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Traditional Chinese medicine successful in HFrEF

Presented by
Dr Xinli Li, First Affiliated Hospital of Nanjing Medical University, China
ESC 2023
Phase 4, QUEST
In the Chinese QUEST trial, qiliqiangxin capsules decreased the risk of cardiovascular death and heart failure hospitalisation in patients with heart failure with reduced ejection fraction (HFrEF). The capsules were well tolerated, and the authors concluded that qiliqiangxin may be a novel approach in the management of patients with HFrEF.

“Qiliqiangxin has been used in traditional Chinese medicine for over 1,000 years,” said Dr Xinli Li (First Affiliated Hospital of Nanjing Medical University, China). “This product has been shown to reduce NT-proBNP in patients with chronic HF [1].” According to Dr Li, qiliqiangxin upregulates PPAR-y and its coactivator PGC1-a, which inhibits ventricular remodeling. The current randomised-controlled phase 4 trial, named QUEST (ChiCTR1900021929), hypothesised that qiliqiangxin capsules on top of standard-of-care outperform placebo on top of standard-of-care in terms of cardiovascular outcomes in patients with HFrEF [2]. In total, 3,119 patients were randomised 1:1 to qiliqiangxin or a placebo. The primary outcome was the composite of cardiovascular death and hospitalisation for HF.

After a median of 18.3 months of follow-up, the primary endpoint was met, favouring participants in the qiliqiangxin arm over those in the placebo arm (HR 0.78; 95% CI 0.68–0.90; P<0.001). Moreover, qiliqiangxin reduced the risk of both hospitalisation for HF (HR 0.76; 95% CI 0.64–0.90; P=0.002) and cardiovascular death (HR 0.83; 95% CI 0.68–1.00; P=0.045) as individual endpoints.

The qiliqiangxin capsules were well tolerated and did not lead to an increase in adverse events (AEs), serious AEs, or discontinuations related to AEs, compared with placebo.

Prof. Carolyn Lam (Duke-National University of Singapore, Singapore) acknowledged that the QUEST trial adds rigorous scientific evidence for a traditional medicine that is potentially used by millions of patients with HF in China. She also said that the trial design and results bring up a couple of unanswered issues. “Since the rate of SGLT2 inhibitors and device therapy was very low in the study population, I wonder what the effect of qiliqiangxin on top of guideline-directed medical therapy (GDMT) including SGLT2 inhibitors and device therapy is,” she reasoned. “Also, since the prescribed doses of GDMTs are low in China, the effect of qiliqiangxin should be reviewed with different doses of GDMTs. Finally, we need to establish the interaction effect of this traditional medicine with other agents, such as digoxin, and study its effects in patients with HFmEF and HFpEF.”

    1. Li X, et al. J Am Coll Cardiol. 2013;62(12):1065–1072.
    2. Li X, et al. Qiliqiangxin in patients with heart failure and reduced ejection fraction - the QUEST study. Hot Line Session 2, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.

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