Dr Jasper Brugts

My name is Jasper Brugts, I'm a cardiologist from Erasmus Medical Centre, and I will talk about TITRATE-HF.

What specific gaps in heart failure management prompted you to establish this quality of care registry?

Well with the new guidelines in 2021 it was important to study the GDMT up-titration and sequencing order of drugs. And we especially wanted to study de novo heart failure: so a patient with a new diagnosis and no chronic heart failure or worsening heart failure. And that's exactly what we did in TITRATE-HF and that is a big cohort study on quality of care in the Netherlands.

Could you tell us about the study design and patient population?

So the TITRATE-HF study is a prospective ongoing registry. It's for quality of care for heart failure patients. And basically we included consecutively about 4,000 patients with impaired LV function, that could either be newly diagnosed heart failure, chronic heart failure or worsening heart failure across 48 sites in the Netherlands—that's about 70% of our heart failure clinics. And we had an inclusion period between 2022 and 2024—so including the latest updates of the guidelines.

What are the key outcomes?

The key outcomes are that the GDMT implementation are quite appropriate in the Netherlands. We reach GDMT levels in the no heart failure of about 65% at six months. But we see that the dosing can be improved and, especially when you look at the titration of GDMT medication after the first one or two quite active months, we see that after two months the activity on up-titration slows down. And I think that's a clear point of improvement for implementation research, how to keep on optimising patients on their treatment.

Were there any surprising or unexpected results?

Well, I think it's important that you see the implementation levels off after the first initial months. That's important if you want to improve the system. But we also encountered that the heart failure care was better at heart failure dedicated clinics with heart failure nurse specialists. That's important for system improvement. And we observed quite some LV remodeling on serial echo data from baseline to 12 months, considerable improvement in LVF with GDMT. And also the prognosis of a de novo heart failure cohorts was relatively good, and that's important for future guidelines as well.

What strategies have been most effective in improving guideline adherence based on your findings?

Yeah, in our study we clearly observed that a strategy with a dedicated heart failure nurse and a dedicated heart failure outpatient clinic setting gives the best GDMT implementation strategy. But also there's room for improvement, especially considering target dose and max dose achieved.

What are the next steps?

The next step is to go with subgroup analysis of the main TITRATE-HF study to look at elderly comorbidities and gender, to see any differences in GDMT implementations. And the next step for the study itself is to study implementational research: how can we go from registration of care to implementing better care? And probably we will design a follow-up study of TITRATE to really look into implementation research as a next step.