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GDMT Mortality Comparison — EECC MCQ

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ModerateCardiac PharmacologyGDMT Mortality ComparisonEECC

A 55-year-old man with HFrEF on carvedilol 25 mg bd, sacubitril/valsartan 97/103 mg bd, eplerenone 50 mg, and dapagliflozin 10 mg asks about the evidence for each individual component. Which GDMT pillar has the largest relative risk reduction for mortality?

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Correct answer: B — Beta-blockers (carvedilol/bisoprolol/metoprolol succinate) have the largest relative mortality reduction in HFrEF (~34% RRR in CIBIS-II, COPERNICUS, MERIT-HF) — though all four pillars provide independent, additive mortality benefits

Comparing the relative risk reductions from landmark trials of each GDMT pillar: (1) Beta-blockers: ~34% RRR all-cause mortality (CIBIS-II: bisoprolol 34%; COPERNICUS: carvedilol 35%; MERIT-HF: metoprolol succinate 34%); (2) ARNI: ~20% RRR CV death (PARADIGM-HF sacubitril/valsartan vs enalapril); ACEi: ~23% RRR mortality (CONSENSUS); (3) MRA: ~30% RRR mortality (RALES: spironolactone); (4) SGLT2i: ~18% RRR CV death (DAPA-HF meta-analysis). However, these comparisons are approximate — trials enrolled different populations at different time points. The key clinical message: all four pillars provide independent, additive benefit, and the combined effect of quadruple therapy is estimated at ~60-70% relative mortality reduction compared with no GDMT. Each untitrated or omitted agent represents missed mortality reduction.

Reference: ESC (2023): HF Guidelines