Does quadruple GDMT improve patient-reported quality of life compared to conventional triple therapy or other partial regimens in adult patients with HFrEF or HFmrEF?
In a real-world Middle Eastern and African cohort, early post-discharge use of quadruple GDMT was associated with significantly better patient-reported quality of life and shorter hospital stays compared to conventional triple therapy in patients with HFrEF or HFmrEF.
Purpose To evaluate whether different real-world prescribing patterns of guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF) or mildly reduced ejection fraction (HFmrEF) are associated with differences in patient-reported quality of life (QoL), and specifically to compare conventional triple therapy, ARNi-based therapy, SGLT2i-based therapy, and full quadruple GDMT. Design/methodology/approach This was a multicentre, cross-sectional descriptive study conducted in two tertiary care centres in Egypt and Saudi Arabia between December 2022 and March 2024. A total of 118 adult patients with LVEF 50% were enrolled at their first follow-up visit after hospital discharge. Participants were grouped according to prescribed HF regimen: conventional triple therapy, ARNi-based therapy, SGLT2i-based therapy, or quadruple GDMT. Quality of life was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) 7–14 days after discharge. Between-group differences were analysed using one-way ANOVA with Tukey HSD post hoc testing, and multivariable linear regression was used to identify predictors of MLHFQ score. Findings Quality-of-life scores differed significantly across the treatment groups. Patients receiving quadruple GDMT had the best QoL, reflected by the lowest mean MLHFQ score (42.77 ± 19.05), whereas those receiving conventional triple therapy had the worst QoL (68.06 ± 19.77). ANOVA showed a statistically significant overall difference between regimens (F(3,114) = 8.135, p 0.001). Post hoc analysis showed significantly better QoL with quadruple GDMT versus conventional triple therapy, and versus the SGLT2i-based triple regimen. In regression analysis, higher serum creatinine and blood urea nitrogen were independently associated with worse QoL, while higher haemoglobin was associated with better QoL. The study also found that patients receiving quadruple GDMT had shorter hospital stays compared with those receiving other regimens. Research limitations/implications The cross-sectional design limits causal inference and temporal interpretation of GDMT effects on quality of life. Residual confounding is possible due to unmeasured factors such as disease severity, medication adherence, duration of therapy, and socioeconomic status. The relatively small sample size and limited geographic scope may affect generalisability. Clinically, the findings support systematic optimisation of GDMT and routine integration of patient-reported outcomes (e.g. MLHFQ) into care. They also highlight the importance of managing renal dysfunction and anaemia to improve QoL and justify further longitudinal and interventional research. Future multicentre, longitudinal studies are warranted to validate these findings and evaluate cost-effectiveness and long-term adherence. Practical implications Clinicians should prioritise early optimisation of full GDMT, particularly incorporating ARNi and SGLT2 inhibitors, where tolerated, to enhance patient-reported quality of life. Routine use of validated tools such as the MLHFQ during follow-up can guide treatment adjustments. Multidisciplinary care – especially pharmacist-led medication reconciliation – may improve GDMT uptake and adherence. Regular monitoring and management of renal function and anaemia are essential to optimise outcomes. Shared decision-making should be emphasised to balance treatment complexity with patient preferences and improve adherence in real-world settings. Social implications Improved optimisation of GDMT may enhance patients' functional status, independence, and ability to participate in daily, social, and occupational activities, thereby reducing caregiver burden and societal costs. Better quality of life and fewer hospitalisations can decrease healthcare resource utilisation and economic strain on health systems. Emphasising patient-reported outcomes supports more equitable, patient-centred care, particularly in diverse and resource-variable settings, helping to reduce disparities in heart failure management and long-term outcomes. Originality/value The study provides novel real-world evidence from the Middle East and Africa on the association between contemporary GDMT combinations and early patient-reported QoL after discharge. Its main value lies in moving beyond traditional clinical endpoints such as mortality and hospitalisation to examine the lived experience of patients receiving different HF regimens. The authors position it as the first multicentre post-discharge study from this region to directly compare QoL across conventional triple therapy, ARNi-based therapy, SGLT2i-based therapy, and full quadruple GDMT.
Mosly et al. (Wed,) studied this question.