Your participation begins during a hospital stay for acute heart failure, which is a sudden worsening of heart failure symptoms. This admission occurs within 24 to 48 hours before the initial screening.

During this time, you experience shortness of breath at rest and fluid buildup in the lungs visible on chest X-ray. Other symptoms may include swelling and abnormal lung sounds when examined with a stethoscope.

Medical staff will measure your blood pressure, which must be at least 100 mmHg, and your heart rate, which must be at least 60 beats per minute.

A blood test will check your potassium level, which must be 5.0 mEq/L or lower.

Blood tests will also measure NT-proBNP, a substance in the blood that indicates heart stress. At this stage, the level must be above 1,800 pg/mL (or 2,350 pg/mL if you have an irregular heart rhythm called atrial fibrillation).

One to two days before leaving the hospital, additional measurements will be taken.

Your blood pressure must still be at least 100 mmHg and your heart rate at least 60 beats per minute within 24 hours before this assessment.

Your potassium level must remain at 5.0 mEq/L or lower within 24 hours before this assessment.

Another NT-proBNP blood test will be performed. At this point, the level must be above 1,000 pg/mL (or 1,300 pg/mL if you have atrial fibrillation) to confirm that heart stress persists.

Your current heart failure medications will be reviewed. If your heart’s pumping ability is reduced (measured as ejection fraction below 50%), you should be taking less than half the optimal dose of medications including ACE inhibitors (such as enalapril, ramipril, lisinopril, quinapril, trandolapril, fosinopril, or captopril), ARBs (such as losartan, valsartan, candesartan, irbesartan, or olmesartan), ARNIs (sacubitril valsartan), mineralocorticoid receptor antagonists (such as spironolactone, eplerenone, canrenone, potassium canrenoate, or finerenone), and beta-blockers (such as bisoprolol, nebivolol, carvedilol, or metoprolol).

If your heart’s pumping ability is preserved (ejection fraction above 50%), you should be taking less than half the optimal dose of mineralocorticoid receptor antagonists.

You will be assigned to one of two approaches: either a program to gradually increase your heart failure medications following a specific schedule, or continuation of your usual care.

This assignment determines how your medications will be managed over the following year.

If assigned to the medication increase program, your doses of heart failure medications will be gradually adjusted over time.

The medications involved may include ACE inhibitors (captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, or trandolapril), ARBs (candesartan, irbesartan, losartan, olmesartan, or valsartan), ARNIs (sacubitril valsartan), beta-blockers (bisoprolol, carvedilol, metoprolol, or nebivolol), mineralocorticoid receptor antagonists (canrenone, eplerenone, finerenone, potassium canrenoate, or spironolactone), and SGLT2 inhibitors (dapagliflozin or empagliflozin).

All medications are taken by mouth.

The specific doses, frequency, and duration of each medication will be determined individually based on your response and tolerance.

If assigned to usual care, your medications will be managed according to standard practice without following the specific increase program.

Your health will be monitored for one year after assignment to your treatment approach.

During this time, information will be collected about hospital readmissions for heart failure, worsening of heart failure symptoms, and survival.

Your quality of life will be assessed using a standardized questionnaire.

Information will be gathered about whether you continue taking your medications as prescribed or if doses are reduced or stopped.

Any unwanted effects from the medications will be recorded.

Blood tests may be performed to measure biomarkers, which are substances in the blood that provide information about your heart condition.

Changes in your heart’s pumping ability may be assessed through imaging tests.