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Hundertmark MJ, Agbaje OF, Coleman R, George JT, Grempler R, Holman RR, Lamlum H, Lee J, Milton JE, Niessen HG, Rider O, Rodgers CT, Valkovič L, Wicks E, Mahmod M, Neubauer S. Design and rationale of the EMPA-VISION trial: investigating the metabolic effects of empagliflozin in patients with heart failure. ESC Heart Fail 2021; 8:2580-2590. [PMID: 33960149 PMCID: PMC8318430 DOI: 10.1002/ehf2.13406] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/10/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022] Open
Abstract
Aims Despite substantial improvements over the last three decades, heart failure (HF) remains associated with a poor prognosis. The sodium‐glucose co‐transporter‐2 inhibitor empagliflozin demonstrated significant reductions of HF hospitalization in patients with HF independent of the presence or absence of type 2 diabetes mellitus in the EMPEROR‐Reduced trial and cardiovascular mortality in the EMPA‐REG OUTCOME trial. To further elucidate the mechanisms behind these positive outcomes, this study aims to determine the effects of empagliflozin treatment on cardiac energy metabolism and physiology using magnetic resonance spectroscopy (MRS) and cardiovascular magnetic resonance (CMR). Methods and results The EMPA‐VISION trial is a double‐blind, randomized, placebo‐controlled, mechanistic study. A maximum of 86 patients with HF with reduced ejection fraction (n = 43, Cohort A) or preserved ejection fraction (n = 43, Cohort B), with or without type 2 diabetes mellitus, will be enrolled. Participants will be randomized 1:1 to receive either 10 mg of empagliflozin or placebo for 12 weeks. Eligible patients will undergo cardiovascular magnetic resonance, resting and dobutamine stress MRS, echocardiograms, cardiopulmonary exercise tests, serum metabolomics, and quality of life questionnaires at baseline and after 12 weeks. The primary endpoint will be the change in resting phosphocreatine‐to‐adenosine triphosphate ratio, as measured by 31Phosphorus‐MRS. Conclusions EMPA‐VISION is the first clinical trial assessing the effects of empagliflozin treatment on cardiac energy metabolism in human subjects in vivo. The results will shed light on the mechanistic action of empagliflozin in patients with HF and help to explain the results of the safety and efficacy outcome trials (EMPEROR‐Reduced and EMPEROR‐Preserved).
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Affiliation(s)
- Moritz J Hundertmark
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Olorunsola F Agbaje
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Ruth Coleman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Rolf Grempler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Hanan Lamlum
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Jisoo Lee
- Boehringer Ingelheim International GmBH, Ingelheim, Germany
| | - Joanne E Milton
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Heiko G Niessen
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Oliver Rider
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Christopher T Rodgers
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Cambridge, UK
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Eleanor Wicks
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Masliza Mahmod
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Oxford NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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Galindo CL, Kasasbeh E, Murphy A, Ryzhov S, Lenihan S, Ahmad FA, Williams P, Nunnally A, Adcock J, Song Y, Harrell FE, Tran TL, Parry TJ, Iaci J, Ganguly A, Feoktistov I, Stephenson MK, Caggiano AO, Sawyer DB, Cleator JH. Anti-remodeling and anti-fibrotic effects of the neuregulin-1β glial growth factor 2 in a large animal model of heart failure. J Am Heart Assoc 2014; 3:e000773. [PMID: 25341890 PMCID: PMC4323814 DOI: 10.1161/jaha.113.000773] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neuregulin-1β (NRG-1β) is a growth factor critical for cardiac development and repair with therapeutic potential for heart failure. We previously showed that the glial growth factor 2 (GGF2) isoform of NRG-1β improves cardiac function in rodents after myocardial infarction (MI), but its efficacy in a large animal model of cardiac injury has not been examined. We therefore sought to examine the effects of GGF2 on ventricular remodeling, cardiac function, and global transcription in post-MI swine, as well as potential mechanisms for anti-remodeling effects. METHODS AND RESULTS MI was induced in anesthetized swine (n=23) by intracoronary balloon occlusion. At 1 week post-MI, survivors (n=13) received GGF2 treatment (intravenous, biweekly for 4 weeks; n=8) or were untreated (n=5). At 5 weeks post-MI, fractional shortening was higher (32.8% versus 25.3%, P=0.019), and left ventricular (LV) end-diastolic dimension lower (4.5 versus 5.3 cm, P=0.003) in GGF2-treated animals. Treatment altered expression of 528 genes, as measured by microarrays, including collagens, basal lamina components, and matricellular proteins. GGF2-treated pigs exhibited improvements in LV cardiomyocyte mitochondria and intercalated disk structures and showed less fibrosis, altered matrix structure, and fewer myofibroblasts (myoFbs), based on trichrome staining, electron microscopy, and immunostaining. In vitro experiments with isolated murine and rat cardiac fibroblasts demonstrate that NRG-1β reduces myoFbs, and suppresses TGFβ-induced phospho-SMAD3 as well as αSMA expression. CONCLUSIONS These results suggest that GGF2/NRG-1β prevents adverse remodeling after injury in part via anti-fibrotic effects in the heart.
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Affiliation(s)
- Cristi L Galindo
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Ehab Kasasbeh
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Abigail Murphy
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Sergey Ryzhov
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Sean Lenihan
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Farhaan A Ahmad
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Philip Williams
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Amy Nunnally
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Jamie Adcock
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Yanna Song
- Department of Biostatistics, Vanderbilt University, Nashville, TN (Y.S., F.E.H.)
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University, Nashville, TN (Y.S., F.E.H.)
| | - Truc-Linh Tran
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - Tom J Parry
- Acorda Therapeutics, Ardsley, NY (T.J.P., J.I., A.G., A.O.C.)
| | - Jen Iaci
- Acorda Therapeutics, Ardsley, NY (T.J.P., J.I., A.G., A.O.C.)
| | | | - Igor Feoktistov
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | | | | | - Douglas B Sawyer
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (C.L.G., E.K., A.M., S.R., S.L., F.A.A., P.W., A.N., J.A., T.L.T., I.F., D.B.S.)
| | - John H Cleator
- Department of Pharmacology, Vanderbilt University, Nashville, TN (J.H.C.)
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