STRONG-HF: This Is the Science, Let's Get It Done

This transcript has been edited for clarity.

Hello. I'm Ileana Piña from Thomas Jefferson University in Philadelphia, and this is my blog.

I want to talk to our audience today about a study that was published relatively recently, mostly out of Europe, named STRONG-HF. This is the baby of Alexander Mebazaa, a wonderful heart failure cardiologist from Paris, and Gad Cotter in Israel.

Get The Drugs on Board Quickly

They thought that we need to get the heart failure drugs on board. You've heard me say so many times on these recordings that we need to get the patients on the right drugs. We've talked about the four pillars of care for low ejection fraction, the heart failure with reduced ejection fraction (HFrEF) population. This includes a sodium-glucose cotransporter 2 (SGLT2) inhibitor, which is our newest addition; a renin-angiotensin system (RAS) inhibitor (in patients with NYHA class II-III disease, the guidelines prefer the angiotensin receptor-neprilysin inhibitor [ARNI]); a beta-blocker; and a mineralocorticoid receptor antagonist (MRA), which is either spironolactone or eplerenone.

How do we do this? We've often talked about how it may take 3 months to do this. Well, the STRONG-HF concept — and it was a randomized trial vs usual care — is to get the drugs on relatively quickly and at good doses. It does require repeated visits, which is something that we do in our postdischarge visit, but not waiting and instead going ahead to uptitrate.

The negative part of it has been very small, which means adverse events in the rapid uptitration and some guides about what's an acceptable blood pressure. I often get asked, well, the blood pressure is 90 mm Hg, so it's too low. I always ask if the patient is symptomatic. Can they stand? Can they walk? Can they talk? Do they look like they're functioning? If so, 90 mm Hg may be acceptable.

I get nervous when it gets into the low 80s. Knowing some guidelines is important. How high do you accept the potassium? When is it that you stop a drug? Is there a break in this where you have to stop and then reassess?

NT-proBNP Guidance

This is all being driven by a very important biomarker that you've heard me talk about before, which is N-terminal pro B-type natriuretic peptide (NT-proBNP). NT-proBNP is such a powerful marker of remodeling and reverse remodeling. If you're uptitrating the drugs and the NT-proBNP is coming down, you're going in the right direction, which is how I use it.

Usually, by the time I'm at 50% of the dose I want, I get an NT-proBNP. If I first see a value of 12,000 pg/mL or 20,000 pg/mL and now in front of me is a value of 2000 or 1000 pg/mL, I am definitely going in the right direction.

Now, we have to implement this very important study. I think every center should be trying to do this. Every heart failure program should be trying to do this. You're going to have to model it to your own system. Not everybody has a postdischarge clinic, and the culture of every system is very different.

If you can adapt it to whatever your system allows, remember that the STRONG-HF strategy had positive benefits. There were certainly decreased hospitalizations. If you want to keep your patients out of the hospital, I've said it before: Let's get them on the right drugs.

We have not been doing a good job, and we've had many excuses for removing the good agents when, in fact, the science does not support it. This is the science. Let's get it done.

This is Ileana Piña, shutting down for today. Thank you.

Ileana L. Piña, MD, MPH, is a heart failure and cardiac transplantation expert. She serves as an advisor/consultant to the FDA's Center for Devices and Radiological Health and has been a volunteer for the American Heart Association since 1982. Originally from Havana, Cuba, she is passionate about enrolling more women and minorities in clinical trials. She also enjoys cooking and taking spin classes.

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