The prevalence of heart failure (HF) continues to steadily rise and now more than
64 million people globally carry the diagnosis.
1
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
Fortunately, for patients with HF with reduced ejection (HFrEF), there are now multiple
medications definitively proven to substantially increase survival, reduce hospitalizations,
and improve patient quality of life. Specifically, the utilization of quadruple GDMT,
which includes simultaneous treatment with an angiotensin receptor-neprilysin inhibitor
[ARNI], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium glucose
co-transporter-2 inhibitor [SGLT2i]), in patients with HFrEF yields an estimated 73%
relative reduction in mortality over a 2-year period.
3
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 US outpatients
with HFrEF may receive triple therapy (angiotensin converting enzyme inhibitors [ACEi]/angiotensin
receptor blockers [ARB]/ARNI, beta-blocker, and MRA).
4
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 US 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
Likewise, sizeable underuse of medication exists for both generic (e.g., mineralocorticoid
receptor antagonist) and branded medications (e.g., sacubitril/valsartan). Instead,
a growing body of evidence strongly suggests clinical inertia towards medication changes
and a systemic lack of therapeutic urgency as dominant drivers of widespread medication
underuse.
4
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References
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- Simultaneous or Rapid Sequence Initiation of Quadruple Medical Therapy for Heart Failure-Optimizing Therapy With the Need for Speed.JAMA Cardiol. 2021; 6: 743-744
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- 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.J Am Coll Cardiol. 2020; 76: 2527-2564
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Article info
Publication history
Accepted:
February 13,
2023
Received:
February 13,
2023
Publication stage
In Press Journal Pre-ProofFootnotes
Funding
None
Conflict of Interest Statement
Dr Fonarow has served as a consultant for Abbott, Amgen, AstraZeneca, Bayer, Cytokinetics, Eli Lilly, Janssen, Medtronic, Merck, Novartis, and Pfizer. Dr Greene has received research support from the Duke University Department of Medicine Chair's Research Award, American Heart Association (#929502), National Heart, Lung, and Blood Institute, Amgen, AstraZeneca, Bristol Myers Squibb, Cytokinetics, Merck, Novartis, Pfizer, and Sanofi; served on the advisory board for Amgen, AstraZeneca, Boehringer Ingelheim/Lilly, Bristol Myers Squibb, Cytokinetics, Roche Diagnostics, scPharmaceuticals, and Sanofi; and served as a consultant for Amgen, Bayer, Boehringer Ingelheim/Lilly, Bristol Myers Squibb, CSL Vifor, Corteria Therapeutics, Merck Sharp, PharmaIN, Roche Diagnostics, Sanofi, Tricog Health, and Urovant Pharmaceuticals; and has received speaker fees from Boehringer Ingelheim and Cytokinetics.
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- Time to Triple Therapy in Patients With de Novo Heart Failure With Reduced Ejection Fraction: a Population-Based StudyJournal of Cardiac Failure
- PreviewHeart 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
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