Current guidelines recommend quadruple therapy, consisting of four drugs: angiotensin receptor-neprilysin inhibitors (ARNis), sodium-glucose cotransporter-2 inhibitor (SGLT2is), mineralocorticoid receptor antagonists (MRAs), and beta blockers (BBs), for the management of patients with heart failure (HF) and reduced ejection fraction (HFrEF), a condition in which the heart is unable to pump out blood effectively. However, even before the arrival of SGLT2is and the era of quadruple therapy, triple therapy, involving angiotensin converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs), BBs, and MRAs, was and remains under-used in clinical practice.
In this Alberta population-based study, researchers examined patients with newly diagnosed HFrEF to identify barriers in timely initiation of triple therapy and explore the time to initiation of triple therapy use and a new potential quality metric called ‘time to triple therapy’.
Despite guideline recommendations, the researchers found that only one-fifth of patients with HFrEF received triple therapy within 1 year of receiving a HF diagnosis. Those patients more likely to be initiated on triple therapy were younger, had lower left ventricle ejection fraction, higher natriuretic peptide levels, and better renal function. These patients also experienced better clinical outcomes compared to those who received no, mono, or dual therapy.
Furthermore, by implementing and testing the innovative new quality-of-care metric, ‘time to triple therapy’, which could subsequently be expanded to time to quadruple therapy or further as new therapies are developed, the authors demonstrate how these metrics can help clinicians and policy makers evaluate quality of care, as well as identify any existing gaps in current practice.
According to the CVC’s Dr. Nariman Sepehrvand, “Without understanding why triple therapy was underutilized during its reign as guideline-directed medical therapy in HFrEF, we cannot expect to effectively implement quadruple therapy in these patients.”
Along with Dr. Sepehrvand, this study was co-authored by CVC faculty members, Drs. Justin Ezekowitz and Finlay McAlister, and Dr. Majid Nabipoor and Erik Youngson (University of Alberta).
