged 18 to 85 admitted to hospital with acute heart failure and not on full-dose guideline-directed treatment (STRONG-HF)

Recipient: Adult; Population: Patients aged 18 to 85 years admitted to hospital with acute heart failure and not treated with full doses of guideline-directed drug treatment, randomized before discharge. 1078 were randomly assigned.; Care setting: Started in hospital before discharge, then outpatient follow-up visits over the 2 months after discharge; 87 hospitals (abstract).; Geography: 14 countries (abstract).; Life stage: Adults aged 18 to 85 years; mean age 63.0 years, 39% female (abstract).; Follow-up: 180 days for the primary endpoint (abstract). Randomization ran from 10 May 2018 to 23 September 2022; data cut-off 13 October 2022.

### In STRONG-HF, an open-label trial of adults aged 18 to 85 admitted to hospital with acute heart failure and not on full doses of guideline-directed drugs, 1078 people were randomly assigned before discharge to usual care or high-intensity care. High-intensity care aimed to raise treatments to 100% of recommended doses within 2 weeks of discharge and added four scheduled outpatient visits over the next 2 months that closely monitored clinical status, laboratory values and NT-proBNP. Heart-failure readmission or all-cause death up to day 180 occurred in 74 of 506 people in the high-intensity group (15.2%, a down-weighted adjusted estimate) and 109 of 502 in the usual-care group (23.3%) (adjusted risk difference 8.1%, 95% CI 2.9 to 13.2; risk ratio 0.66, 95% CI 0.50 to 0.86). By day 90, full doses had been reached by 55% of the high-intensity group for renin-angiotensin blockers (against 2% with usual care), 49% for beta blockers (4%) and 84% for mineralocorticoid receptor antagonists (46%). More adverse events occurred by 90 days with high-intensity care (223 of 542, 41%, against 158 of 536, 29%), with similar numbers of serious adverse events (88 against 92) and fatal adverse events (25 against 32). The trial was stopped early on the data and safety monitoring board's recommendation because the between-group differences were greater than expected.

- Category: Effect
- Evidence stage: Interventional
- Certainty: Certainty not assessed
- Applies to: Recipient: Adult; Population: Patients aged 18 to 85 years admitted to hospital with acute heart failure and not treated with full doses of guideline-directed drug treatment, randomized before discharge. 1078 were randomly assigned.; Care setting: Started in hospital before discharge, then outpatient follow-up visits over the 2 months after discharge; 87 hospitals (abstract).; Geography: 14 countries (abstract).; Life stage: Adults aged 18 to 85 years; mean age 63.0 years, 39% female (abstract).; Follow-up: 180 days for the primary endpoint (abstract). Randomization ran from 10 May 2018 to 23 September 2022; data cut-off 13 October 2022.
- Limitations: One open-label trial, stopped early, and the results of patients enrolled before a protocol amendment to the primary endpoint were down-weighted. The percentages for the primary endpoint are adjusted Kaplan-Meier estimates and not simple counts. Roche Diagnostics funded the trial according to the abstract. The numbers come from the PubMed abstract; the full text was not read. The registry record still shows an unknown status and an estimated enrollment of 1800, which does not match the paper. PubMed lists no correction for the paper (checked 2026-10-14). No certainty rating was assessed.
- Last checked: 2026-10-14
- Sources:
  1. Supports: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, FINDINGS, sentence 1. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: Randomized numbers and dates. Abstract of the paper from PubMed; the full text was not read.
  2. Supports: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, FINDINGS, sentence 3. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: The trial was stopped early. Abstract of the paper from PubMed; the full text was not read.
  3. Supports: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, FINDINGS, sentence 4. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: Share of patients on full doses by day 90. Abstract of the paper from PubMed; the full text was not read.
  4. Supports: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, FINDINGS, sentence 6. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: Primary endpoint results. Abstract of the paper from PubMed; the full text was not read.
  5. Supports: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, FINDINGS, sentence 7. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: Adverse events. Abstract of the paper from PubMed; the full text was not read.
  6. Background: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, METHODS, sentence 1. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: Population and sites. Abstract of the paper from PubMed; the full text was not read.
  7. Background: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, METHODS, sentence 3. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: What high-intensity care involved. Abstract of the paper from PubMed; the full text was not read.
  8. Background: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, METHODS, sentence 4. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: The primary endpoint. Abstract of the paper from PubMed; the full text was not read.
  9. Background: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, METHODS, sentence 7. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: The primary endpoint amendment and down-weighting. Abstract of the paper from PubMed; the full text was not read.
  10. Background: Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial (Publication, edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched.) <https://doi.org/10.1016/S0140-6736(22)02076-1>
     Locator: Abstract, FUNDING, sentence 1. Retrieved 2026-10-14T18:18:46Z. Source state: Current. Snapshot hash: 6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5.
     How it applies: Funder named in the abstract. Abstract of the paper from PubMed; the full text was not read.
  11. Background: Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies (Registry, edition ClinicalTrials.gov API v2 record, last update posted 2021-02-12.) <https://clinicaltrials.gov/study/NCT03412201>
     Locator: protocolSection.statusModule.overallStatus. Retrieved 2026-10-14T18:18:44Z. Source state: Current. Snapshot hash: 3afb59a53e64cdd6f00bcba48f637f97f197998949918f073750fc515e5278a7.
     How it applies: The registry still shows UNKNOWN, while the paper says the study is complete.

## Connected pages

- Proposed fix: Many people with HFrEF do not receive all recommended medicines at target doses (`cardio:bottleneck-hfref-medicine-gaps`)
- Files under this front: Medicines (`cardio:front-medicines`)

## Provenance

Content hash: 1a87e10113c45b433e67a1c3613116225fa90ed9e043e6e92a5ba86655a8a179
Last substantive edit: 2026-10-14
Evidence last checked: 2026-10-14