Sacubitril/Valsartan versus Spironolactone in Heart Failure with Preserved Ejection Fraction; A Cost per Outcome Analysis

Introduction: Heart failure with preserved ejection fraction (HFpEF) is associated with frequent hospitalizations and an increased risk of death. There are no therapies with certain benefits for the treatment of HFpEF. Spironolactone and Sacubitril/Valsartan have shown marginal significance benefits in HFpEF and are approved to treat this condition. We aimed to compare the value for money of these treatments. Hypothesis: Spironolactone provides better value for money than Sacubitril/Valsartan for preventing HF events in patients with HFpEF. Methods: We compared the cost needed to treat (CNT) to prevent the composite outcome of HF hospitalization and CV death with Spironolactone or Sacubitril/Valsartan. The CNT was estimated by multiplying the annualized number needed-to-treat (aNNT) by the annual cost of therapy. The aNNTs were calculated based on data from the TOP-CAT and PARAGON trials. Costs were based on 2021 US prices. Scenario analyses were performed to attenuate the differences in the studies’ populations. Subgroup analyses were performed for mildly reduced EF. Results: The aNNT to prevent the composite outcome with Sacubitril/Valsartan in PARAGON was 53 [95% CI:28-∞] versus 107 (95% CI:51-∞), with spironolactone in TOPCAT. At an annual cost of $5,100 versus $1,353, The corresponding CNTs were $270,273 (95% CI:142,786-∞) for Sacubitril/Valsartan and $144,773 (95% CI:69,004-∞) for spironolactone. Figure 1 illustrates the results of the scenario and subgroup analysis. Conclusion: Despite lower clinical efficacy, spironolactone provides better value for money than Sacubitril/Valsartan in preventing HF hospitalizations and cardiovascular death among patients with HFpEF.