A novel treatment score (QUAD score) to promote treatment optimization in heart failure with a reduced ejection fraction

Abstract

Aims: To help avoid therapeutic inertia, we developed a pragmatic treatment score (QUAD Score) for use in daily practice by healthcare professionals managing patients with a left ventricular ejection fraction (LVEF) < 50% and heart failure. We now investigate the association between achieved QUAD scores and 1 year outcomes.

Methods: This was a multicentre cohort study in consecutive patients with incident heart failure and LVEF <50%, who completed therapy titration between January 2021 and June 2023. The primary outcome was a composite of first hospitalization for heart failure (HHF) and all-cause mortality at 1 year after final therapy titration, for QUAD scores that were poor (<8), good (8-14) or excellent (15-24).

Results: Data were analysed from 1691 participants, collected from 10 UK centres, of whom 30% were women and 82% were White. Median age, N terminal pro-B-type natriuretic peptide (NTproBNP) and LVEF were 70 (59-78.5) years, 1624 (536-4138) ng/L and 34 (25-38) %, respectively. At the start of therapy titration, only 97 (5%) patients were naïve to any of the four pillars of therapy. After investigator-declared final titration, QUAD scores were excellent in 806 (48%), good in 382 (22%) and poor in 503 (30%) patients. Patients who failed eventually to achieve a good or excellent QUAD score were more often women, older and had poorer renal function and higher plasma NTproBNP (P < 0.01). The median number of days to final therapy titration was longer in those who achieved an excellent QUAD score, [174 (99-290) days,133 (80-232) days and 108 (57-193) days P < 0.01, for excellent, good and poor QUAD groups, respectively. There was wide variation in titration schedules across participating centres and overall, 33% of patients completed therapy titration within 90 days, 63% within 6 months and 88% within 1 year. The primary composite outcome at 1 year for those with poor, good and excellent QUAD scores were respectively 16.9%, 9.4% and 5.6%, (log rank P < 0.01), for mortality were 13.1%, 6.5% and 2.4% (log rank P < 0.001) and for first HHF were 7.7%, 3.9% and 3.2% (log rank P < 0.001).

Conclusions: The QUAD score is a simple tool that can help audit and incentivize uptake of guideline-recommended therapy for HFrEF and prevent treatment inertia. Excellent QUAD scores are associated with better outcomes.

Keywords: GRMT; QUAD score; heart failure; optimization; treatment.