A list of all quality 4 items from The Binding of Isaac: Rebirth, ranked from best to worst. We combined votes from 29 players to create this list. Based on the latest version of The Binding of Isaac: Repentance. Quality is the game's internal tier list for items. Quality 4 is the highest tier, so these items are typically the most powerful.
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Death Certificate, Sacred Heart, R Key
C Section, Brimstone, Twisted Pair, Glitched Crown, Godhead
Polyphemus, Sacred Orb, The D6, Spindown Dice, Cricket's Head, Tech X, Incubus, Mom's Knife, The Wafer, Crown of Light, Haemolacria, Magic Mushroom, Holy Mantle, 20/20, D Infinity
Revelation, Pyromaniac, Stop Watch, Ipecac, Psy Fly, Mega Mush, Flip
Dr. Fetus, Satanic Bible, Epic Fetus, Mega Blast, Binge Eater, Void, Abyss
Mom's Shovel, Broken Shovel
