Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis, Sacramento, California, USA.
School of Medicine, Keck School of Medicine of USC, Los Angeles, California, USA.
JACC Heart Fail. 2023 May;11(5):541-551. doi: 10.1016/j.jchf.2023.01.004. Epub 2023 Mar 1.
Heart failure with reduced ejection fraction (HFrEF) is one of the most costly and deadly chronic disease states. The cost effectiveness of a comprehensive quadruple therapy regimen for HFrEF has not been studied.
The authors sought to determine the cost-effectiveness of quadruple therapy comprised of beta-blockers, mineralocorticoid receptor antagonists, angiotensin receptor-neprilysin inhibitors, and sodium glucose cotransporter-2 inhibitors vs regimens composed of only beta-blockers, angiotensin-converting enzyme inhibitors, and mineralocorticoid receptor antagonists (triple therapy), and angiotensin-converting enzyme inhibitors and beta-blockers (double therapy).
Using a 2-state Markov model, the authors performed a cost-effectiveness study using simulated populations of 1,000 patients with HFrEF based on the participants in the PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) trial and compared them by treatment strategy (quadruple therapy vs triple and double therapy) from a United States health care system perspective. The authors also performed 10,000 probabilistic simulations.
Treatment with quadruple therapy resulted in an increase of 1.73 and 2.87 life-years compared with triple therapy and double therapy, respectively, and an increase in quality-adjusted life-years of 1.12 and 1.85 years, respectively. The incremental cost-effectiveness ratios of quadruple therapy vs triple therapy and double therapy were $81,000 and $51,081, respectively. In 91.7% and 99.9% of probabilistic simulations quadruple therapy had an incremental cost-effectiveness ratio of <$150,000 compared with triple therapy and double therapy, respectively.
At current pricing, the use of quadruple therapy in patients with HFrEF was cost effective compared with triple therapy and double therapy. These findings highlight the need for improved access and optimal implementation of comprehensive quadruple therapy in eligible patients with HFrEF.
射血分数降低的心力衰竭（HFrEF）是最昂贵和最致命的慢性疾病状态之一。尚未研究综合四联疗法治疗 HFrEF 的成本效益。
作者旨在确定由β受体阻滞剂、盐皮质激素受体拮抗剂、血管紧张素受体-脑啡肽酶抑制剂和钠-葡萄糖共转运蛋白 2 抑制剂组成的四联疗法与仅由β受体阻滞剂、血管紧张素转换酶抑制剂和盐皮质激素受体拮抗剂组成的方案（三联疗法）以及血管紧张素转换酶抑制剂和β受体阻滞剂（二联疗法）相比的成本效益。
作者使用两状态马尔可夫模型，基于 PARADIGM-HF（ARNI 与 ACEI 对心力衰竭全球死亡率和发病率影响的前瞻性比较）试验中的参与者，对 1000 例 HFrEF 患者的模拟人群进行了成本效益研究，并从美国医疗保健系统的角度按治疗策略（四联疗法与三联和二联疗法）进行了比较。作者还进行了 10000 次概率模拟。
与三联疗法和二联疗法相比，四联疗法治疗可分别增加 1.73 和 2.87 个生命年，并分别增加 1.12 和 1.85 个质量调整生命年。四联疗法与三联疗法和二联疗法相比的增量成本效益比分别为 81000 美元和 51081 美元。在 91.7%和 99.9%的概率模拟中，与三联疗法和二联疗法相比，四联疗法的增量成本效益比均<150000 美元。
在当前价格下，与三联疗法和二联疗法相比，四联疗法在 HFrEF 患者中的应用具有成本效益。这些发现强调了需要改善获得途径并在符合条件的 HFrEF 患者中优化实施综合四联疗法。
