From evidence to implementation: Insights from the STRONG-HF Early Adopter Program

• Successful implementation of accelerated titration care pathways inspired by the STRONG-HF trial may be facilitated by multidisciplinary ownership, a shift toward active nurse-led medication titration, and strong patient relationships before discharge

• Early adopters reported encouraging local experience with structured rapid optimization pathways, including high follow-up engagement and reduced use of diuretics in some settings 

• Scaling these models requires addressing staffing and infrastructure barriers, strengthening education around biomarker-guided monitoring, and providing structured implementation and change-management support

The translation of clinical evidence into routine practice requires a shift in operational design. Earlier this year, a first of two global advisory boards took place virtually and brought together leading heart failure specialists and advanced practice nurses to discuss the real-world implementation of high-intensity care models inspired by the STRONG-HF trial.^1,2

The STRONG-HF Early Adopters Program (EAP) has been established to support hospitals and health systems in the implementation of evidence-based post-discharge heart failure care pathways. Building on insights from the STRONG-HF clinical protocol, the program is designed to facilitate the translation of clinical evidence into routine practice, with the objective of reducing unwarranted variation in care delivery and accelerating the adoption of guideline-directed medical therapy.^1,2

The attending specialists, whose institutions are part of the STRONG-HF EAP, were Prof. Alexandre Mebazaa (France), Dr. Parin Shah (UK), Dr. Rajiv Sankaranarayanan (UK), Matt Sunter (HF Nurse) (UK),  Dr. Mohammed Farouk (Kuwait), Dr. Sandeep Das (USA), Dr. Emmanuella Egbonim (USA), Dr. Jean-Michel Tartière (France), Dr. Juan Cosin (Spain), and Melinda Copley (Specialist HF Nurse, New Zealand). 

The discussion highlighted that while STRONG-HF demonstrated the clinical benefit of a high-intensity care strategy combining rapid up-titration of guideline-directed therapy with close follow-up , achieving these results systematically depends on structured change management and multidisciplinary collaboration. In a subsequent segment, we will provide an overview of the second in-person advisory board due to take place in Basel, Switzerland. This article focuses on the outcomes of the very first STRONG-HF early adopter program advisory board.

Implementing an accelerated care pathway requires a broad base of stakeholders from the outset. Advisory board participants identified early engagement of heart failure clinicians, specialized nurses, pharmacists and primary care practitioners as an important enabler of implementation. While specialized cardiology clinics typically retain primary ownership of the patient during the initial 8 to 12 weeks of intense titration, transition models vary globally. For example, some institutions utilize a dedicated steering committee to bridge hospital medicine and cardiology, ensuring seamless continuity.

The board emphasized a necessary shift in the role of nursing staff. In models like the Accelerated Treatment Pathway (a protocol inspired by the STRONG-HF study) in New Zealand, highly trained nurse specialists and practitioners drive medication titration directly. This model supports a shift from a predominantly symptom- and congestion-focused approach toward early optimization of guideline-directed, disease-modifying therapy. Successful sites also emphasize front loading care, which involves building strong relationships with patients and families before hospital discharge. Experts considered this early relationship-building important for supporting attendance during the intensive follow-up phase.

Early adopters shared encouraging experience from implementation of structured high-intensity care pathways, although these observations are descriptive and should not be interpreted as comparative effectiveness evidence.

Participating centres reported very low rates of heart failure readmissions among patients enrolled in structured implementation pathways. These observations are descriptive and reflect local implementation experience rather than comparative clinical evidence. For example, specialist HF nurse Melinda Copley shared that in New Zealand the implementation of accelerated treatment pathway led to a reduction of long term diuretic use, with only 15% of patients requiring diuretics by week six. Contrary to historical apprehensions, participants reported that rapid titration was feasible and well accepted within structured implementation pathways.

Despite enthusiasm for these models , across healthcare systems, participants identified several recurring implementation barriers to widespread adoption. Clinical personnel shortages and a lack of dedicated physical space to accommodate frequent initial visits remain the primary global barriers. Furthermore, institutional and political inertia often manifests as staff resistance or a lack of confidence among clinicians when moving away from traditional, slower titration speeds.

Funding pathways also present regional challenges. For instance, in the US, securing sustainable funding for non resident or charity eligible patients can delay clinic access due to administrative staffing constraints. Patient handoff to primary care also requires careful navigation. While some regions retain control within the hospital until week twelve to ensure titration is complete, other systems face challenges due to varying levels of general practitioner confidence in prescribing advanced heart failure therapies.

To scale these care models successfully, hospitals must integrate advanced diagnostics and modern IT infrastructure. Beyond its established role in supporting HF diagnosis, participants highlighted the importance of education on the prognostic information provided by NT-proBNP and on its use alongside clinical assessment and other safety parameters during early post-discharge follow-up.

Innovations in diagnostics, such as existing capillary blood testing technologies, with additional biomarkers relevant to heart failure expected to become available in 2027, offer a promising solution to phlebotomy barriers in rural or home care settings. However, advisory board experts noted that traditional laboratory testing remains critical, as tracking creatinine and potassium levels is essential when altering medication doses.

Overcoming some of the institutional inertia and operational friction could benefit from a non transactional partnership with an industry partner. Participants discussed the potential value of external implementation support, including change-management frameworks, practical deployment tools and approaches for tracking implementation metrics. Such support may complement locally identified clinical champions and multidisciplinary leadership when adapting evidence-based pathways to different healthcare systems.