Cardiovascular Atlas
About
Menu

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

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.

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

  • Idea
  • In this atlas

Overview

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.

Hypothesis

Hypothesis, not a result. Nothing here has been demonstrated.

Raising guideline-directed heart-failure medicines to full recommended doses within about 2 weeks of discharge, with close follow-up, lowers the risk of heart-failure readmission or death in the following months compared with usual care.

Maturity
Tested
Rationale
The STRONG-HF abstract says there is little evidence on the dose and pace of up-titration after admission for acute heart failure.
Proposed test
STRONG-HF randomly assigned 1078 people to high-intensity care or usual care before discharge and compared heart-failure readmission or all-cause death up to day 180. High-intensity care used four scheduled outpatient visits over 2 months that closely monitored clinical status, laboratory values and NT-proBNP.

Objections

  • The trial was open-label.
  • It was stopped early on the data and safety monitoring board's recommendation, and results of patients enrolled before a protocol amendment to the primary endpoint were down-weighted.
  • More adverse events occurred by 90 days with high-intensity care (41% against 29%), although serious and fatal adverse events were similar.
  • The approach needs four scheduled visits over 2 months and regular laboratory tests, so it depends on clinic capacity.
  • It is one trial, and the registry record still shows an unknown status and an enrollment target that does not match the paper.

Claims and evidence

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.
Eligibility: 3 inclusion criteria; 1 exclusion criterion
Included
  • Aged 18 to 85 years
  • Admitted to hospital with acute heart failure
  • Not treated with full doses of guideline-directed drug treatment
Excluded
  • Exclusion criteria were not read; the abstract does not list them

  • Effect Interventional Certainty not assessed

    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.

    Applies to Adult
    • 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.
    • Started in hospital before discharge, then outpatient follow-up visits over the 2 months after discharge; 87 hospitals (abstract).
    • 14 countries (abstract).
    • 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.
    Certainty method
    Not assessed
    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
    Next evidence check due
    Not scheduled
    Sources and citations (11)

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, FINDINGS, sentence 1
      How it applies
      Randomized numbers and dates. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, FINDINGS, sentence 3
      How it applies
      The trial was stopped early. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, FINDINGS, sentence 4
      How it applies
      Share of patients on full doses by day 90. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, FINDINGS, sentence 6
      How it applies
      Primary endpoint results. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, FINDINGS, sentence 7
      How it applies
      Adverse events. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, METHODS, sentence 1
      How it applies
      Population and sites. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, METHODS, sentence 3
      How it applies
      What high-intensity care involved. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, METHODS, sentence 4
      How it applies
      The primary endpoint. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, METHODS, sentence 7
      How it applies
      The primary endpoint amendment and down-weighting. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    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 · Lancet (London, England) · Edition PubMed record (abstract and bibliographic data) from NCBI E-utilities. The full text and the version of record were not fetched. · Published 2022-12-03 · DOI: 10.1016/S0140-6736(22)02076-1 · PMID: 36356631

      Locator
      Abstract, FUNDING, sentence 1
      How it applies
      Funder named in the abstract. Abstract of the paper from PubMed; the full text was not read.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      6bca9f958f9cab95e607850af7d99db8cab7c54c1efd6325b859731b003a11f5
      Reuse basis
      PubMed record fetched through NCBI E-utilities. Only the hash of the bytes is kept, because publisher copyright may apply to the abstract (https://pubmed.ncbi.nlm.nih.gov/disclaimer/). Short factual quotations under 25 words, with the citation.

    11. Background Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies

      Registry · U.S. National Library of Medicine (ClinicalTrials.gov) · Edition ClinicalTrials.gov API v2 record, last update posted 2021-02-12. · NCT: NCT03412201

      Locator
      protocolSection.statusModule.overallStatus
      How it applies
      The registry still shows UNKNOWN, while the paper says the study is complete.
      Retrieved
      Source effective date
      2021-02-12
      Source state
      Current
      Snapshot hash
      3afb59a53e64cdd6f00bcba48f637f97f197998949918f073750fc515e5278a7
      Reuse basis
      Registry record. The raw API JSON is committed at research/snapshots/ce-ctgov-NCT03412201.json. The ClinicalTrials.gov terms page is rendered by JavaScript and its text was not read, so the redistribution basis is unverified. Public text is quote, following Ben's decision of 2026-10-13 (medical-atlas-core issue 2) that registries allow short quotations with attribution. Any quotation stays short.

Record details

Record id
cardio:idea-rapid-hf-medicine-uptitration
Content hash
1a87e10113c45b433e67a1c3613116225fa90ed9e043e6e92a5ba86655a8a179