Heart failure: an economic meta-analysis favors a combination of four treatments

An analysis of 47 randomized trials

The NET-COST-HFrEF study brings together 47 randomized trials involving 75,978 patients. The researchers conducted a random-effects network meta-analysis, a method that allows multiple treatment strategies to be compared, even when not all have been compared directly within the same trial.

The primary analysis focuses on drugs evaluated in the clinical settings recommended by the 2021 European heart failure guidelines. The main outcomes studied are all-cause mortality and the total number of hospitalizations for heart failure. The available abstract does not specify follow-up durations.

Four classes stand out in the comparison

According to the abstract, mortality and hospitalizations decrease as the number of combined treatments increases. The combination that emerges as most favorable includes an angiotensin receptor–neprilysin inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor.

However, the abstract provides neither absolute risk reductions nor their uncertainty intervals. It therefore does not allow the expected benefit for an individual patient to be quantified, or the differences between strategies to be assessed precisely.

A modeled economic result, not guaranteed savings

The researchers then incorporated efficacy estimates, quality-of-life data and costs into a health economic model. The primary analysis takes the perspective of the UK healthcare system, with scenarios for Sweden and the United States.

Quadruple therapy has the highest probability of being the most cost-effective strategy. Results point in the same direction across the three countries studied. This does not mean it is the cheapest: cost-effectiveness weighs expenditure against estimated health gains.

These results do not constitute an evaluation for France. The authors themselves emphasize that decisions must also account for affordability, budget impact and implementation feasibility.

What we can take away

This analysis supports the clinical and economic value of quadruple therapy for heart failure with reduced ejection fraction. It is not enough to determine the right treatment for each patient or to justify a prescription change without medical advice.