Perspective:

It is well established that there is great benefit associated with HF GDMT, but getting patients on evidence-based recommended doses of these therapies has remained a challenge. The reasons for this are complex and generally are not solely due to a single clinical factor. The STRONG-HF trial addressed an aspect of this dilemma by demonstrating the value of an early and intense medication titration strategy with close clinical follow-up after hospitalization for acute HF. This approach helped to reduce the composite outcome of all-cause death or first HF rehospitalization at 180 days and was generally safe with increased rates of nonserious adverse events but similar rates of serious adverse events.

The secondary analysis carried out in this studied examined if these outcomes were similar when stratifying patients by baseline HF risk, as determined by a broadly applicable MAGGIC risk calculator. This approach was intended to capture the multifactorial nature of HF risk rather than focus on a single clinical variable (like left ventricular ejection fraction or natriuretic peptide level). In practice, a patient’s perceived level of baseline risk may affect treatment choices, such as deciding not to rapidly up-titrate medications in those at high HF risk with significant co-morbidities. It is reassuring that the results of this study demonstrated similar benefit with an HIC strategy despite baseline HF risk, giving clinicians confidence that all patients in this setting can safely benefit from early optimization of HF care. Of note, this study was conducted before the recommendations for routine SGLT2 inhibitor use in HF, so the impact of this change on the study findings is unclear.