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Segar MW, Patel KV, Keshvani N, Kannan V, Willett D, Klonoff DC, Pandey A. Electronic Health Record Alert With Heart Failure Risk and Sodium Glucose Cotransporter 2 Inhibitor Prescriptions in Diabetes: A Randomized Clinical Trial. J Diabetes Sci Technol 2024:19322968241264747. [PMID: 39254082 DOI: 10.1177/19322968241264747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND Sodium glucose cotransporter 2 inhibitors (SGLT2i) prevent heart failure (HF) in patients with type 2 diabetes mellitus (T2DM) but prescription rates are low. The effect of an electronic health record (EHR) alert notifying providers of patients' estimated risk of developing HF on SGTL2i prescriptions is unknown. METHODS This was a pragmatic, randomized clinical trial that compared an EHR alert and usual care among patients with T2DM and no history of HF or SGLT2i use at a single center. The EHR alert notified providers of their patient's HF risk and recommended HF prevention strategies. Randomization was performed at the provider level across general and subspecialty internal medicine as well as family medicine outpatient clinics. The primary outcome was proportion of SGLT2i prescriptions within 30 days. Proportion of natriuretic peptide (NP) tests within 90 days was also assessed. RESULTS A total of 1524 patients (median age 75 years, 45% women, 23% Black) were enrolled between September 28, 2021, and April 29, 2022 from 189 outpatient clinics. SGLT2i were prescribed to 1.2% (9/780) of patients in the EHR alert group and 0% (0/744) of those in the usual care group (P value = 0.009). Natriuretic peptide testing was performed within 90 days among 10.8% (84/780) of patients in the EHR alert group and 7.3% (54/744) of patients in the usual care group (P value = 0.02). CONCLUSIONS In a single-center trial with low overall SGLT2i use, an EHR alert incorporating HF risk information significantly increased SGLT2i prescriptions and NP testing although the absolute rates were low.
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Affiliation(s)
- Matthew W Segar
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
| | - Kershaw V Patel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vaishnavi Kannan
- Department of Health System Information Resources (Clinical Informatics), The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Duwayne Willett
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Haller PM, Jarolim P, Palazzolo MG, Bellavia A, Antman EM, Eikelboom J, Granger CB, Harrington J, Healey JS, Hijazi Z, Patel MR, Patel SM, Ruff CT, Wallentin L, Braunwald E, Giugliano RP, Morrow DA. Heart Failure Risk Assessment Using Biomarkers in Patients With Atrial Fibrillation: Analysis From COMBINE-AF. J Am Coll Cardiol 2024:S0735-1097(24)07965-8. [PMID: 39230543 DOI: 10.1016/j.jacc.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Heart failure (HF) is common among patients with atrial fibrillation (AF), and accurate risk assessment is clinically important. OBJECTIVES The goal of this study was to investigate the incremental prognostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), and growth differentiation factor (GDF)-15 for HF risk stratification in patients with AF. METHODS Individual patient data from 3 large randomized trials comparing direct oral anticoagulants (DOACs) with warfarin (ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation], ENGAGE AF-TIMI 48 [Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48], and RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy]) from the COMBINE-AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) cohort were pooled; all patients with available biomarkers at baseline were included. The composite endpoint was hospitalization for HF (HHF) or cardiovascular death (CVD), and secondary endpoints were HHF and HF-related death. Cox regression was used, adjusting for clinical factors, and interbiomarker correlation was addressed using weighted quantile sum regression analysis. RESULTS In 32,041 patients, higher biomarker values were associated with a graded increase in absolute risk for CVD/HHF, HHF, and HF-related death. Adjusting for clinical variables and all biomarkers, NT-proBNP (HR per 1 SD: 1.68; 95% CI: 1.59-1.77), hs-cTnT (HR: 1.39; 95% CI: 1.33-1.44), and GDF-15 (HR: 1.20; 95% CI: 1.15-1.25) were significantly associated with CVD/HHF. The discrimination of the clinical model improved significantly upon addition of the biomarkers (c-index: 0.70 [95% CI: 0.69-0.71] to 0.77 [95% CI: 0.76-0.78]; likelihood ratio test, P < 0.001). Using weighted quantile sum regression analysis, the contribution to risk assessment was similar for NT-proBNP and hs-cTnT for CVD/HHF (38% and 41%, respectively); GDF-15 provided a statistically significant but lesser contribution to risk assessment. Results were similar for HHF and HF-related death, individually, and across key subgroups of patients based on history of HF, AF pattern, and reduced or preserved left ventricular ejection fraction. CONCLUSIONS NT-proBNP, hs-cTnT, and GDF-15 contributed significantly and independently to the risk stratification for HF endpoints in patients with AF, with hs-cTnT being as important as NT-proBNP for HF risk stratification. Our findings support a possible future use of these biomarkers to distinguish patients with AF at low or high risk for HF.
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Affiliation(s)
- Paul M Haller
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany. https://twitter.com/PaulMHaller
| | - Petr Jarolim
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Michael G Palazzolo
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea Bellavia
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elliott M Antman
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - John Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada
| | - Christopher B Granger
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Josephine Harrington
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada
| | - Ziad Hijazi
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Manesh R Patel
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Siddharth M Patel
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Lars Wallentin
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA.
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3
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Taheri H, Chiti H, Reshadmanesh T, Gohari S, Jalilvand A, Arsang-Jang S, Ismail-Beigi F, Ghanbari S, Dadashi M, Asgari A, Mahjani M, Karbalaee‑Hasani A, Ahangar H. Empagliflozin improves high-sensitive cardiac troponin-I and high-density lipoprotein cholesterol in patients with type 2 diabetes mellitus and coronary artery disease: a post-hoc analysis of EMPA-CARD Trial. J Diabetes Metab Disord 2023; 22:1723-1730. [PMID: 37975102 PMCID: PMC10638116 DOI: 10.1007/s40200-023-01305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/05/2023] [Indexed: 11/19/2023]
Abstract
Background Empagliflozin is a sodium glucose cotransporter-2 (SGLT2) inhibitor that has been suggested to improve cardiac function and vascular recovery. The risk of coronary artery diseases is much higher in diabetic patients and is associated with greater morbidity and mortality. High-sensitivity cardiac troponin-I (hs-cTnI) is an important prognostic biomarker in cardiac diseases. Therefore, this study aimed to investigate the effect of empagliflozin compared to placebo on changes in hs-cTnI and lipid profile after 26 weeks of treatment. Methods This was an ancillary study in a randomized trial of patients with concomitant type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) (The EMPA-CARD study). Patients who were already on standard anti-diabetic/anti-ischemic medications were randomized to receive either placebo or empagliflozin 10 mg/daily. Serum hs-cTnI and lipid profile were measured at baseline and after 26 weeks. Results Of the 95 randomized patients, hs-cTnI and lipid profile were measured for a total of 77 patients. No significant difference was observed regarding the baseline characteristics between the two arms. Compared to placebo, empagliflozin significantly reduced hs-cTnI after 26 weeks (mean difference (MD) of -13.242, 95%CI: -14.151 to -12.333, p < 0.001). In the empagliflozin group, non-significant reductions in total cholesterol, LDL-C, and triglyceride have resulted; however, there was an increase in HDL-C level (MD = 2.40,95%CI:0.16-4.60, p < 0.04). Conclusion Empagliflozin compared to placebo was superior in reducing circulating hs-cTnI that may indicate improvements in cardiomyocytes function in patients with T2DM and CAD. Moreover, empagliflozin had a modest impact on the serum lipid profile biomarkers. Trial registration The original EMPA-CARD study has been registered in Iranian Registry of Clinical Trials. www.IRCT.ir, Identifier: IRCT20190412043247N2. Registration Date: 6/13/2020. Registration timing: prospective.
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Affiliation(s)
- Homa Taheri
- Department of Cardiology, Mousavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Hossein Chiti
- Endocrinology and Metabolism Research Centre, Vali-E-Asr Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Tara Reshadmanesh
- Student Research Center, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Sepehr Gohari
- Student Research Center, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ahmad Jalilvand
- Department of Pathology, Mousavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Shahram Arsang-Jang
- Department of Biostatistics, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Faramarz Ismail-Beigi
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Samin Ghanbari
- Department of Cardiology, Mousavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mohsen Dadashi
- Department of Cardiology, Mousavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Atieh Asgari
- Department of Cardiology, Mousavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mahsa Mahjani
- Endocrine Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Karbalaee‑Hasani
- Department of Clinical Biochemistry, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Hassan Ahangar
- Department of Cardiology, Mousavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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4
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Kasiakogias A, Ragavan A, Halliday BP. Your Heart Function Has Normalized-What Next After TRED-HF? Curr Heart Fail Rep 2023; 20:542-554. [PMID: 37999902 PMCID: PMC10746577 DOI: 10.1007/s11897-023-00636-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW With the widespread implementation of contemporary disease-modifying heart failure therapy, the rates of normalization of ejection fraction are continuously increasing. The TRED-HF trial confirmed that heart failure remission rather than complete recovery is typical in patients with dilated cardiomyopathy who respond to therapy. The present review outlines key points related to the management and knowledge gaps of this growing patient group, focusing on patients with non-ischaemic dilated cardiomyopathy. RECENT FINDINGS There is substantial heterogeneity among patients with normalized ejection fraction. The specific etiology is likely to affect the outcome, although a multiple-hit phenotype is frequent and may not be identified without comprehensive characterization. A monogenic or polygenic genetic susceptibility is common. Ongoing pathophysiological processes may be unraveled with advanced cardiac imaging, biomarkers, multi-omics, and machine learning technologies. There are limited studies that have investigated the withdrawal of specific heart failure therapies in these patients. Diuretics may be safely withdrawn if there is no evidence of congestion, while continued therapy with at least some disease-modifying therapy is likely to be required to reduce myocardial workload and sustain remission for the vast majority. Understanding the underlying disease mechanisms of patients with normalized ejection fraction is crucial in identifying markers of myocardial relapse and guiding individualized therapy in the future. Ongoing clinical trials should inform personalized approaches to therapy.
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Affiliation(s)
- Alexandros Kasiakogias
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aaraby Ragavan
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Brian P Halliday
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK.
- National Heart and Lung Institute, Imperial College London, London, UK.
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5
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Palazzuoli A, Iacoviello M. Diabetes leading to heart failure and heart failure leading to diabetes: epidemiological and clinical evidence. Heart Fail Rev 2023; 28:585-596. [PMID: 35522391 PMCID: PMC10140137 DOI: 10.1007/s10741-022-10238-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/11/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is a risk factor that plays a major role in the onset of heart failure (HF) both directly, by impairing cardiac function, and indirectly, through associated diseases such as hypertension, coronary disease, renal dysfunction, obesity, and other metabolic disorders. In a population of HF patients, the presence of T2DM ranged from 20 to 40%, according to the population studied, risk factor characteristics, geographic area, and age, and it is associated with a worse prognosis. Finally, patients with HF, when compared with those without HF, show an increased risk for the onset of T2DM due to several mechanisms that predispose the HF patient to insulin resistance. Despite the epidemiological data confirmed the relationship between T2DM and HF, the exact prevalence of HF in T2DM comes from interventional trials rather than from observational registries aimed to prospectively evaluate the risk of HF occurrence in T2DM population. This review is focused on the vicious cycle linking HF and T2DM, from epidemiological data to prognostic implications.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, S. Maria Alle Scotte Hospital, University of Siena, Siena, Italy
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Via Luigi Pinto 1, 71121, Foggia, Italy.
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6
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Aziri B, Begic E, Jankovic S, Mladenovic Z, Stanetic B, Kovacevic‐Preradovic T, Iglica A, Mujakovic A. Systematic review of sodium‐glucose cotransporter 2 inhibitors: a hopeful prospect in tackling heart failure‐related events. ESC Heart Fail 2023; 10:1499-1530. [PMID: 36967133 DOI: 10.1002/ehf2.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/13/2023] [Accepted: 02/16/2023] [Indexed: 03/28/2023] Open
Abstract
In modern cardiology, sodium-glucose cotransporter 2 (SGLT2) inhibitors are critical components of heart failure (HF) treatment algorithms and exert their effects primarily by preventing glucose reabsorption and facilitating its urinary excretion. The objective was to systematically review randomized controlled trials (RCTs) assessing the effects of SGLT2 inhibitors, particularly canagliflozin, empagliflozin, dapagliflozin, ertugliflozin, sotagliflozin (dual SGLT inhibitor), and their use in HF. Systematic searches of PubMed/Medline, The Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases were performed. There were no restrictions imposed on the date and status of publication; however, there were restrictions on language for the searched studies. A total of 1139 records were identified in the bibliographic searches from both databases and the register of choice for this systematic review. Following duplicate removal, screening for titles and abstracts, and thorough assessment of full-text articles, 12 RCTs met the inclusion criteria. Altogether, 83 878 patients were included in this review. Among the included studies, two RCTs, with six respective reports, investigated canagliflozin, four RCTs with 13 derived reports investigated dapagliflozin, three RCTs with 12 separate reports studied the effects of empagliflozin, one RCT and its three respective reports assessed ertugliflozin's effects, and two RCTs with one added report investigated the dual inhibitor sotagliflozin. Pooled meta-analytic effects of SGLT2 inhibitors were as follows: on atrial fibrillation odds ratio (OR) = 0.83, 95% confidence interval (CI): 0.68-1.01, prediction interval (PI): 0.57-1.19; on HF hospitalization OR = 0.69, 95% CI: 0.60-0.78, PI: 0.60-0.78; on cardiovascular death OR = 0.82, 95% CI: 0.58-1.15, PI: 0.42-1.60; and on major adverse cardiovascular events OR = 0.90, 95% CI: 0.77-1.06, PI: 0.71-1.15. SGLT2 inhibitors significantly improve the quality of life in HF patients. Their beneficial effects on HF, especially in left ventricular dysfunction, have made their use possible irrespective of diabetes mellitus or atrial fibrillation status.
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7
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Agdashian D, Daniels LB. What Is the Clinical Utility of Cardiac Troponins in Heart Failure? Are They Modifiable Beyond Their Prognostic Value? Curr Heart Fail Rep 2023; 20:33-43. [PMID: 36719500 DOI: 10.1007/s11897-023-00588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW To review the role of cardiac troponin (cTn) for prognosis in acute and chronic heart failure, and for predicting heart failure; and to explore the association between troponin and response to heart failure therapies, with an eye toward a possible role for troponin in a personalized approach to heart failure management, beyond prognosis. RECENT FINDINGS A number of therapies, including the neprilysin inhibitor sacubitril/valsartan and sodium-glucose cotransporter-2 inhibitors, have recently been shown to improve outcomes in heart failure patients. Most studies suggest that these agents improve outcomes regardless of baseline cTn concentration, but have greater absolute benefit among patients with highest cTn and baseline risk. Troponin is prognostic across the heart failure spectrum, but whether it can significantly help with heart failure prevention and with tailoring and guiding heart failure treatments and interventions remains unknown.
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Affiliation(s)
- David Agdashian
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, UC San Diego, 9452 Medical Center Drive, La Jolla, CA, 92037-7411, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, UC San Diego, 9452 Medical Center Drive, La Jolla, CA, 92037-7411, USA.
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8
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Tomasoni D, Adamo M, Metra M. January 2023 at a glance: focus on acute heart failure and medical therapy. Eur J Heart Fail 2023; 25:1-3. [PMID: 36715130 DOI: 10.1002/ejhf.2786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/20/2022] [Accepted: 12/31/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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9
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Razaghizad A, Sharma A, Ni J, Ferreira JP, White WB, Mehta CR, Bakris GL, Zannad F. External validation and extension of the TIMI risk score for heart failure in diabetes for patients with recent acute coronary syndrome: An analysis of the EXAMINE trial. Diabetes Obes Metab 2023; 25:229-237. [PMID: 36082521 DOI: 10.1111/dom.14867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 02/01/2023]
Abstract
AIMS The Thrombolysis in Myocardial Infarction Risk Score for Heart Failure (HF) in Diabetes (TRS-HFDM ) prognosticates HF hospitalization in people with type 2 diabetes (T2D). This study aimed to externally validate and extend its use for those with recent acute coronary syndrome (ACS). MATERIALS AND METHODS The TRS-HFDM was externally validated in the Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care (EXAMINE) trial (n = 5380) and extended with natriuretic biomarkers. Missing data were multiply imputed. Initial TRS-HFDM variables were previous HF (2 points), atrial fibrillation (1 point), coronary artery disease (1 point), estimated glomerular filtration rate <60 ml/min/1.73 m2 (1 point), and urine albumin-to-creatinine ratio 30-300 mg/g (1 point) and >300 mg/g (2 points). RESULTS In total, HF hospitalization occurred in 193 (3.6%) patients. Based on the TRS-HFDM , 25% of patients were classified as intermediate risk (1 point), 30% were classified as high risk (2 points), 19% were classified as very-high risk (3 points) and 26% were classified as severe risk (≥4 points). Before model extension, discrimination (C-index 0.76, 95%·CI 0.73-0.80) and calibration (calibration slope 0.82, 95%·CI 0.65-1.0; calibration-in-the-large -0.15, 95%·CI -0.37-0.64) were moderate-to-good in individuals with T2D and recent ACS. The extension of TRS-HFDM with the addition of N-terminal pro-B-type natriuretic peptide (NT-ProBNP) improved discrimination (C-index 0.82, 95%·CI 0.79-0.85) and calibration (calibration slope 0.84, 95%·CI 0.66-1.02; calibration-in-the-large -0.12, 95%·CI -0.33-0.081) for this higher-risk population. CONCLUSION The TRS-HFDM with the extension of NT-ProBNP improves risk stratification and generalizes the use of the risk score for patients with T2D and ACS. Future validation studies in ACS populations may be warranted.
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Affiliation(s)
- Amir Razaghizad
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Jiayi Ni
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique Inserm 1433, Université de Lorraine, CHRU de Nancy, Inserm U1116, FCRIN INI-CRCT & Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - William B White
- Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | | | - George L Bakris
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique Inserm 1433, Université de Lorraine, CHRU de Nancy, Inserm U1116, FCRIN INI-CRCT & Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Université de Lorraine, CIC Insert-CHRU, Nancy, France
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10
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Myhre PL, Vaduganathan M, Claggett BL, Miao ZM, Jhund PS, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Shah SJ, Desai AS, Lindholm D, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Influence of NT-proBNP on Efficacy of Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction. JACC. HEART FAILURE 2022; 10:902-913. [PMID: 36114137 DOI: 10.1016/j.jchf.2022.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND N-terminal pro-B-type natriuretic peptide (NT-proBNP) is used for diagnostic and prognostic evaluation in heart failure (HF). Previous clinical trials in heart failure with mildly reduced ejection fraction (HFmrEF) or heart failure with preserved ejection fraction (HFpEF) have shown potential heterogeneity in the treatment response by baseline NT-proBNP levels. OBJECTIVES The purpose of this study was to assess the treatment effect of dapagliflozin across baseline levels of NT-proBNP among patients with HFmrEF or HFpEF. METHODS This was a post hoc analysis from DELIVER (Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure), a randomized, placebo-controlled trial of dapagliflozin in patients with HFmrEF or HFpEF. Elevated NT-proBNP was part of the inclusion criteria (≥300 ng/L for non-atrial fibrillation or flutter [AFF]; ≥600 ng/L for AFF). Baseline NT-proBNP was categorized in quartiles and additionally analyzed continuously. The primary composite outcome was cardiovascular death or worsening HF events. RESULTS Among the 6,262 included patients (mean: 71.7 years and 3,516 [56%] men), the median baseline concentration of NT-proBNP was 716 (Q1-Q3: 469-1,280) ng/L and 1,399 (Q1-Q3: 962-2,212) ng/L for non-AFF and AFF, respectively. Higher NT-proBNP levels were linearly associated with a greater risk of the primary outcome (adjusted HR for log2NTpro-BNP was 1.53 [95% CI: 1.46-1.62] and Q4 vs Q1: 3.46 [95% CI: 2.48-4.22]; P < 0.001), with consistent results regardless of AFF status. The clinical benefit of dapagliflozin was present irrespective of baseline NT-proBNP concentration (P value for interaction = 0.40 by quartiles and = 0.19 continuously for the primary outcome) and the absolute risk reduction was, therefore, greater with higher NT-proBNP concentrations. The effect on health status and safety of dapagliflozin was similarly consistent across NT-proBNP quartiles. CONCLUSIONS Dapagliflozin is safe and improves outcomes irrespective of baseline NT-proBNP concentrations in HFmrEF or HFpEF, with the greatest absolute benefit likely seen in patients with higher NT-proBNP concentrations. (Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
- Peder L Myhre
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Medicine, Akershus University Hospital, Oslo, Norway; Division of Medicine, University of Oslo, Oslo, Norway
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- British Heart Foundation, University of Glasgow, Glasgow, Scotland, United Kingdom
| | | | | | | | | | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore, Singapore; Duke-National University of Singapore, Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Lindholm
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- British Heart Foundation, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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11
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Riccardi M, Sammartino AM, Piepoli M, Adamo M, Pagnesi M, Rosano G, Metra M, von Haehling S, Tomasoni D. Heart failure: an update from the last years and a look at the near future. ESC Heart Fail 2022; 9:3667-3693. [PMID: 36546712 PMCID: PMC9773737 DOI: 10.1002/ehf2.14257] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San DonatoUniversity of MilanMilanItaly
- Department of Preventive CardiologyUniversity of WrocławWrocławPoland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | | | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Goettingen Medical CenterGottingenGermany
- German Center for Cardiovascular Research (DZHK), Partner Site GöttingenGottingenGermany
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
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12
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Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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13
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Nazer R, Albratty M, Aldhahi MI, Alqurashy M, Halawi MA, Albarrati A. Effect of Dapagliflozin on Exercise Capacity and Cardiovascular Risk in Patients with Heart Failure. Healthcare (Basel) 2022; 10:2133. [PMID: 36360474 PMCID: PMC9690048 DOI: 10.3390/healthcare10112133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/15/2022] [Accepted: 10/21/2022] [Indexed: 09/08/2024] Open
Abstract
Heart failure (HF) is a serious disorder that affects millions of people worldwide, with a high rate of exercise intolerance, rehospitalization, and death. HF has many underlying causes, including type 2 diabetes mellitus (T2DM), which corresponds with high mortality and short survival among patients with HF. Numerous studies have shown the crucial role of gliflozins, a new generation of blood glucose-lowering medications, in cardiac remodeling, with beneficial impacts on exercise capacity and cardiovascular (CV) mortality, even in non-diabetic individuals. The foundational CV-protective frameworks of these agents are intricate and multifaceted. Dapagliflozin is a new widely used drug and a valuable alternative for patients with T2DM and CV risk factors. Dapagliflozin was approved by the Food and Drug Administration (FDA) in 2019 to lower the risk of HF hospitalization in patients with concurrent T2DM and CV disease or associated risk factors. However, the effects of this new drug on exercise capacity and CV risk still need to be elucidated. The primary objective of this review is to summarize the effect of dapagliflozin on exercise capacity and CV risk in patients with HF.
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Affiliation(s)
- Rakan Nazer
- Cardiac Sciences Department, College of Medicine, King Saud University, P.O. Box 2460, Riyadh 11451, Saudi Arabia
| | - Mohammed Albratty
- Department of Pharmaceutical Chemistry & Pharmacognosy, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| | - Monira I. Aldhahi
- Department of Rehabilitation Sciences, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh 11564, Saudi Arabia
| | - Maiasa Alqurashy
- Internal Medicine Department, Security Forces Hospital, P.O. Box 11481, Riyadh 11481, Saudi Arabia
| | - Maryam A. Halawi
- Department of Pharmacy Practice, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
- Department of Haematology, Division of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff CF14 4XN, Wales, UK
| | - Ali Albarrati
- Rehabilitation Health Sciences Department, College of Applied Medical Sciences, King Saud University, P.O. Box 2460, Riyadh 11451, Saudi Arabia
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14
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Diabetes Mellitus and Heart Failure. J Pers Med 2022; 12:jpm12101698. [PMID: 36294837 PMCID: PMC9604719 DOI: 10.3390/jpm12101698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/22/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
The coexistence of diabetes mellitus (DM) and heart failure (HF) is frequent and is associated with a higher risk of hospitalization for HF and all-cause and cardiovascular mortality. It has been estimated that millions of people are affected by HF and DM, and the prevalence of both conditions has increased over time. Concomitant HF and diabetes confer a worse prognosis than each alone; therefore, managing DM care is critical for preventing HF. This article reviews the prevalence of HF and diabetes and the correlated prognosis as well as provides a basic understanding of diabetic cardiomyopathy, including its pathophysiology, focusing on the relationship between DM and HF with a preserved ejection fraction and summarizes the potential aldosterone and the mineralocorticoid receptor antagonists approaches for managing heart failure and DM. Sodium–glucose cotransporter 2 inhibitors (SGLT2Is) are an emerging class of glucose-lowering drugs, and the role of SGLT2Is in DM patients with HF was reviewed to establish updated and comprehensive concepts for improving optimal medical care in clinical practice.
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15
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Hofer F, Pailer U, Sulzgruber P, Gerges C, Winter M, Giugliano RP, Gottsauner‐Wolf M, Hülsmann M, Kazem N, Koller L, Schönbauer R, Niessner A, Hengstenberg C, Zelniker TA. Relationship of diabetes, heart failure, and N-terminal pro-B-type natriuretic peptide with cardiovascular outcomes in patients with atrial fibrillation. ESC Heart Fail 2022; 9:2367-2377. [PMID: 35593128 PMCID: PMC9288777 DOI: 10.1002/ehf2.13930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 03/20/2022] [Accepted: 04/04/2022] [Indexed: 12/11/2022] Open
Abstract
AIMS We aim to explore the relationship of heart failure (HF) and diabetes with cardiovascular (CV) death or hospitalization for HF (HHF) and to study the clinical utility of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in an unselected patient population with atrial fibrillation (AF). METHODS AND RESULTS Patients with AF admitted to a tertiary academic center between January 2005 and July 2019 were identified through a search of electronic health records. We used Cox regression models adjusted for age, sex, estimated glomerular filtration rate, diabetes, HF, body mass index, prior myocardial infarction, coronary artery disease, hypertension, smoking, C-reactive protein, and low-density lipoprotein cholesterol. To select the most informative variables, we performed a least absolute shrinkage and selection operator Cox regression with 10-fold cross-validation. In total, 7412 patients (median age 70 years, 39.7% female) were included in this analysis and followed over a median of 4.5 years. Both diabetes [adjusted (Adj.) HR 1.87, 95% CI 1.55-2.25] and HF (Adj. HR 2.57, 95% CI 2.22-2.98) were significantly associated with CV death/HHF after multivariable adjustment. Compared with patients with diabetes, HF patients had a higher risk of HHF but a similar risk of CV and all-cause death. NT-proBNP showed good discriminatory performance (area under the curve 0.78, 95% CI 0.77-0.80) and the addition of NT-proBNP to the covariates used for adjustment resulted in a significant area under the curve improvement (Δ = 0.04, P < 0.001). With least absolute shrinkage and selection operator, the strongest associations for CV death/HHF were obtained for NT-proBNP [HR 1.91 per 1-SD in log-transformed biomarker], HF (HR 1.72), and diabetes (HR 1.56). CONCLUSIONS Diabetes and HF were independently associated with an increased risk of CV death/HHF in an unselected AF patient population, and NT-proBNP improved risk assessment. These findings suggest that AF patients with diabetes and/or HF should be managed not only for their risk of stroke and systemic embolic events but also for CV death/HHF.
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Affiliation(s)
- Felix Hofer
- Division of CardiologyMedical University of ViennaViennaAustria
| | | | | | | | - Max‐Paul Winter
- Division of CardiologyMedical University of ViennaViennaAustria
| | - Robert P. Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | | | - Martin Hülsmann
- Division of CardiologyMedical University of ViennaViennaAustria
| | - Niema Kazem
- Division of CardiologyMedical University of ViennaViennaAustria
| | - Lorenz Koller
- Division of CardiologyMedical University of ViennaViennaAustria
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16
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Kilpatrick ES. Cardiac Troponin as a Marker of Heart Failure Risk in Diabetes. Clin Chem 2022; 68:1232-1234. [PMID: 35897125 DOI: 10.1093/clinchem/hvac124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Eric S Kilpatrick
- Department of Clinical Biochemistry, Manchester Royal Infirmary, Manchester, UK
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17
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Scheen AJ. Counteracting heart failure with diabetes drugs: a review into the pharmacokinetic and pharmacodynamic properties. Expert Opin Drug Metab Toxicol 2022; 18:381-393. [PMID: 35876091 DOI: 10.1080/17425255.2022.2105693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION : Heart failure (HF) is becoming a huge public health burden. New diabetes drugs for type 2 diabetes (T2D), sodium-glucose cotransporter type 2 inhibitors (SGLT2is), reduce the rate of hospitalization for HF in placebo-controlled trials. AREAS COVERED : Pharmacokinetics of dapagliflozin and empagliflozin (in presence of renal impairment and hepatic dysfunction, two comorbidities frequently associated with HF) and pharmacodynamic studies in patients with HF. Main HF outcomes in T2D patients with cardiovascular risk and in patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction, with or without T2D, from DAPA-HF, EMPEROR-Reduced and EMPEROR-Preserved original findings and post hoc analyses. EXPERT OPINION : No clinically relevant changes are expected concerning SGLT2i pharmacokinetics in patients with HF while pharmacodynamic studies reported improvements in myocardium/vascular parameters, biomarkers and functional status. All SGLT2is showed a remarkable reduction in hospitalization for HF in patients with T2D and high cardiovascular risk. Furthermore, both dapagliflozin and empagliflozin improved the prognosis of patients with HFrEF, independently of the presence of T2D. Similar results were reported with empagliflozin in patients with HFpEF, to be confirmed with dapagliflozin in an ongoing trial (DELIVER). Thus, SGLT2is offer a new opportunity for the prevention and management of HF in patients with or without T2D.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.,Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
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18
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Seferović P, Farmakis D, Bayes-Genis A, Ben Gal T, Böhm M, Chioncel O, Ferrari R, Filippatos G, Hill L, Jankowska E, Lainscak M, Lopatin Y, Lund LH, Mebazaa A, Metra M, Moura B, Rosano G, Thum T, Voors A, Coats AJS. Biomarkers for the prediction of heart failure and cardiovascular events in patients with type 2 diabetes: a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2022; 24:1162-1170. [PMID: 35703329 DOI: 10.1002/ejhf.2575] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/21/2022] [Accepted: 06/13/2022] [Indexed: 11/08/2022] Open
Abstract
Knowledge on risk predictors of incident heart failure (HF) in patients with type 2 diabetes (T2D) is crucial given the frequent coexistence of the two conditions and the fact that T2D doubles the risk of incident HF. In addition, HF is increasingly being recognized as an important endpoint in trials in T2D. On the other hand, the diagnostic and prognostic performance of established cardiovascular biomarkers may be modified by the presence of T2D. The present position paper, derived by an expert panel workshop organized by the Heart Failure Association of the European Society of Cardiology, summarizes the current knowledge and gaps in evidence regarding the use of a series of different biomarkers, reflecting various pathogenic pathways, for the prediction of incident HF and cardiovascular events in patients with T2D and in those with established HF and T2D.
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Affiliation(s)
- Peter Seferović
- Faculty of Medicine, University of Belgrade Belgrade, Serbia and Serbian Academy of Sciences and Arts, Belgrade, Serbia.,University of Belgrade Belgrade, Belgrade, Serbia
| | | | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari German Trias i Pujol, Badalona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,CIBERCV, Instituto de Salud, Madrid, Spain
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, and University of Medicine Carol Davila, Bucharest, Romania
| | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, Ravenna, Italy.,Laboratory for Technologies of Advanced Therapies (LTTA), Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Gerasimos Filippatos
- Second Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrina University of Athens Medical School, Athens, Greece
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Ewa Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Alexandre Mebazaa
- INSERM UMR-S 942, Paris, France; Department of Anesthesiology and Critical Care Medicine, St. Louis and Lariboisère University Hospitals, Paris, France
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Brenda Moura
- CINTESIS - Centro de Investigação em Tecnologias e Serviços de Saúde, Porto, Portugal; Serviço de Cardiologia, Hospital das Forças Armadas - Pólo do Porto, Porto, Portugal
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,IRCCS San Raffaele Pisana, Rome, Italy
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany.,REBIRTH Center for Translational Regenerative Medicine, Hannover Medical School, Hannover, Germany.,Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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19
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Berezin AE, Berezin AA. Sodium-Glucose Co-transporter-2 Inhibitors in Heart Failure with Preserved Ejection Fraction: A Breakthrough in Improvement of Clinical Outcomes? EUROPEAN MEDICAL JOURNAL 2022. [DOI: 10.33590/emj/22-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The conventional conception of the therapy of heart failure (HF) with reduced ejection fraction has been recently modified by adding sodium-glucose co-transporter-2 (SGLT2) inhibitors to the combination consisting of beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors, with the aim of improving clinical outcomes. It remains unclear whether other sub-populations of patients with HF, having either HF with preserved ejection fraction (HFpEF) or HF with mildly reduced ejection fraction, are relevant candidates for the effective therapeutic intervention that includes SGLT2 inhibitors.
The purpose of the narrative review is to elucidate plausible perspectives for the clinical implementation of SGLT2 inhibitors into optimal medical therapy in patients with HFpEF. The authors searched the bibliographic databases (Embase, Medline, and the Web of Science) and the Cochrane Central to find English-written publications satisfying the purpose of this study. The authors included eight studies and two meta-analyses that have been reported as completed and found that there were high heterogeneous data regarding the fact that SGLT2 inhibitors had strict resemblance in their efficacy among patients with HFpEF with and without Type 2 diabetes. Due to the use of unpublished data and findings from the trials ended early, there is a lack of upper left ventricular ejection fraction threshold levels to identify inclusion criteria and no agreement in heart failure with reduced ejection fraction determination. However, the results of the meta-analysis, especially come from subgroups’ analysis, appeared to be relevantly optimistic for use of SGLT2 inhibitors in HFpEF therapy.
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Affiliation(s)
| | - Alexander A. Berezin
- Department of Internal Medicine, Medical Academy of Post-Graduate Education, Zaporozhye, Ukraine
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20
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Cleland JG, Butler J, Januzzi JL, Pellicori P, McDonagh T. Only people with increased plasma concentrations of natriuretic peptides should be included in outcome trials of diabetes, cardiovascular and kidney disease; implications for clinical practice. Eur J Heart Fail 2022; 24:678-680. [PMID: 35297132 DOI: 10.1002/ejhf.2488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- John Gf Cleland
- Institute of Health & Wellbeing, Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow and Visiting Professor of Cardiology, Imperial College London, UK
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - James L Januzzi
- Department of Cardiology Division, Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA, USA
| | - Pierpaolo Pellicori
- Institute of Health & Wellbeing, Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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21
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Klimczak-Tomaniak D, de Bakker M, Bouwens E, Akkerhuis KM, Baart S, Rizopoulos D, Mouthaan H, van Ramshorst J, Germans T, Constantinescu A, Manintveld O, Umans V, Boersma E, Kardys I. Dynamic personalized risk prediction in chronic heart failure patients: a longitudinal, clinical investigation of 92 biomarkers (Bio-SHiFT study). Sci Rep 2022; 12:2795. [PMID: 35181700 PMCID: PMC8857321 DOI: 10.1038/s41598-022-06698-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 02/02/2022] [Indexed: 11/28/2022] Open
Abstract
The aim of our observational study was to derive a small set out of 92 repeatedly measured biomarkers with optimal predictive capacity for adverse clinical events in heart failure, which could be used for dynamic, individual risk assessment in clinical practice. In 250 chronic HFrEF (CHF) patients, we collected trimonthly blood samples during a median of 2.2 years. We selected 537 samples for repeated measurement of 92 biomarkers with the Cardiovascular Panel III (Olink Proteomics AB). We applied Least Absolute Shrinkage and Selection Operator (LASSO) penalization to select the optimal set of predictors of the primary endpoint (PE). The association between repeatedly measured levels of selected biomarkers and the PE was evaluated by multivariable joint models (mvJM) with stratified fivefold cross validation of the area under the curve (cvAUC). The PE occurred in 66(27%) patients. The optimal set of biomarkers selected by LASSO included 9 proteins: NT-proBNP, ST2, vWF, FABP4, IGFBP-1, PAI-1, PON-3, transferrin receptor protein-1, and chitotriosidase-1, that yielded a cvAUC of 0.88, outperforming the discriminative ability of models consisting of standard biomarkers (NT-proBNP, hs-TnT, eGFR clinically adjusted) − 0.82 and performing equally well as an extended literature-based set of acknowledged biomarkers (NT-proBNP, hs-TnT, hs-CRP, GDF-15, ST2, PAI-1, Galectin 3) − 0.88. Nine out of 92 serially measured circulating proteins provided a multivariable model for adverse clinical events in CHF patients with high discriminative ability. These proteins reflect wall stress, remodelling, endothelial dysfunction, iron deficiency, haemostasis/fibrinolysis and innate immunity activation. A panel containing these proteins could contribute to dynamic, personalized risk assessment. Clinical Trial Registration: 10/05/2013 https://clinicaltrials.gov/ct2/show/NCT01851538?term=nCT01851538&draw=2&rank=1.
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Affiliation(s)
- Dominika Klimczak-Tomaniak
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Cardiology, Hypertension and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marie de Bakker
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Elke Bouwens
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - K Martijn Akkerhuis
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sara Baart
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Jan van Ramshorst
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Tjeerd Germans
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Alina Constantinescu
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Olivier Manintveld
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Victor Umans
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Room NA-316, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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22
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Stress Cardiac Biomarkers, Cardiovascular and Renal Outcomes, and Response to Canagliflozin. J Am Coll Cardiol 2022; 79:432-444. [DOI: 10.1016/j.jacc.2021.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 01/14/2023]
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23
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Echouffo-Tcheugui JB, Selvin E. Eligibility and Response to Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors Therapy. J Am Coll Cardiol 2022; 79:445-447. [PMID: 35115100 PMCID: PMC10125554 DOI: 10.1016/j.jacc.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Justin B Echouffo-Tcheugui
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Welch Prevention Center for Prevention, Epidemiology and Clinical Research; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Elizabeth Selvin
- Welch Prevention Center for Prevention, Epidemiology and Clinical Research; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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24
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Risiko für Krankenhauseinweisung wegen Herzinsuffizienz bei Patienten mit Diabetes. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00843-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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25
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Butt JH, Adamson C, Docherty KF, de Boer RA, Petrie MC, Inzucchi SE, Kosiborod MN, Maria Langkilde A, Lindholm D, Martinez FA, Bengtsson O, Schou M, O'Meara E, Ponikowski P, Sabatine MS, Sjöstrand M, Solomon SD, Jhund PS, McMurray JJV, Køber L. Efficacy and Safety of Dapagliflozin in Heart Failure With Reduced Ejection Fraction According to N-Terminal Pro-B-Type Natriuretic Peptide: Insights From the DAPA-HF Trial. Circ Heart Fail 2021; 14:e008837. [PMID: 34802253 DOI: 10.1161/circheartfailure.121.008837] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Effective therapies for HFrEF usually reduce NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, and it is important to establish whether new treatments are effective across the range of NT-proBNP. METHODS We evaluated both these questions in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) trial. Patients in New York Heart Association functional class II to IV with a left ventricular ejection fraction ≤40% and a NT-proBNP level ≥600 pg/mL (≥600 ng/L; ≥400 pg/mL if hospitalized for HF within the previous 12 months or ≥900 pg/mL if atrial fibrillation/flutter) were eligible. The primary outcome was the composite of an episode of worsening HF or cardiovascular death. RESULTS Of the 4744 randomized patients, 4742 had an available baseline NT-proBNP measurement (median, 1437 pg/mL [interquartile range, 857-2650 pg/mL]). Compared with placebo, treatment with dapagliflozin significantly reduced NT-proBNP from baseline to 8 months (absolute least-squares mean reduction, -303 pg/mL [95% CI, -457 to -150 pg/mL]; geometric mean ratio, 0.92 [95% CI, 0.88-0.96]). Dapagliflozin reduced the risk of worsening HF or cardiovascular death, irrespective of baseline NT-proBNP quartile; the hazard ratio for dapagliflozin versus placebo, from lowest to highest quartile was 0.43 (95% CI, 0.27-0.67), 0.77 (0.56-1.04), 0.78 (0.60-1.01), and 0.78 (0.64-0.95); P for interaction=0.09. Consistent benefits were observed for all-cause mortality. Compared with placebo, dapagliflozin increased the proportion of patients with a meaningful improvement (≥5 points) in Kansas City Cardiomyopathy Questionnaire total symptom score (P for interaction=0.99) and decreased the proportion with a deterioration ≥5 points (P for interaction=0.87) across baseline NT-proBNP quartiles. CONCLUSIONS In patients with HFrEF, dapagliflozin reduced NT-proBNP by 300 pg/mL after 8 months of treatment compared with placebo. In addition, dapagliflozin reduced the risk of worsening HF and death, and improved symptoms, across the spectrum of baseline NT-proBNP levels included in DAPA-HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (J.H.B., L.K.)
| | - Carly Adamson
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center and University of Groningen, the Netherlands (R.A.d.B.)
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT (S.E.I.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | | | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Herlev, Denmark (M. Schou)
| | - Eileen O'Meara
- Montreal Heart Institute, Université de Montréal, Quebec, Canada (E.O.)
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland (P.P.)
| | - Marc S Sabatine
- TIMI Study Group (M.S.S.), Brigham and Women's Hospital, Boston, MA.,Division of Cardiovascular Medicine (M.S.S., S.D.S.), Brigham and Women's Hospital, Boston, MA
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | - Scott D Solomon
- Division of Cardiovascular Medicine (M.S.S., S.D.S.), Brigham and Women's Hospital, Boston, MA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (J.H.B., L.K.)
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26
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Abstract
Patients with type 2 diabetes mellitus (T2D) are at increased risk of cardiovascular (CV) disease. Sodium glucose cotransporter 2 (SGLT2) inhibitors, also known as gliflozins, are a class of medications used to treat T2D by preventing the reabsorption of glucose filtered through the kidney and thereby facilitating glucose excretion in the urine. Over the past 5 years, many cardiovascular outcome trials (CVOTs) have evaluated the safety and efficacy of SGLT2 inhibitors in preventing CV events. The results of 7 CVOTs have provided solid evidence that the use of SGLT2 in patients with T2D and at high CV risk significantly reduced the risk of death from CV causes. Moreover, in patient with heart failure with reduced ejection fraction, regardless of the presence or absence of T2D, SGLT2 inhibitors use significantly reduced the risk of worsening heart failure and death from CV causes. Although the exact mechanism of the cardiorenal benefit of SGLT2 inhibitors is still unknown, studies have shown that the beneficial effect of these drugs cannot be exclusively explained by their glucose lowering effect, and several possible mechanisms have been proposed. This review will explore the changing role of SGLT2 inhibitors from a diabetes drug to clinical practice guideline-supported therapy for the prevention and treatment of CV diseases, including heart failure.
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Affiliation(s)
- Reza Mohebi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Baim Institute for Clinical Research, Boston, MA, USA
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27
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Berg DD, Kolkailah AA, Sarraju A, Kerchberger AM, Eljalby M, McGuire DK. Interpreting Absolute and Relative Risk Reduction in the Context of Recent Cardiovascular Outcome Trials in Patients with Type 2 Diabetes. Curr Diab Rep 2021; 21:45. [PMID: 34741199 DOI: 10.1007/s11892-021-01417-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The cardiovascular benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) have increased the focus of type 2 diabetes mellitus (T2DM) care on comprehensive cardiovascular risk reduction. Herein, we review the results of the cardiovascular outcomes trials of SGLT2i and GLP-1 RA, discuss the concepts of relative vs. absolute risk reduction in the context of these trials, and highlight the importance of individualized risk assessment when applying trial results to clinical practice. RECENT FINDINGS To enable personalized treatment approaches, multiple clinical risk scores have been developed to assess risk of atherosclerotic cardiovascular disease (ASCVD) outcomes and hospitalization for heart failure (HHF) in patients with T2DM. In addition, circulating biomarkers of myocardial injury (cardiac troponin) and hemodynamic stress (natriuretic peptides) have been shown to further refine risk prediction of these clinically important cardiovascular complications. When making decisions about whether to initiate SGLT2i and GLP-1 RA, clinicians should consider the anticipated relative and absolute treatment benefits from these antihyperglycemic therapies. Clinicians can use available clinical and biomarker-based risk tools when counseling patients about their individual cardiovascular risk profiles and when estimating absolute treatment benefits from SGLT2i and GLP-1 RA.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA, 02115, USA.
| | - Ahmed A Kolkailah
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Anne Marie Kerchberger
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Mahmoud Eljalby
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
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28
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Lebedev DA, Lyasnikova EA, Vasilyeva EY, Likhonosov NP, Sitnikova MY, Babenko AY. Association between Markers of Fibrosis and Heart Failure Incidence in Patients with Type 2 Diabetes Mellitus. J Diabetes Res 2021; 2021:9589185. [PMID: 34778465 PMCID: PMC8589473 DOI: 10.1155/2021/9589185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/05/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) and chronic heart failure (HF) have close association, and several biomarkers have been studied to better understand this association and improve prediction of HF in T2DM. Furthermore, in recent clinical trials, sodium glucose cotransporter 2 inhibitors (SGLT2i), glucose-lowering drugs, improved HF outcomes. The objective of the present study was to evaluate association between circulating biomarkers of fibrosis and incidence of HF with preserved ejection fraction (HFpEF) in patients with T2DM receiving sodium glucose cotransporter 2 inhibitors (SGLT2i). Materials and Methods. At baseline, transthoracic echocardiography and laboratory assessment of N-terminal fragment of the brain natriuretic peptide (Nt-proBNP), soluble suppression of tumorigenesis-2 (sST2), galectin-3 (Gal-3), C-terminal propeptide of procollagen type I (PICP), N-terminal propeptide of procollagen type III (PIIINP), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of matrix proteinase-1 (TIMP-1) were done. After 3 years of follow-up, information about HF events (hospitalization for HF, established HF in outpatient department by a cardiologist) was obtained. Results. Seventy-two patients were included in the study. The mean age was 57 (49.7; 63.2) years; 44% were female. Most patients had T2DM for more than 4 years. All patients were overweight or had obesity, and 93% patients had arterial hypertension (AH). After 3 years of follow-up, HFpEF was established in 21% patients. Patients were divided into two groups according to the presence of HFpEF, and baseline characteristics were compared. Patients with HF were older and had longer diabetes and AH duration and higher Nt-proBNP, Gal-3, PIIINP, and PICP levels at baseline than patients without HF (all p < 0.05). Gal - 3 > 10 ng/ml (OR = 2.25; 95% CI, 1.88-5.66; p = 0.01) and NT - pro - BNP > 80 pg/ml (OR = 2.64; 95% CI, 1.56-4.44; p = 0.001) were associated with increased risk of HF incidence. Age > 60 years, diabetes duration > 10 years, and presence of abdominal obesity were independent predictors of HFpEF as well. Conclusions. T2DM patients treated with SLGT2i, who developed HFpEF after 3 years of follow-up, had higher PICP, PIIINP, Gal-3, and NT-proBNP serum concentrations at baseline, and Gal-3 level was an independent predictor of HFpEF.
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Affiliation(s)
- Denis A. Lebedev
- Almazov National Medical Research Centre, Saint Petersburg, Russia
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29
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Berg DD, Wiviott SD, Scirica BM, Zelniker TA, Goodrich EL, Jarolim P, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Johanson P, Langkilde AM, Raz I, Braunwald E, Sabatine MS, Morrow DA. A Biomarker-Based Score for Risk of Hospitalization for Heart Failure in Patients With Diabetes. Diabetes Care 2021; 44:2573-2581. [PMID: 34535469 PMCID: PMC8546278 DOI: 10.2337/dc21-1170] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/25/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Heart failure (HF) is an impactful complication of type 2 diabetes mellitus (T2DM). We aimed to develop and validate a risk score for hospitalization for HF (HHF) incorporating biomarkers and clinical factor(s) in patients with T2DM. RESEARCH DESIGN AND METHODS We derived a risk score for HHF using clinical data, high-sensitivity troponin T (hsTnT), and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) from 6,106 placebo-treated patients with T2DM in SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53). Candidate variables were assessed using Cox regression. The strongest indicators of HHF risk were included in the score using integer weights. The score was externally validated in 7,251 placebo-treated patients in DECLARE-TIMI 58 (Dapagliflozin Effect on CardiovascuLAR Events-Thrombolysis in Myocardial Infarction 58). The effect of dapagliflozin on HHF was assessed by risk category in DECLARE-TIMI 58. RESULTS The strongest indicators of HHF risk were NT-proBNP, prior HF, and hsTnT (each P < 0.001). A risk score using these three variables identified a gradient of HHF risk (P-trend <0.001) in the derivation and validation cohorts, with C-indices of 0.87 (95% CI, 0.84-0.89) and 0.84 (0.81-0.86), respectively. Whereas there was no significant effect of dapagliflozin versus placebo on HHF in the low-risk group (hazard ratio [HR] 0.98 [95% CI 0.50-1.92]), dapagliflozin significantly reduced HHF in the intermediate-, high-, and very-high-risk groups (HR 0.64 [0.43-0.95], 0.63 [0.43-0.94], and 0.72 [0.54-0.96], respectively). Correspondingly, absolute risk reductions (95% CI) increased across these latter 3 groups: 1.0% (0.0-1.9), 3.0% (0.7-5.3), and 4.4% (-0.2 to 8.9) (P-trend <0.001). CONCLUSIONS We developed and validated a risk score for HHF in T2DM that incorporated NT-proBNP, prior HF, and hsTnT. The risk score identifies patients at higher risk of HHF who derive greater absolute benefit from dapagliflozin.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Avivit Cahn
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Aintree University Hospital, University of Liverpool, Liverpool, U.K
| | | | | | - Itamar Raz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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30
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Savarese G, Butler J, Lund LH, Bhatt DL, Anker SD. CARDIOVASCULAR EFFECTS OF NON-INSULIN GLUCOSE-LOWERING AGENTS: A COMPREHENSIVE REVIEW OF TRIAL EVIDENCE AND POTENTIAL CARDIOPROTECTIVE MECHANISMS. Cardiovasc Res 2021; 118:2231-2252. [PMID: 34390570 DOI: 10.1093/cvr/cvab271] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is highly prevalent and associated with a 2-fold increased mortality, mostly explained by cardiovascular diseases. Trial evidence on older glucose-lowering agents such as metformin and sulfonylureas is limited in terms of cardiovascular efficacy. Since 2008, after rosiglitazone was observed to increase the risk of myocardial infarction and heart failure (HF), cardiovascular outcome trials (CVOT) have been required by regulators for licensing new glucose-lowering agents. In the following CVOTs, dipeptidyl peptidase 4 inhibitors (DPP4i) have been shown to be safe but not to improve morbidity/mortality, except for saxagliptin which increased the risk of HF. Several glucagon-like peptide-1 receptor agonists (GLP1-Ra) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been demonstrated to reduce the risk of cardiovascular morbidity and mortality. SGLT2i have shown a class effect for the reduction in risk of HF events in patients with T2DM, leading to trials testing their efficacy/safety in HF regardless of T2DM. In the DAPA-HF and the EMPEROR-Reduced trials dapagliflozin and empagliflozin, respectively, improved cardiovascular mortality/morbidity in patients with HF and reduced ejection fraction (HFrEF), with and without T2DM. Therefore, these drugs are now key part of HFrEF pharmacotherapy. In the SOLOIST-WHF, sotagliflozin reduced cardiovascular mortality/morbidity in patients with T2DM and a recent acute episode of HF regardless of EF. The DELIVER and the EMPEROR-Preserved are testing dapagliflozin and empagliflozin, respectively, in patients with HF with mildly reduced and preserved EF. A strong renal protective role of SGLT2i has also emerged in trials enrolling patients with and without T2DM.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Javed Butler
- University of Mississippi School of Medicine, Jackson, MI, USA
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany
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Tomasoni D, Adamo M, Metra M. June 2021 at a glance: focus on epidemiology, biomarkers and medical treatment. Eur J Heart Fail 2021; 23:847-849. [PMID: 34271596 DOI: 10.1002/ejhf.1884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/08/2021] [Accepted: 06/12/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiac Catheterization Laboratory and Cardiology, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiac Catheterization Laboratory and Cardiology, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiac Catheterization Laboratory and Cardiology, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Savarese G, Merlo M, Coats AJS, Metra M. Best of European Journal of Heart Failure at the ESC/HFA Heart Failure Congress 2021. Eur J Heart Fail 2021; 23:1424-1427. [PMID: 34263508 DOI: 10.1002/ejhf.2306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Merlo
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | | | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia, Italy
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Sabatine MS, Braunwald E. Thrombolysis In Myocardial Infarction (TIMI) Study Group: JACC Focus Seminar 2/8. J Am Coll Cardiol 2021; 77:2822-2845. [PMID: 34082913 DOI: 10.1016/j.jacc.2021.01.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 01/14/2023]
Abstract
In 1984, the National Heart, Lung, and Blood Institute (NHLBI) decided to study the efficacy and safety of the treatment of acute myocardial infarction with an emerging therapy, coronary thrombolysis, and thus the TIMI (Thrombolysis In Myocardial Infarction) Study Group was born. Following completion of 3 clinical trials of thrombolytic therapy supported by the NHLBI, TIMI became an academic research organization headquartered at Brigham and Women's Hospital and subsequently branched out to study a wide range of patients, including those with stable coronary, cerebrovascular, and peripheral arterial disease; dyslipidemia; heart failure; atrial fibrillation; diabetes; and obesity. TIMI also began to study a wide range of interventions including thrombolytic, antithrombotic, lipid-modifying, anti-inflammatory, heart failure, glucose-lowering, and weight loss agents. TIMI, now in its 37th year, has completed >70 trials. This review describes the origins of the TIMI Study Group, summarizes several of its completed trials and the major lessons learned from them, and discusses ongoing trials and future directions.
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Affiliation(s)
- Marc S Sabatine
- TIMI (Thrombolysis In Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
| | - Eugene Braunwald
- TIMI (Thrombolysis In Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Packer M, Januzzi JL, Ferreira JP, Anker SD, Butler J, Filippatos G, Pocock SJ, Brueckmann M, Jamal W, Cotton D, Iwata T, Zannad F. Concentration-dependent clinical and prognostic importance of high-sensitivity cardiac troponin T in heart failure and a reduced ejection fraction and the influence of empagliflozin: the EMPEROR-Reduced trial. Eur J Heart Fail 2021; 23:1529-1538. [PMID: 34053177 PMCID: PMC9291909 DOI: 10.1002/ejhf.2256] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 11/18/2022] Open
Abstract
Aims Circulating troponin is an important measure of risk in patients with heart failure, but it has not been used to determine if disease severity influences the responses to drug treatments in randomized controlled trials. Methods and results In the EMPEROR‐Reduced trial, patients with class II–IV heart failure and a reduced ejection fraction were randomly assigned to placebo or empagliflozin 10 mg daily and followed for the occurrence of serious heart failure and renal events. High‐sensitivity cardiac troponin T (hs‐cTnT) was measured in 3636 patients (>97%) at baseline, and patients were divided into four groups based on the degree of troponin elevation. With increasing concentrations of hs‐cTnT, patients were progressively more likely to have diabetes and atrial fibrillation, to have New York Heart Association class III–IV symptoms and been hospitalized for heart failure within the prior year, and to have elevated levels of natriuretic peptides and worse renal function (P‐trend < 0.0001 for all comparisons), but importantly, the troponin groups did not differ with respect to ejection fraction. A linear relationship was observed between the logarithm of hs‐cTnT and the combined risk of cardiovascular death or hospitalization for heart failure (P = 0.0015). When treated with placebo, patients with the highest levels of hs‐cTnT had risks of cardiovascular death and hospitalization for heart failure that were 3–5 fold greater than those with values in the normal range. Patients with higher levels of hs‐cTnT were also more likely to experience worsening of renal function and serious adverse renal events and showed the least improvement in health status (as measured by the Kansas City Cardiomyopathy Questionnaire). When compared with placebo, empagliflozin reduced the combined risk of cardiovascular death or hospitalization for heart failure, regardless of the baseline level of hs‐cTnT, whether the effects of treatment were analysed as hazard ratios or absolute risk reductions. Conclusions Elevations in hs‐cTnT reflect the clinical severity, stability and prognosis of patients with heart failure and a reduced ejection fraction, with biomarkers, comorbidities, clinical course and risks that are proportional to the magnitude of hs‐cTnT elevation. Empagliflozin exerted favourable effects on heart failure and renal outcomes, regardless of the baseline concentration of hs‐cTnT.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | | | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH and Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Daniel Cotton
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Faiez Zannad
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France
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Sattar N, Januzzi JL. Can biomarkers help find the 'sweet spot' for treating patients with diabetes? Eur J Heart Fail 2021; 23:1037-1039. [PMID: 33786946 DOI: 10.1002/ejhf.2175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/27/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - James L Januzzi
- Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA, USA
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Cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors in diabetic and nondiabetic patients. Cardiovasc Diabetol 2021; 20:78. [PMID: 33827579 PMCID: PMC8028072 DOI: 10.1186/s12933-021-01266-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/19/2021] [Indexed: 12/25/2022] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were developed as antidiabetic agents, but accumulating evidence has shown their beneficial effects on the cardiovascular system. Analyses of the EMPA-REG OUTCOME trial (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) suggested that these benefits are independent of glycemic control. Several large-scale outcome trials of SGLT2i also showed cardiovascular benefits in nondiabetic patients, strengthening this perspective. Extensive animal and clinical studies have likewise shown that mechanisms other than the antihyperglycemic effect underlie the cardiovascular benefits. Recent clinical guidelines recommend the use of SGLT2i in patients with type 2 diabetes mellitus and cardiovascular diseases because of the proven cardiovascular protective effects. Since the cardiovascular benefits are independent of glycemic control, the therapeutic spectrum of SGLT2i will likely be extended to nondiabetic patients.
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