Time to Quadruple Guideline-Directed Medical Therapy as a Key Performance Measure for Heart Failure

The prevalence of heart failure (HF) continues to rise steadily, and now more than 64 million people globally carry the diagnosis. 1 Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392: 1789-1858 Abstract Full Text Full Text PDF PubMed Scopus (6548) Google Scholar Together with a 5-year survival rate of ∼ 50% and high rates of hospitalization, there are few other conditions across medicine that have such an unfortunate combination of being exceedingly common, morbid and deadly. 2 Taylor CJ Ordóñez-Mena JM Roalfe AK Lay-Flurrie S Jones NR Marshall T Hobbs FDR Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population-based cohort study. BMJ. 2019; 364: l223 Crossref PubMed Scopus (215) Google Scholar Fortunately, for patients with HF with reduced ejection (HFrEF), there are now multiple medications definitively proven to substantially increase survival rates, reduce hospitalizations and improve patients’ quality of life. Specifically, the use of quadruple guideline-directed medical therapy (GDMT), which includes simultaneous treatment with an angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA), and sodium glucose cotransporter-2 inhibitor (SGLT2i) in patients with HFrEF yields an estimated 73% relative reduction in mortality over a 2-year period. 3 Bassi NS Ziaeian B Yancy CW Fonarow GC Association of optimal implementation of sodium-glucose cotransporter 2 inhibitor therapy with outcome for patients with heart failure. JAMA Cardiol. 2020; 5: 948-951 Crossref PubMed Scopus (55) Google Scholar However, despite robust clinical trial evidence and Class I guideline recommendations, the implementation of GDMT in real-world clinical practice remains overall poor among patients eligible to receive therapy. For example, less than 25% of eligible U.S. outpatients with HFrEF may receive triple therapy (angiotensin converting enzyme inhibitor [ACEi]/angiotensin receptor blocker [ARB]/ARNI, beta-blocker, and MRA). 4 Greene SJ Butler J Albert NM DeVore AD Sharma PP Duffy CI et al. Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF Registry. J Am Coll Cardiol. 2018; 72: 351-366 Crossref PubMed Scopus (552) Google Scholar Although medication costs are barriers in select circumstances, the totality of evidence strongly suggests that this is not the dominant factor for widespread GDMT underuse. For example, even in the U.S. Veterans Affairs Health system, where cost and access to medication should be much less of an issue, there are comparable gaps in GDMT prescribing. 5 Sandhu AT Kohsaka S Turakhia MP Lewis EF Heidenreich PA Evaluation of quality of care for US veterans with recent-onset heart failure with reduced ejection fraction. JAMA Cardiol. 2022; 7: 130-139 Crossref PubMed Scopus (7) Google Scholar Likewise, sizable underuse of medication exists for both generic (eg, mineralocorticoid receptor antagonists) and branded medications (eg, sacubitril/valsartan). Instead, a growing body of evidence strongly suggests clinical inertia toward medication changes and a systemic lack of therapeutic urgency as dominant drivers of widespread medication underuse. 4 Greene SJ Butler J Albert NM DeVore AD Sharma PP Duffy CI et al. Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF Registry. J Am Coll Cardiol. 2018; 72: 351-366 Crossref PubMed Scopus (552) Google Scholar Time to Triple Therapy in Patients With de Novo Heart Failure With Reduced Ejection Fraction: a Population-Based StudyJournal of Cardiac FailureVol. 29Issue 5PreviewHeart failure (HF) is a major public health problem that involves frequent emergency department (ED) visits, hospital admissions and a 5-year survival rate of approximately 50%.1 With the advent of novel therapies, such as angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is), quadruple therapy is now recommended by practice guidelines for treating patients with HF and reduced ejection fraction (HFrEF).2–4 Full-Text PDF