Heidi James, MD, and Vanessa Cardy, MD
As requested by a listener, Heidi and Vanessa discuss quadruple therapy for reduced ejection fraction (HFrEF) heart failure, as laid out in the ACC/AHA/HFSA (American College of Cardiology/American Heart Association/Heart Failure Society of America) 2022 Guideline for the Management of Heart Failure.
- Quadruple therapy consists of
- Beta blocker
- Mineralocorticoid antagonist
- Angiotensin receptor-neprilysin inhibitors (ARNi)
- Actually 2 medications
- Neprilysin inhibitor (sacubitril) + angiotensin receptor blocker (ARB) (valsartan)
- Sodium-glucose cotransporter-2 inhibitor (SGLT-2i)
- Key takeaways
- Replace angiotensin-converting enzyme (ACE) or ARB alone
- Improve quality and quantity of life
- Recommend regardless of whether or not patient has diabetes
- Studies show
- Are well tolerated
- Are associated with fewer admissions
- Result in improved cardiovascular outcomes
- Show a mortality reduction at 2 years
- Slow progression of renal dysfunction
- Heidi’s and Vanessa’s concerns
- How many BP-lowering meds can one body handle?
- Most patients with heart failure (HF) are already on a lot of meds and we’re now supposed to add 4 (actually 5!)?
- Medications are expensive—who can afford this?
- Real-world implementability
- Can we actually follow through on these recommendations?
- It’s a lot of work!
- Back when HF was managed with triple therapy, only one-third of patients were started on all 3 meds; of those, <1% were at target doses of all 3 meds.
- Stay tuned
- Steve and Ken will discuss and dissect this guideline in an upcoming PCMA!
PEARL: The latest ACC/AHA/HFSA guidelines recommend quadruple therapy, consisting of a beta blocker, mineralocorticoid antagonist, angiotensin receptor-neprilysin inhibitor, and sodium-glucose cotransporter-2 inhibitor, for patients with HFrEF. This is an ambitious goal that is likely beyond the financial and physical tolerability of many patients.
Quadruple medical therapy for heart failure: medications working together to provide the best care
Greene SJ, Khan MS. J Am Coll Cardiol. 2021;77(11):1408-1411. doi: 10.1016/j.jacc.2021.02.006. PMID: 33736822
In-hospital initiation of quadruple medical therapy for heart failure: making the post-discharge vulnerable phase far less vulnerable
Greene SJ, Butler J, Fonarow GC. Eur J Heart Fail. 2022;24(1):227-229. doi: 10.1002/ejhf.2382. PMID: 34779112
La tripla/quadrupla terapia antineurormonale nello scompenso cardiaco tra dubbi, evidenze scientifiche e buon senso clinico [Triple/quadruple therapy in heart failure: integrating scientific evidence with clinical reasoning]
Sinagra G, Sabbadini G, Zecchin M, et al. G Ital Cardiol (Rome). 2007;8(9):559-567.
2022 AHA/ACC/HFSA Heart Failure Guideline: Key Perspectives
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
Heidenreich PA, Bozkurt B, Aguilar D, et al. Circulation. 2022;145(18):e895-e1032. doi: 10.1161/CIR.0000000000001063.