Management of Patients with Heart Failure At Home After Hospital Discharge (STRONG@HOME)

Contemporary Post-Discharge Management in Heart Failure At Home

This study aims to assess whether patients with acute heart failure (HF) can achieve the same level of HF-therapies by digital follow-up at home as compared to hospital visits according to the STRONG-HF strategy. Patients admitted to hospital with acute HF will be enrolled and randomized to either follow-up at the hospital out-patient clinic or digital follow-up at home.

Study Overview

• Status: Recruiting
• Conditions: Heart Failure
• Intervention / Treatment: Other: Digital follow-up and uptitration of medications at home after hospital discharge for heart failure; Other: Follow-up and uptitration of medications at the hospital outpatient-clinic after hospital discharge for heart failure

Detailed Description

This study seeks to enhance the management of HF patients by demonstrating that follow-up and medication up-titration can be effectively carried out digitally at home, thereby relieving the burden on healthcare systems and patients. There exists a substantial knowledge gap in the implementation of life-saving HF drugs that have been shown to significantly reduce mortality in HF patients, by as much as 73%. Despite strong evidence from clinical trials and guidelines, the utilization of optimal HF therapy among patients remains low. The successful STRONG-HF trial demonstrated improved outcomes through early and rapid up-titration of HF medications and follow-up at specialized HF clinics after discharge, and this strategy is now strongly recommended in the updated European Society of Cardiology Heart Failure Guidelines from 2023. However, a major challenge was the need for patients to travel to the hospital for weekly visits, which posed significant barriers for many patients, especially in geographically dispersed regions due to travel distance, immobility, and logistical challenges. To address this gap, the STRONG@HOME trial aims to conduct visits and rapid up-titration of medications in the patient's home, a strategy not previously tested in a clinical trial and with direct clinical implications. The success of this approach has the potential to improve HF care globally and advance the field of implementation science in HF and other chronic diseases.

• Study Type: Interventional
• Enrollment (Estimated): 450
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Peder L Myhre, MD, PhD; Phone Number: +47 93025644; Email: p.l.myhre@medisin.uio.no
• Study Contact Backup: Name: Henrik Schirmer, MD, PhD; Email: henrik.schirmer@medisin.uio.no

Study Locations

• Norway
  • Akershus
    • Lørenskog, Akershus, Norway, 1478
      • Recruiting
      • Akershus University Hospital
      • Contact: Terjei Øvrebotten, MD; Phone Number: +4767960000; Email: tarjei.ovrebotten@gmail.com
  • Vestre Viken
    • Drammen, Vestre Viken, Norway, 1878
      • Recruiting
      • Drammen Hospital, Vestre Viken HF
      • Contact: John Munkhaugen, MD PhD; Phone Number: +47 32 80 30 00; Email: johmun@vestreviken.no

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Hospital admission within the 72 hours prior to screening for acute HF.
• NT-proBNP > 1,500 pg/mL measured during the hospitalization
• Systolic blood pressure ≥ 100 mmHg and of heart rate ≥ 60 bpm within 24 hours before randomization
• Serum potassium ≤ 5.0 mEq/L (mmol/L).
• ≤ ½ the optimal dose of ACEi/ARB/ARNi or beta-blocker or MRA.
• Written informed consent to participate in the study.

Exclusion Criteria:

1. Age below 18 or above 85 years.
2. Clearly documented intolerance to high doses of beta-blockers
3. Clearly documented intolerance to high doses of renin-angiotensin system (RAS) blockers (both ACEi and ARB).
4. Renal disease or estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73m2 at screening or history of dialysis.
5. Prior (defined as less than 30 days from screening) or current enrollment in a HF intervention or participation in an investigational drug or device study within the 30 days prior to screening
6. Index event (admission for acute HF) triggered primarily by a completely reversable etiology so that it is unlikely the patient will be classified with chronic HF after discharge, such as Takotsubo syndrome (stress cardiomyopathy). In the setting of acute coronary syndrome or tachycardia, this should be managed before considering the presence of HF. This does not apply to patients with chronic HF prior to the index event.
7. Severe non-adherence to medications
8. Psychiatric or neurological disorder, cirrhosis, or active malignancy leading to a life expectancy less than 6 months.
9. History of heart transplant or on a transplant list, or using or planned to be implanted with a ventricular assist device.
10. Uncorrected thyroid disease, active myocarditis, or known amyloid or hypertrophic obstructive cardiomyopathy.
11. Inability to comply with all study requirements, due to major co-morbidities, social or financial issues, or a history of noncompliance with medical regimens, that might compromise the patients ability to understand and/or comply with the protocol instructions or follow-up procedures.
12. Low digital competency classified as inability to handle a smartphone or tablet.
13. Language barriers requiring the need for an external interpreter.
14. Pregnant or nursing (lactating) women.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Home care; Follow-up and management of HF medications at home visits after 1, 2, 3 and 6 weeks performed by telecommunication led by HF nurses in close communication with physician at the institution. Around week 2 a single visit to the primary care physician's office is required.	Other: Digital follow-up and uptitration of medications at home after hospital discharge for heart failure; Both arms will treat the patients according to the STRONG-HF intensive care strategy, as recommended by current guidelines. That is up-titration to at least half of maximum tolerated doses of HF medications at discharge, followed by up-titration to maximum tolerated doses after 2 weeks. Safety visits will be performed after 1, 3 and 6 weeks.; Other Names: Dignio (digital healthcare platform); Checkware (digital healthcare platform); Nimble (digital healthcare platform)
Active Comparator: Hospital care; Follow-up and management of HF medications provided by specialists at the participating institutions' outpatient clinics after 1, 2, 3 and 6 weeks. (Same as the high-intensity arm in STRONG-HF)	Other: Follow-up and uptitration of medications at the hospital outpatient-clinic after hospital discharge for heart failure; Both arms will treat the patients according to the STRONG-HF intensive care strategy, as recommended by current guidelines. That is up-titration to at least half of maximum tolerated doses of HF medications at discharge, followed by up-titration to maximum tolerated doses after 2 weeks. Safety visits will be performed after 1, 3 and 6 weeks.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Guideline recommended medical treatment Score (0-9)	Patients are assigned a score for each of the four drug classes, and the sum of these is the total score. For beta-blockers and ACEi/ARBs, patients are assigned 0 (no treatment), 1 (<50% target daily dose), or 2 points (≥50% target daily dose) for each therapy. Any dose of ARNI instead of ACEi/ARB are assigned 3 points. Any dose of MRA and SGLT2i are assigned 2 points. Proportion of patients with ≥50% dose of ACEi/ARB/ARNI, MRA and beta blocker and treatment with SGLT2i	90 days
Treatment-emergent adverse events	Proportion of patients with eGFR of <30 mL/min/1.73 m2, systolic BP of <95 mm Hg, heart rate of <50 bpm, and serum potassium of >5.5 mmol/L.	90 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Achieved dose in each of the components of the primary endpoint (mg)	Renin-angiotensin-system blockers, mineralocorticoid receptor antagonists and beta blockers, and treatment with sodium-glucose cotransporter-2-inhibitors	90 days
Proportion of patients with baseline LVEF<40% with ≥50% dose of guideline recommended heart failure medications	Proportion of patients with ≥50% dose of renin-angiotensin-system blockers, mineralocorticoidreceptor antagonists and beta blockers, and treatment with sodium-glucose cotransporter-2-inhibitors in the subgroup with baseline left ventricular ejection fraction<40%	90 days
Change in quality of life by EQ-5D index	Measured by EuroQol Group (EQ-5D) index questionnaire (range 11111 to 55555, higher is worse)	90 days
Change in quality of life by EQ-5D VAS	Measured by EuroQol Group (EQ-5D) questionnaire (range 0 to 100, lower is worse)	90 days
Change in N-terminal pro-B-type natriuretic peptide (ng/L)	From baseline	90 days
Change in echocardiographic measures of left ventricular structure	Left ventricular end diastolic volume index (ml/m^2)	90 days
Change in body weight (kg)	From baseline	90 days
Self-care	European Heart Failure Self-care Behaviour [EHFScB] scale (range 9-45, higher is worse)	90 days
Patient satisfaction with digital follow-up	IT-HEART questionnaire (range 10-50, higher is worse)	90 days
Number of heart failure readmissions	Admissions to the hospital for heart failure	12 months and 24 months
Number of total readmissions	All admissions to the hospital	12 months and 24 months
Time out of hospital	Days not admitted to a hospital after baseline	12 months and 24 months
Number of deaths	All-cause mortality	12 months and 24 months
Cost	To evaluate the total cost of each follow up strategy by summarizing the cost of healthcare utilization, digital platform costs and travel costs	90 days, 12 months, 24 months
Change in HF-specific quality of life	Minnesota Living with HF questionnaire (range 0-105, higher is worse)	90 days
Change in echocardiographic measure of cardiac diastolic function	E/e' (ratio)	90 days
Change in echocardiographic measure of cardiac systolic function	Left ventricular ejection fraction (%)	90 days

Collaborators and Investigators

• Sponsor: University Hospital, Akershus
• Collaborators: Oslo University Hospital; Drammen sykehus

Publications and helpful links

General Publications

• Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G, Metra M, Ponikowski P, Sliwa K, Voors AA, Edwards C, Novosadova M, Takagi K, Damasceno A, Saidu H, Gayat E, Pang PS, Celutkiene J, Cotter G. 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 Dec 3;400(10367):1938-1952. doi: 10.1016/S0140-6736(22)02076-1. Epub 2022 Nov 7.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2024
• Primary Completion (Estimated): April 1, 2026
• Study Completion (Estimated): April 1, 2028

Study Registration Dates

• First Submitted: August 13, 2024
• First Submitted That Met QC Criteria: August 27, 2024
• First Posted (Actual): August 29, 2024

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: March 21, 2025
• Last Verified: March 1, 2025

More Information

Terms related to this study

• Keywords: heart failure; digital health; remote monitoring
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Heart Diseases; Heart Failure
• Other Study ID Numbers: 721190

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The investigators do not plan to share individual participant data

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No