Quadruple therapy in HFpEF with type 2 diabetes: Time to implement?

Heart failure with preserved ejection fraction (HFpEF) has entered a new therapeutic era.After years of largely symptomatic management, multiple disease-modifying drug classes now offer meaningful benefit across the ejection fraction (EF) >40% spectrum [1][2][3][4][5][6].The practical challenge is no longer whether any single agent works, but how to deliver a coherent, rapid, phenotype-aligned combination strategy (Figure 1).In this context, Gu and colleagues [7] studied 1445 patients hospitalized with HFpEF (EF 50%) and type 2 diabetes, comparing outcomes across post-discharge regimens using 4 drug classes: sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), angiotensin receptor-neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonist (MRA).Patients on all 4 drugs had the lowest rates of cardiovascular (CV) death or HF hospitalization (45.4%), compared to 54.1%-57.5% in