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Multicenter Study
. 2025 Dec;12(6):4150-4159.
doi: 10.1002/ehf2.15407. Epub 2025 Sep 8.

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

Henry Oluwasefunmi Savage  1   2 , Jason N Dungu  1   2 , Anthony Dimarco  1   2 , Brian Li  1   2 , Samantha Langley  1 , Jonathan Kojo Amoah  1 , Paraic Cliffe  1 , Archana Ganapathy  1 , Peter Watters  1 , Patricia Campbell  3 , Nicola Melarkey  3 , Simon Duckett  4 , Sean Davies  4 , Matthew Dewhurst  5 , Karen Hann  5 , Louise Clayton  6 , Rhys Williams  7 , Victoria Ruszala  8 , Teresa Onwere-Tan  9 , Fozia Zahir Ahmed  10   11 , Ibrahim Arosi  10 , Kimberly Gray  12 , Mark C Petrie  13 , John G F Cleland  14
Affiliations
Multicenter Study

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

Henry Oluwasefunmi Savage et al. ESC Heart Fail. 2025 Dec.

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.

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Conflict of interest statement

H. O. S. declares educational grant to institution from Abbott and Medtronic; speaker fees from Novartis, Bayer, AstraZeneca; consulting fees from Abbott and Medtronic; travel support from Novartis. P. Cambell reports speaker fees from Pharmacosmos, Vifor Pharma, Boehringer Ingelheim, AstraZeneca, Novartis; non‐financial support from Boehringer Ingelheim. L. C. declares grants from British Heart Foundation; speaker and consulting fees from Novartis, Boehringer Ingelheim and AstraZeneca. J. G. F. C. reports grants from British Heart Foundation; personal fees from Abbott, personal fees from Astra‐Zeneca, grants and personal fees from Bayer, personal fees from Biopeutics, personal fees and non‐financial support from Boehringer‐Ingelheim, grants and personal fees from Bristol Myers Squibb, non‐financial support from Corvia, grants and personal fees from CSL‐Vifor, stock options from HeartFellt, personal fees from Holosis, personal fees from Idorsia, personal fees from Medtronic, personal fees and non‐financial support from NI Medical, grants and personal fees from Pharmacosmos, personal fees from Vectorious, grants and stock options from Viscardia. J. N. D., A. D., B. L., S. L., J. K. A., P. Cliffe, A. G., P. W., N. M., S. Duckett, S. Davies, M. D., K. H., R. W., V. R., T. O.‐T., F. Z. A., I. A., K. G., M. C. P. declare no conflict of interest.

Figures

Figure 1
Figure 1
QUAD score form. Dose, percentage of maximum guideline recommended HFrEF dose of drug; weight, premium score added if all four foundational medication classes prescribed—8. QUAD score interpretation, poor <8, good 8–14, excellent 15–24. HFrEF, heart failure with a reduced ejection fraction; ACEi, angiotensin‐converting enzyme inhibitor; ARNI, angiotensin receptor, neprilysin inhibitor; AIIRB, angiotensin II receptor blocker; BB, beta‐blocker; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium glucose co‐transporter II Inhibitor.
Figure 2
Figure 2
Comparison amongst centres according to treatment optimization time (Panel A) and end optimization QUAD group (Panel B).
Figure 3
Figure 3
Kaplan Meier plot for the composite outcome of mortality and hospitalization for heart failure at 1 year (panel A) and for individual components of mortality at 1 year (panel B) and hospitalization for heart failure at 1 year (panel C), according to QUAD score Groups.
See this image and copyright information in PMC

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