Quadruple therapy outperforms 'Golden Triangle' in heart failure treatment: Study

A recent study by Jia Tang et al. has highlighted the efficacy of adding SGLT-2 to the combination therapy of angiotensin receptor neprilysin inhibitors (ARNI), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) for cardiac remodelling reversal.

This new quadruple regimen, ARNI + BB + MRA + SGLT-2i, was demonstrated to be superior over the traditional "golden triangle" therapy of Angiotensin-converting enzyme (ACE) inhibitors (ACEI) + BB + MRA in improving left ventricular ejection fraction (LVEF) and associated symptoms.

The ‘Chinese Medical Journal’ featured this study that explored the effectiveness of SGLT-2, ARNI, BB, MRA, ACEIs and ARBs for treating heart failure with reduced ejection fraction (HFrEF). The PubMed, Embase and Cochrane Library databases were searched for relevant randomized trials. Sixty RCTs with 16,425 patients were counted.

Study results in comparison with placebo:

• ARNI + BB + MRA + SGLT-2icombination appears to be superior in improving both left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume index (LVEDVI) compared to other combinations.
• ARNI + BB + MRA + SGLT-2i /ARNI + BB + MRA are better than ACEI + BB + MRA (the golden triangle) in improving LVEF.
• ACEI + BB + MRA + SGLT-2i is better than ACEI + BB + MRA and ARB + BB + MRA to improve LVEDVI and reduce N-terminal pro-BNP, respectively.

Adding SGLT-2i to ARNI/ACEI + BB + MRA reverses cardiac remodelling effectively and the quadruple therapy "ARNI + BB + MRA + SGLT-2i" surpasses the "golden triangle" in enhancing LVEF, as concluded.