Semaglutide and cardiovascular outcomes in patients with obesity and prevalent heart failure: a prespecified analysis of the SELECT trial

Obesity accelerates cardiovascular ageing

A global obesity pandemic, coupled with an increasingly ageing population, is exacerbating the burden of cardiovascular disease. Indeed, clinical and experimental evidence underscores a potential connection between obesity and ageing in the pathogenesis of various cardiovascular disorders. This is further supported by the notion that weight reduction not only effectively reduces major cardiovascular events in elderly individuals but is also considered the gold standard for lifespan extension, in obese and non-obese model organisms. This review evaluates the intricate interplay between obesity and ageing from molecular mechanisms to whole organ function within the cardiovascular system. By comparatively analysing their characteristic features, shared molecular and cell biological signatures between obesity and ageing are unveiled, with the intent to shed light on how obesity accelerates cardiovascular ageing. This review also elaborates on how emerging metabolic interventions targeting obesity might protect from cardiovascular diseases largely through antagonizing key molecular mechanisms of the ageing process itself. In sum, this review aims to provide valuable insight into how understanding these interconnected processes could guide the development of novel and effective cardiovascular therapeutics for a growing aged population with a concerning obesity problem.

Review Article: GLP-1 Receptor Agonists and Glucagon/GIP/GLP-1 Receptor Dual or Triple Agonists-Mechanism of Action and Emerging Therapeutic Landscape in MASLD

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is primarily managed through diet and lifestyle modifications. However, these behavioural interventions alone may not achieve disease regression or remission, and maintaining long-term adherence is challenging. Incretin mimetics and other gastrointestinal hormones targeting the pleiotropic pathophysiological pathways underlying MASLD have now emerged as promising disease-modifying therapies.

AIMS

This is a comprehensive review summarising the role of glucagon-like peptide-1 (GLP-1) receptor agonists and glucagon/glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor dual or triple agonists in the treatment of metabolic dysfunction-associated steatohepatitis (MASH).

METHODS

Only clinical trials with endpoints assessed by liver histology were included for a robust evaluation of therapeutic efficacy.

RESULTS

Recent evidence from phase 2 clinical trials for MASH demonstrated that pharmacological agents based on GLP-1 receptor agonism are effective in improving disease activity. Additionally, tirzepatide and survodutide showed potential clinical benefits in reducing fibrosis. Other cardiometabolic benefits observed include weight loss and improvements in glycaemic control and lipid profile. Adherence to treatment may be limited by gastrointestinal side effects, though they were found to be generally mild to moderate in severity. An interim analysis of the semaglutide phase 3 trial confirmed its efficacy in improving steatohepatitis and demonstrated its potential to improve fibrosis.

CONCLUSIONS

GLP-1 receptor agonists, alone or in combination with GIP and/or glucagon receptor agonists, represent promising, effective pharmacotherapies for the treatment of MASLD/MASH. Larger and longer-duration clinical trials are needed to further evaluate the efficacy and safety of GIP receptor and glucagon receptor agonism.

The Impact of Cardio-Renal-Metabolic Profile in Dilated Cardiomyopathy

PURPOSE OF REVIEW

Dilated cardiomyopathy is an important contributor to heart failure burden worldwide. With an aging population and rising multimorbidity, in this review, we describe the prevalence of metabolic syndrome and renal failure in patients with dilated cardiomyopathy and focus on common underlying mechanisms, evaluate outcomes in these patients and highlight newer therapeutic strategies.

RECENT FINDINGS

A significant proportion of patients with dilated cardiomyopathy has concomitant metabolic syndrome and renal disease. This combination of multimorbidity portends worse prognosis and often presents unique challenges in treatment given the complex interplay and shared pathophysiological pathways. Optimization of the cardio-renal-metabolic profile should be a key consideration in the management of patients with dilated cardiomyopathy. Therapeutic strategies targeting common pathophysiological pathways are needed in order to improve overall outcomes.

Refining the link between obesity and heart failure: insights from GLP-1 receptor agonist trials and studies adopting direct adiposity measures

Overweight and obesity are major risk factors for heart failure (HF), contributing to its development through metabolic, neurohormonal, haemodynamic, and inflammatory alterations. While overweight/obesity increases the risk of developing HF, its impact on patient outcomes remains complex. The "obesity paradox" suggests that a higher BMI may be associated with improved survival in patients with established HF. However, recent GLP-1 receptor agonist (GLP-1 RA) trials suggest that intentional weight loss positively influences outcomes in overweight/obese patients with HF. This seemingly contradictory evidence highlights the need for a deeper understanding of the mechanisms linking adiposity to HF outcomes. A more precise characterization of adiposity phenotypes using alternative and accurate measures of pathological fat accumulation is crucial in identifying individuals who may benefit most from anti-obesity treatments. In this context, recent research underscores the role of epicardial adipose tissue (EAT) in HF pathophysiology, as it directly influences cardiac function and structure through inflammatory, metabolic, and mechanical effects. This narrative review summarises current evidence on the impact of weight loss on HF outcomes, focusing on recent GLP-1 RA trial results. Additionally, it highlights epidemiological and molecular data supporting EAT as a novel adiposity measure that might allow refining patient selection for pharmacological weight-loss treatments. Finally, it emphasizes the need for future research to identify causal pathways linking alternative measures of visceral fat accumulation to HF outcomes. These efforts will be essential in optimizing the benefits of novel weight-loss treatments, ensuring effective and individualized therapeutic strategies for overweight or obese patients with HF.

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

A Comprehensive Review: Unraveling the Role of Inflammation in the Etiology of Heart Failure

Heart failure (HF) remains a leading cause of morbidity and mortality worldwide, with inflammation playing a pivotal role in its pathogenesis. This comprehensive review aims to elucidate the intricate mechanisms by which inflammation contributes to the development and progression of HF. The review synthesizes current research on the involvement of both innate and adaptive immune responses in HF, highlighting the roles of cytokines, chemokines, and other inflammatory mediators. Recent studies have demonstrated that chronic inflammation, driven by factors such as oxidative stress, neurohormonal activation, and metabolic disturbances, leads to adverse cardiac remodeling and impaired myocardial function. The review explores how systemic inflammation, characterized by elevated levels of inflammatory biomarkers like C-reactive protein (CRP) and interleukin-6 (IL-6), correlates with HF severity and outcomes. Additionally, it discusses the impact of comorbid conditions such as diabetes, obesity, and hypertension on inflammatory pathways and HF risk. The review also delves into the therapeutic implications of targeting inflammation in HF. Despite mixed results from early clinical trials, emerging evidence suggests that anti-inflammatory therapies offer benefits in specific HF phenotypes. The potential of novel therapeutic strategies, including the use of biologics and small molecule inhibitors, is examined in the context of their ability to modulate inflammatory responses and improve clinical outcomes.

Hypertension after solid-organ transplantation: special considerations for management

PURPOSE OF REVIEW

Hypertension is one of the most common comorbidities affecting patients after solid organ transplantation. Here we review the mechanisms leading to hypertension, along with common practices in terms of medical management. Glucagon-like peptide-1 receptor (GLP-1R) agonists, baroreflex therapy, and renal denervation are common interventions utilized prior to heart transplant. Special considerations for their management throughout the perioperative and postoperative period are covered here.

RECENT FINDINGS

Most common medical management includes utilization of calcium channel blockers, followed by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. GLP-1R agonists have shown significant benefit in recent cardiovascular outcome trials. Preoperative management centers around risks associated with slowed gastric emptying, while reinitiation after heart transplant must take into consideration initiation and tolerance of immunosuppressive therapies. Baroreflex activation therapy has been approved for therapy of heart failure, with many patients proceeding to heart transplant. The device is frequently deactivated after transplantation, with little published experience regarding reinitiation of therapy after heart transplant. There is renewed interest in renal denervation as a treatment for refractory hypertension. The incidence of hypertension after heart transplant in those patients that have undergone previous renal denervation remains unknown, however there is limited experience with its use after renal transplant.

SUMMARY

Further studies are required to elucidate optimal medical management of hypertension following heart transplantation. GLP-1R agonists, baroreflex activation therapy, and renal denervation are emerging therapies prior to transplant that require further investigation.

New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2024

Despite substantial advances in cardiovascular pharmacotherapy and devices in recent years, prevention and treatment of many cardiovascular diseases (CVDs) remain limited, thus reflecting the need for more effective and safer pharmacological strategies. In this review, we summarize the most relevant studies in cardiovascular pharmacotherapy in 2024, including the approval of first-in-class drugs for the treatment of resistant hypertension and pulmonary arterial hypertension, label expansions for bempedoic acid and semaglutide, and the results of major randomized clinical trials (RCTs) that have met the pre-specified primary endpoints, thereby filling some gaps in knowledge and opening new perspectives in the management of CVD, and those RCTs whose results did not confirm the proposed research hypotheses. We also include a section on drug safety, where we describe the newest data on adverse reactions and drug-drug interactions that may complicate treatment and/or reduce drug adherence with the consequent decrease in drug effectiveness. Finally, we present the most important ongoing phase 2 and phase 3 clinical trials assessing the efficacy and safety of cardiovascular drugs for the prevention and treatment of CVD.

ANMCO statement: semaglutide in the cardio-nephro-metabolic continuum

Semaglutide, a glucagon-like peptide-1 receptor agonist, has emerged as a pivotal therapeutic agent in the management of the cardio-renal-metabolic continuum. Initially developed for glycaemic control in Type 2 diabetes mellitus, its benefits extend far beyond glucose regulation. Clinical trials have demonstrated semaglutide's potential to reduce major adverse cardiovascular events, particularly in overweight/obese patients with high cardiovascular risk, as well as improving functional capacity in patients suffering from heart failure with preserved left ventricular function. Additionally, it has shown promise in improving renal outcomes, such as slowing the progression of albuminuria and reducing the risk of chronic kidney disease in diabetic populations. These effects are likely due to its multifaceted mechanisms, including anti-inflammatory properties, weight reduction, blood pressure lowering, and direct renal protection. This review synthesizes current evidence on semaglutide's role in the interrelated domains of cardiovascular, renal, and metabolic health.

Advances in the management of obesity and heart failure: latest evidence from clinical trials

PURPOSE OF REVIEW

Obesity is an important risk factor for heart failure with preserved ejection fraction (HFpEF). In patients who already have HFpEF, obesity contributes to high symptom burden and increased risk for heart failure (HF) hospitalization. This review examines the latest clinical trials assessing the efficacy of pharmacological interventions in the treatment of obesity-related HFpEF.

RECENT FINDINGS

Recent results from randomized clinical trials (RCTs) suggest that incretin-based therapies, including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) (e.g., semaglutide) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RAs (e.g., tirzepatide), can improve quality of life, exercise tolerance, and markers of HF severity while promoting weight loss in patients with obesity and HFpEF. Some evidence also suggests that these therapies may reduce risk for HF hospitalizations. Additionally, exploratory analyses of the nonsteroidal mineralocorticoid receptor antagonist finerenone has been associated with reduced cardiovascular mortality and total worsening HF events across all body mass index (BMI) levels, with greater benefits observed in patients with higher BMIs.

SUMMARY

Antiobesity medications such as semaglutide and tirzepatide may represent important treatment options for patients with obesity-related HFpEF. Additional evidence suggests that certain other HF medications may have increased efficacy in patients with obesity.

Semaglutide in Patients with Obesity and Heart Failure Irrespective of Their Baseline Ejection Fraction: An Efficacy and Safety Meta-analysis of Randomized Controlled Trials

Obesity in heart failure (HF) patients often experience a significant burden of symptoms and physical limitations. Semaglutide, a glucagon-like peptide 1 receptor agonist, has a beneficial impact on cardiovascular outcomes in obese patients, but its role in patients with HF remains unclear. In our meta-analysis, we aimed to evaluate the safety and efficacy of semaglutide in obese HF patients. Five databases were searched from inception to August 2024 to identify randomized controlled trials (RCTs) that compared semaglutide to placebo in obese patients with HF regardless of the baseline ejection fraction (EF). Our primary outcome was the incidence of cardiovascular (CV) mortality. We performed a main subgroup analysis based on the ejection fraction [heart failure with preserved ejection fraction (HFpEF) and HF with reduced EF (HFrEF)]. Five RCTs with a total of 6898 patients were included in our meta-analysis. Semaglutide significantly reduced the overall incidence of CV mortality compared with placebo [risk ratio (RR), 0.74; 95% confidence interval (CI), 0.58-0.94; P = 0.02]. Similar rates were observed in HFrEF patients (RR, 0.66; 95% CI, 0.47-0.92; P = 0.01), without difference in HFpEF patients (RR, 0.84; 95% CI, 0.59-1.22; P = 0.37). Moreover, semaglutide demonstrated a positive impact on KCCQ-CSS [mean difference (MD), 7.72; 95% CI, 5.28-10.17; P < 0.001] and 6-minute walk test (MD, 14.83; 95% CI, 4.23-25.43; P = 0.006) compared with placebo. Semaglutide exhibited a significant reduction in CV mortality and improvement in the Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score and 6-minute walk distance. Long-term RCTs are warranted to validate the current findings in obese HF patients.

Effect of a Meal on Invasive Hemodynamics and Plasma Incretin Levels in Patients With Heart Failure

BACKGROUND

The importance of gastrointestinal hormones, including the incretins glucagon-like peptide-1 (GLP-1) and GIP (glucose-dependent insulinotropic polypeptide), in heart failure pathophysiology is debated. The postprandial incretin response and its relation to hemodynamic changes in patients with heart failure, however, remains unknown.

METHODS

A pulmonary artery catheter was placed in 14 patients with chronic heart failure and 10 healthy controls, who subsequently consumed a standardized meal (3.2 MJ). Hemodynamic measures and blood samples were collected over 120 minutes. Bowel wall thickness and superior mesenteric artery blood flow were measured by ultrasound. Gastrointestinal symptoms were assessed through questionnaires.

RESULTS

Patients, compared with controls, exhibited an impaired postprandial peak in cardiac index (2.8 versus 4.0 L/min per m², P<0.001) and a blunted cardiac index response in the postprandial period (baseline-substracted area under the curve, P=0.030). Patients had higher fasting total GLP-1 levels (14.0 versus 7.5 pmol/L, P=0.015) and a greater postprandial peak (33.5 versus 21.0 pmol/L, P=0.013). Fasting total GLP-1 concentrations correlated with central venous pressure (P=0.025). There was a trend toward a correlation between area under the curve total GLP-1 and cardiac index (P=0.054). There was no change in GIP concentrations. Patients had a higher gastrointestinal symptom burden (P=0.033), and an indigestion score that correlated with peak superior mesenteric artery blood flow (P=0.017).

CONCLUSIONS

Patients with heart failure showed a blunted cardiac index response to meal intake, elevated total GLP-1 levels that were associated with hemodynamic parameters, and increased gastrointestinal symptom burden.

Evolving Role of Double and Triple Therapy With GLP-1 Receptor Agonists in Obesity and Cardiovascular Disease

Glucagon-like peptide 1 receptor agonists (GLP-1RAs) have emerged as a transformative class of therapies, expanding their clinical utility far beyond glycemic control. Initially developed for the treatment of diabetes, these agents are now recognised as potent therapies for managing overweight and obesity, atherosclerosis, and heart failure. This review explores the evolution of GLP-1RA-based therapies, with a focus on novel advances such as dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists ("double G") and triple receptor agonists incorporating glucagon modulation ("triple G"). We also provide an overview of completed and ongoing clinical trials investigating the role of GLP-1RAs in atherosclerosis and heart failure. These developments underscore the expanding therapeutic landscape of GLP-1RAs and their growing significance in cardiometabolic medicine.

Population Pharmacokinetics of Efsubaglutide Alfa in Healthy Subjects and Subjects with Type 2 Diabetes

BACKGROUND AND OBJECTIVES

Efsubaglutide alfa is a novel long-acting human glucagon-like peptide-1 receptor agonist. Clinical studies in patients with type 2 diabetes (T2D) have shown excellent glucose-lowering effects. This study aims to develop a population pharmacokinetic (popPK) model for efsubaglutide alfa to characterize its pharmacokinetic (PK) profile and assess the impact of intrinsic and extrinsic factors.

METHODS

A popPK model was developed using a nonlinear mixed-effects model (NONMEM) based on 4173 plasma concentration measurements of efsubaglutide alfa from 911 participants, including 36 healthy subjects and 875 patients with T2D, across four clinical trials. These trials involved once-weekly subcutaneous injections of efsubaglutide alfa at doses ranging from 0.375 mg to 9.0 mg, with treatment durations spanning from 1 to 24 weeks. Diagnostic plots, visual predictive checks, nonparametric bootstrap methods, and simulations were employed to validate the model's robustness and performance. Covariates were identified using stepwise covariate modeling.

RESULTS

A two-compartment model with first-order absorption and first-order elimination adequately described the PK characteristics of efsubaglutide alfa. Efsubaglutide alfa exhibited favorable absorption (Ka = 0.0255 per hour) and a relatively large apparent volume of distribution (V2/F of 14.5 L with relative standard error [RSE] of 3%; V3/F of 3.01 L). It showed moderate clearance (CL/F of 0.0680 L/h, RSE of 1%, inter-individual variability of 16.6%) and an extended half-life. In subjects with T2D, the geometric mean half-life was estimated between 182 and 215 h across the 1-3 mg dose range, supporting once-weekly or once-every-two-week dosing. Efsubaglutide alfa exposure increased proportionally with dose and remained consistent across studies. Baseline body weight (WT), baseline estimated glomerular filtration rate (eGFR), neutralizing antidrug antibody (Nab), STUDY, and planned dose (ARM) were identified as significant covariates for CL/F, while baseline WT and STUDY influenced V2/F. Although baseline WT and eGFR affected exposure parameters (AUCss, Cmax,ss, and Cmin,ss), these effects were not clinically significant, suggesting no need for dose adjustment.

CONCLUSIONS

The final popPK model, incorporating significant covariates (baseline WT, baseline eGFR, Nab, STUDY, and ARM), provided robust and precise PK parameter estimates, confirming its applicability in both healthy subjects and those with T2D. The minimal and clinically insignificant impact of baseline WT and eGFR on drug exposure supports the conclusion that no dose adjustment is necessary based on these factors. Moreover, the higher absorption rate constant suggests a rapid onset of action, and the extended half-life supports less frequent dosing, potentially improving patient adherence.

TRIAL REGISTRATION

The trials were registered at Clinicaltrials.gov (identifiers: NCT03745885, NCT04314622, NCT04994288, and NCT04998032).

How to Enhance Cardiorenal Benefits in Patients With Chronic Heart Failure?

Chronic heart failure (CHF) is frequently complicated by chronic kidney disease (CKD), a comorbidity that profoundly influences disease progression, therapeutic decision-making, and clinical outcomes. The management of CHF in patients with advanced CKD presents substantial challenges, often requiring dose adjustments or even discontinuation of standard therapies. Effective therapeutic strategies must prioritize cardiorenal protection during the early stages of disease progression. Recent advancements in pharmacotherapy, including angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists, have demonstrated remarkable dual cardiorenal protective effects. These therapies not only reduce the risk of de novo heart failure in high-risk populations and improve clinical outcomes in CHF patients, but also slow the progression of renal dysfunction by targeting critical pathophysiological processes, such as glomerular hyperfiltration, inflammation, ischemia, and endothelial dysfunction. Although transient declines in estimated glomerular filtration rate may occur upon initiating these agents, renal function typically stabilizes over time, facilitating sustained clinical benefits, particularly in patients with diabetes mellitus, albuminuric CKD, and CHF. This review focuses on the latest advancements in heart failure pharmacotherapy, emphasizing the cardiorenal protective mechanisms and clinical efficacy of novel therapeutic agents. It underscores the importance of bridging knowledge gaps and personalizing therapy to enhance cardiorenal benefits avoiding adverse effects.

How 'miracle' weight-loss semaglutide promises to change medicine but can we afford the expense?

Obesity is a complex and growing global concern, affecting one in eight individuals and compromising health, quality of life and life expectancy. It carries significant metabolic, cardiovascular, oncological, hepatorenal, skeletal and psychiatric risks, imposing substantial costs on health-care systems. Traditional treatments have often been ineffective or have led to relapse after lifestyle changes. Whereas bariatric surgery is effective, it also involves risks such as mortality and hospitalisation. Semaglutide, licensed in 2018, is a synthetic analogue of glucagon-like peptide 1 which regulates glucose metabolism and gastrointestinal (GI) motility. Studies show that semaglutide, administered either weekly and subcutaneously, or daily orally, induces an average weight loss of -11.62 kg compared to placebo and reduces waist circumference by up to -9.4 cm. It also improves blood pressure, fasting glucose levels, C-reactive protein levels and lipid profiles. The most common adverse events are mild-to-moderate GI complaints occurring more frequently with daily administration than weekly doses; hypoglycaemia is more common without lifestyle intervention. Weight regain often follows semaglutide withdrawal. Furthermore, semaglutide offers cardiovascular benefits for patients with established atherosclerotic cardiovascular disease (CVD), lowers the risk of kidney outcomes and cardiovascular-related death, resolves nonalcoholic steatohepatitis in many cases, and positively impacts mental health and quality of life. In conclusion, semaglutide therapy could significantly benefit many adults regarding CVD and mortality if made widely accessible. Ethical and financial considerations must be addressed for personalised obesity treatment approaches.

Semaglutide in heart failure and atherosclerotic cardiovascular disease: the current state-of-the-art

Cardiovascular disease mortality rates, which had steadily declined over decades, are now plateauing or reversing due to the global rise in type 2 diabetes mellitus (T2DM) and obesity. These cardiometabolic conditions contribute significantly to atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease. Among emerging pharmacological treatments, glucagon-like peptide-1 receptor agonists, particularly semaglutide, have shown benefits beyond diabetes and obesity management, including cardioprotective and renoprotective effects. This state-of-the-art review comprehensively analyzes current evidence from clinical trials, identifies critical insights, and outlines research directions regarding semaglutide use in HF, ASCVD, and diabetic nephropathy. In ASCVD, semaglutide has demonstrated significant reductions in major adverse cardiovascular events, supported by findings from meta-analyses of trials in patients with T2DM and the SELECT trial for patients without T2DM. In a prespecified analysis of the SELECT trial, semaglutide demonstrated significant reductions in cardiovascular mortality and HF hospitalizations for patients with HF and ASCVD. In HF with preserved ejection fraction and mildly reduced ejection fraction, semaglutide improved symptoms, physical function, natriuretic peptide levels, echocardiographic parameters, and HF hospitalizations, as shown in the STEP-HFpEF program and a pooled analysis of trials. Furthermore, evidence from the FLOW trial underscores semaglutide's renal and cardiovascular benefits in diabetic nephropathy, irrespective of body mass index. While these findings suggest semaglutide's efficacy in cardiorenal diseases, gaps in evidence remain, including the need for event-driven trials in HF populations without ASCVD and irrespective of obesity. Future research should address these gaps, which could potentially update guideline recommendations.

Leptin and heart failure: the chicken or the egg?

Leptin plays a dual role in heart failure (HF), acting as either a primary driver or a secondary phenomenon depending on the HF subtype. In HF with preserved ejection fraction (HFpEF), chronic hyperleptinemia is a primary mediator of disease initiation and progression, closely linked to obesity and metabolic dysfunction. Elevated leptin levels promote systemic inflammation, sympathetic nervous system activation, arterial stiffness, myocardial hypertrophy, fibrosis, and sodium retention, culminating in diastolic dysfunction and elevated ventricular filling pressures. Conversely, in HF with reduced ejection fraction (HFrEF), elevated leptin levels arise as a secondary response to myocardial dysfunction, systemic inflammation, and tissue hypoperfusion. Here, leptin exacerbates cardiac dysfunction by amplifying neurohormonal activation, inflammation, and cardiac remodeling. Understanding these distinct roles has potential therapeutic implications. In HFpEF, interventions such as weight loss, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, and mineralocorticoid receptor antagonists can improve symptoms and prognosis, partly by mitigating chronic hyperleptinemia. Furthermore, leptin-specific therapies should be investigated in clinical trials as potential approach in managing cardiometabolic HFpEF. In HFrEF, management focuses on guideline-directed therapies targeting neurohormonal activation-the key mechanism driving disease progression. However, future research should explore whether modulating leptin signaling could provide additional benefits translated in hard clinical endpoints. By framing leptin as the initiator ("chicken") in HFpEF and a consequence ("egg") in HFrEF, this manuscript highlights the need for individualized, integrated treatment strategies. Addressing both metabolic and cardiovascular components could potentially further improve patient outcomes and quality of life.

Can a New Commission Make America Healthy Again?

This JAMA Forum discusses the recently formed Make America Healthy Again commission and suggests a few key policies that align with ongoing federal programs and initiatives.

Cardiovascular-Endocrine-Metabolic Medicine: Proposing a New Clinical Sub-Specialty Amid the Cardiometabolic Pandemic

Cardiovascular-Renal-Hepatic-Metabolic diseases are on the rise worldwide, creating major challenges for patient care and clinical research. Although these conditions share common mechanisms and often respond to similar treatments-such as lifestyle changes and newer cardiometabolic drugs (e.g., SGLT2 inhibitors, GLP-1 receptor agonists)-clinical management remains divided among multiple specialties. Recently proposed curricula in Cardiometabolic Medicine and Preventive Cardiology reflect an effort to address this fragmentation. In addition, recent studies reveal that hormonal deficiencies may increase cardiovascular risk and worsen heart failure, with emerging data showing that correcting these imbalances can improve exercise capacity and possibly reduce major cardiac events. To overcome gaps in care, we propose a new sub-specialty: Cardiovascular-Endocrine-Metabolic Medicine. This approach unifies three main pillars: (1) Lifestyle medicine, emphasizing nutrition, physical activity, and smoking cessation; (2) the Integrated Medical Management of obesity, diabetes, hypertension, dyslipidemia, heart failure with preserved ejection fraction, early-stage kidney disease, metabolic-associated liver disease, and related conditions; and (3) hormonal therapies, focused on optimizing sex hormones and other endocrine pathways to benefit cardiometabolic health. By bridging cardiology, endocrinology, and metabolic medicine, this sub-specialty offers a more seamless framework for patient care, speeds up the adoption of new treatments, and sets the stage for innovative research-all critical steps in addressing the escalating cardiometabolic pandemic.

Fabry Disease: Insights into Pathophysiology and Novel Therapeutic Strategies

Fabry disease (FD) is an X-linked lysosomal storage disorder characterized by deficiency of α-galactosidase A (α-GalA), leading to the accumulation of glycosphingolipids and multi-organ dysfunction, particularly affecting the cardiovascular and renal systems. Disease-modifying treatments such as enzyme replacement therapy (ERT) and oral chaperone therapy (OCT) have limited efficacy, particularly in advanced disease, prompting a need for innovative therapeutic approaches targeting underlying molecular mechanisms beyond glycosphingolipid storage alone. Recent insights into the pathophysiology of FD highlights chronic inflammation and mitochondrial, lysosomal, and endothelial dysfunction as key mediators of disease progression. Adjunctive therapies such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, and mineralocorticoid receptor antagonists (MRAs) demonstrate significant cardiovascular and renal benefits in conditions including heart failure and chronic kidney disease. These drugs also modulate pathways involved in the pathophysiology of FD, such as autophagy, oxidative stress, and pro-inflammatory cytokine signaling. While theoretical foundations support their utility, dedicated trials are necessary to confirm efficacy in the FD-specific population. This narrative review highlights the importance of expanding therapeutic strategies in FD, advocating for a multi-faceted approach involving evidence-based adjunctive treatments to improve outcomes. Tailored research focusing on diverse FD phenotypes, including females and non-classical variants of disease, will be critical to advancing care and improving outcomes in this complex disorder.

Obesity update: cardiovascular risk and therapeutic innovations (focus on semaglutide and tirzepatide)

Excess or dysfunctional adipose tissue is a key pathophysiological factor in cardiovascular-kidney-metabolic syndrome. However, until very recently, there was no evidence that pharmacological treatments for obesity could significantly impact major cardiovascular outcomes. Recently, the SELECT study represented the first, and to date the only, cardiovascular outcome trial conducted in the context of pharmacological treatment for obesity, and subcutaneous (s.c.) semaglutide 2.4 mg is the first molecule capable of leading to a statistically significant reduction in the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke in obese, non-diabetic patients with pre-existing cardiovascular disease. Furthermore, in the context of heart failure with preserved ejection fraction with obesity-related phenotype, s.c. semaglutide 2.4 mg and tirzepatide have been shown to improve prognosis, functional capacity, and quality of life. The main limiting factors for the implementation of semaglutide and tirzepatide are represented by the suboptimal adherence to treatment due to gastrointestinal intolerance, as well as by the reduced accessibility and economic sustainability. It is therefore necessary to wait to see how the drug regulatory agencies and international guidelines will implement the evidence of semaglutide and tirzepatide in the specific setting of the cardiovascular risk of obese patients.

The promise of glucagon-like peptide 1 receptor agonists (GLP-1RA) for the treatment of obesity: a look at phase 2 and 3 pipelines

INTRODUCTION

GLP-1-based therapies have changed the treatment of overweight/obesity. Liraglutide 3.0 mg daily, the first GLP-1 RA approved for treatment of overweight, induced a weight loss of 6-8%, Semaglutide 2.4 mg once weekly improved weight loss to about 12-15%, while the dual GIP/GLP-1 receptor agonist tirzepatide once weekly has induced a weight loss of about 20% in obese people without diabetes.

AREAS COVERED

This review describes results obtained with GLP-1 mono-agonists, GLP-1/GIP dual agonists, GLP-1/glucagon co-agonists, and the triple agonist retatrutide (GIP/GLP-1/glucagon), which have shown beneficial effect both on body weight and steatotic liver disease. A combination of semaglutide (a GLP-1 agonist) and cagrilintide (a long-acting amylin analogue) for weekly administration is currently in phase III development, and so is oral semaglutide and several non-peptide small molecule GLP-1 agonists for oral administration. The adverse events with the GLP-1-based therapies are primarily gastrointestinal and include nausea, vomiting, obstipation, or diarrhea, which often can be mitigated by slow up titration.

EXPERT OPINION

The GLP-1-based therapies will change the treatment of obesity and its comorbidities including steatotic liver disease in the future. Outstanding question is maintenance of the weight loss, possibly pharmacological treatment needs to be life-long.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2024

Rapid shifts in evidence-based medicine challenge clinicians to adapt their practices based on new information. Synthesizing relevant evidence can drive clinical advancements. To enhance knowledge of practice-changing literature, a group of six internists reviewed titles and abstracts from seven internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. In addition, collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster ACCESSSS/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to reach consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Articles pertaining to the same topic were considered together. In total,7 practice-changing articles were included.

Efficacy of GLP-1 Receptor Agonists in Patients With Heart Failure and Mildly Reduced or Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

BACKGROUND

Heart failure (HF) with mildly reduced or preserved ejection fraction (HFpEF) accounts for over half of cases of HF, with obesity playing a key role. Residual risk remains high despite available therapies. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have shown potential cardiometabolic benefits, but their role in HFpEF remains unclear.

METHODS

A systematic review and meta-analysis of randomized controlled trials evaluating GLP-1RAs in HFpEF were conducted. Studies evaluating GLP-1RA in combination with glucose-dependent insulinotropic polypeptide (GIP) were also included. The analyzed outcomes included cardiovascular (CV) death, worsening HF events and their composite. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled by using a random-effects model.

RESULTS

Six randomized controlled trials involving 8788 patients were included. GLP-1RAs significantly reduced the composite outcome of CV death or worsening HF events (HR: 0.68 [0.51-0.89]; P = 0.006, I² = 47%) as well as worsening HF events alone (HR: 0.56 [0.38-0.82]; P = 0.003, I² = 51%). No significant reduction was observed for CV death alone (HR: 0.86 [0.67-1.12]; P = 0.27, I² = 0%).

CONCLUSION

GLP-1RAs reduce worsening HF events and the composite of CV death or worsening HF in HFpEF, particularly in patients with obesity or diabetes. These findings support their role as a promising therapy requiring further HFpEF-focused trials.

Reaching the SUMMIT? Benefits and potential risks associated with the use of tirzepatide in heart failure with preserved ejection fraction

The SUMMIT trial1 showed that the dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist tirzepatide improves quality of life and reduces worsening heart failure (HF) events in patients with HF with preserved ejection fraction (HFpEF) and obesity. Some concerns, however, remain.

From Cardiovascular-Kidney-Metabolic Syndrome to Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Proposing an Expanded Framework

Cardiometabolic diseases represent an escalating global health crisis, slowing or even reversing earlier declines in cardiovascular disease (CVD) mortality. Traditionally, conditions such as obesity, type 2 diabetes mellitus (T2DM), atherosclerotic CVD, heart failure (HF), chronic kidney disease (CKD), and metabolic dysfunction-associated steatotic liver disease (MASLD) were managed in isolation. However, emerging evidence reveals that these disorders share overlapping pathophysiological mechanisms and treatment strategies. In 2023, the American Heart Association proposed the Cardiovascular-Kidney-Metabolic (CKM) syndrome, recognizing the interconnected roles of the heart, kidneys, and metabolic system. Yet, this model omits the liver-a critical organ impacted by metabolic dysfunction. MASLD, which can progress to metabolic dysfunction-associated steatohepatitis (MASH), is closely tied to insulin resistance and obesity, contributing directly to cardiovascular and renal impairment. Notably, MASLD is bidirectionally associated with the development and progression of CKM syndrome. As a result, we introduce an expanded framework-the Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome-to more comprehensively capture the broader inter-organ dynamics. We provide guidance for an integrated diagnostic approach aimed at halting progression to advanced stages and preventing further organ damage. In addition, we highlight advances in medical management that target shared pathophysiological pathways, offering benefits across multiple organ systems. Viewing these conditions as an integrated whole, rather than as discrete entities, and incorporating the liver into this framework fosters a more holistic management strategy and offers a promising path to addressing the cardiometabolic pandemic.

Clinical Outcomes of Catheter Ablation for Atrial Fibrillation in Patients with Acute Decompensated Heart Failure

Background: The prognosis of acute decompensated heart failure (ADHF) and heart failure (HF) with atrial fibrillation (AF) has been dismal. This study was performed to investigate the clinical outcomes of catheter ablation (CA) performed in patients with concurrent ADHF and AF. Methods: We retrospectively analyzed ADHF patients with AF who were admitted to our institution from 2007 to 2017. Results: In total, 472 patients were included in this study, with a mean follow-up duration of 32.8 ± 32.9 months. The 5-year event-free rate (cardiovascular death and HF hospitalization) was 61.4%, and the 10-year event-free rate was 42.7%. A comparative analysis of the event group and control group revealed that patients in the event group were older (event group vs. control group: 72.1 ± 11.0 vs. 68.8 ± 13.4 years, p = 0.008) and had a higher proportion of Clinical Scenario 3 classifications (event group vs. control group: 24% vs. 12%, p = 0.001). Notably, patients in the event group had a lower sinus rhythm maintenance rate (event group vs. control group: 17% vs. 31%, p < 0.001) and CA rate (event group vs. control group: 9% vs. 21%, p = 0.003). The CA group had a higher event-free rate than the non-CA group, and this trend persisted even after matching the patients' backgrounds (log-rank test: p < 0.001). Conclusions: Patients presenting with AF at the onset of ADHF showed a poor prognosis, whereas CA demonstrated potential for improving the prognosis for some of these patients.

Integrated Management of Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Expanding Roles of SGLT2is, GLP-1RAs, and GIP/GLP-1RAs

Cardiovascular-Kidney-Metabolic syndrome, introduced by the American Heart Association in 2023, represents a complex and interconnected spectrum of diseases driven by shared pathophysiological mechanisms. However, this framework notably excludes the liver-an organ fundamental to metabolic regulation. Building on this concept, Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome incorporates the liver's pivotal role in this interconnected disease spectrum, particularly through its involvement via metabolic dysfunction-associated steatotic liver disease (MASLD). Despite the increasing prevalence of CRHM syndrome, unified management strategies remain insufficiently explored. This review addresses the following critical question: How can novel anti-diabetic agents, including sodium-glucose cotransporter-2 inhibitors (SGLT2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dual gastric inhibitory polypeptide (GIP)/GLP-1RA, offer an integrated approach to managing CRHM syndrome beyond the boundaries of traditional specialties? By synthesizing evidence from landmark clinical trials, we highlight the paradigm-shifting potential of these therapies. SGLT2is, such as dapagliflozin and empagliflozin, have emerged as cornerstone guideline-directed treatments for heart failure (HF) and chronic kidney disease (CKD), providing benefits that extend beyond glycemic control and are independent of diabetes status. GLP-1RAs, e.g., semaglutide, have transformed obesity management by enabling weight reductions exceeding 15% and improving outcomes in atherosclerotic cardiovascular disease (ASCVD), diabetic CKD, HF, and MASLD. Additionally, tirzepatide, a dual GIP/GLP-1RA, enables unprecedented weight loss (>20%), reduces diabetes risk by over 90%, and improves outcomes in HF with preserved ejection fraction (HFpEF), MASLD, and obstructive sleep apnea. By moving beyond the traditional organ-specific approach, we propose a unified framework that integrates these agents into holistic management strategies for CRHM syndrome. This paradigm shift moves away from fragmented, organ-centric management toward a more unified approach, fostering collaboration across specialties and marking progress in precision cardiometabolic medicine.

GLP-1 and Its Analogs: Does Sex Matter?

While obesity and diabetes are prevalent in both men and women, some aspects of these diseases differ by sex. A new blockbuster class of therapeutics, glucagon-like peptide 1 (GLP-1) analogs (eg, semaglutide), shows promise at curbing both diseases. This review addresses the topic of sex differences in the endogenous and therapeutic actions of GLP-1 and its analogs. Work on sex differences in human studies and animal research is reviewed. Preclinical data on the mechanisms of potential sex differences in the endogenous GLP-1 system as well as the therapeutic effect of GLP-1 analogs, focusing on the effects of the drugs on the brain and behavior relating to appetite and metabolism, are highlighted. Moreover, recent clinical evidence of sex differences in the therapeutic effects of GLP-1 analogs in obesity, diabetes, and cardiovascular disease are discussed. Lastly, we review evidence for the role of GLP-1 analogs in mood and reproductive function, with particular attention to sex differences. Overall, while we did not find evidence for many qualitative sex differences in the therapeutic effect of clinically approved GLP-1 analogs, a growing body of literature highlights quantitative sex differences in the response to GLP-1 and its analogs as well as an interaction of these therapeutics with estrogens. What also clearly emerges is the paucity of data in female animal models or women in very basic aspects of the science of GLP-1-gaps that should be urgently mended, given the growing popularity of these medications, especially in women.

Survodutide for the Treatment of Obesity: Rationale and Design of the SYNCHRONIZE Cardiovascular Outcomes Trial

Dual agonism of glucagon and glucagon-like peptide-1 (GLP-1) receptors may be more effective than GLP-1 receptor agonism alone in reducing body weight, but the cardiovascular (CV) effects are unknown. The authors describe the rationale and design of SYNCHRONIZE-CVOT, a phase 3, randomized, double-blind, parallel-group, event-driven, CV safety study of survodutide, a dual glucagon and GLP-1 receptor agonist, administered subcutaneously once weekly compared with placebo in adults with a body mass index ≥27 kg/m2 and established CV disease or chronic kidney disease, and/or at least 2 weight-related complications or risk factors for CV disease. The primary endpoint of SYNCHRONIZE-CVOT is time to first occurrence of the composite adjudicated endpoint of 5-point major adverse CV events. This global CV outcomes trial is currently enrolling, with a target recruitment of 4,935 participants. SYNCHRONIZE-CVOT is the first trial that will determine the CV safety and efficacy of survodutide in people with obesity and increased CV risk. (A Study to Test the Effect of Survodutide [BI 456906] on Cardiovascular Safety in People With Overweight or Obesity [SYNCHRONIZE-CVOT]; NCT06077864).

Gut Hormones in Heart Failure

Heart failure (HF) is a syndrome affecting all organ systems. While some organ interactions have been studied intensively in HF (such as the cardiorenal interaction), the endocrine gut has to some degree been overlooked. However, there is growing evidence of direct cardiac effects of several hormones secreted from the gastrointestinal tract. For instance, GLP-1 (glucagon-like peptide-1), an incretin hormone secreted from the distal intestine following food intake, has notable effects on the heart, impacting heart rate and contractility. GLP-1 may even possess cardioprotective abilities, such as inhibition of myocardial ischemia and cardiac remodeling. While other gut hormones have been less studied, there is evidence suggesting cardiostimulatory properties of several hormones. Moreover, it has been reported that patients with HF have altered bioavailability of numerous gastrointestinal hormones, which may have prognostic implications. This might indicate an important role of gut hormones in cardiac physiology and pathology, which may be of particular importance in the failing heart. We present an overview of the current knowledge on gut hormones in HF, focusing on HF with reduced ejection fraction, and discuss how these hormones may be regulators of cardiac function and central hemodynamics. Potential therapeutic perspectives are discussed, and knowledge gaps are highlighted herein.

Pharmacological management of heart failure: a patient-centred approach

INTRODUCTION

Heart failure (HF) is a global health challenge that requires a multidisciplinary approach. Despite recent advances in pharmacological and interventional therapy, morbidity and mortality in these patients remain high. For this reason, and because of its interplay with other cardiovascular and non-cardiovascular diseases, HF represents a major area of research, with new trials being published every year and international guidelines constantly updated.

AREAS COVERED

The authors review the current status and possible future developments in HF pharmacotherapy.

EXPERT OPINION

The treatment of HF has made significant advances in recent years, and the current recommendations are based on large outcome trials. This has led to significant reductions in both mortality and morbidity, but the death rate remains unacceptably high. In this context, a patient-centered approach that considers comorbidities and specific clinical scenarios when dosing HF medication is essential. Prevention of hospital admissions for cardiac decompensation is of utmost importance in patients with HF as is the enablement of activities of daily living, an endpoint which has only recently been incorporated into major HF trials.

Impact of semaglutide on weight and functional outcomes among obese heart failure patients: a propensity scores matching analysis

BACKGROUND & OBJECTIVES

Obesity is a common comorbidity in heart failure, yet effective pharmacological options for weight loss in these patients are limited. Semaglutide, a glucagon-like peptide 1 receptor agonist, has shown promise for weight reduction in obese adults. This study aims to evaluate semaglutide's impact on weight loss, functional status, and clinical outcomes in obese patients with heart failure.

METHODS

A retrospective analysis was conducted on all consecutive obese (BMI > 30 kg/m²) patients with heart failure at the University Hospital Bonn outpatient clinic from July 2019 to July 2022. Propensity score matching paired patients receiving semaglutide as an add-on therapy (SEMA) with those on medical therapy alone (Control).

RESULTS

Among 1,942 patients with heart failure screened, 26 matched pairs were identified. At one year, the SEMA group exhibited significant weight loss, with a mean BMI reduction of -2.91 kg/m² (95% CI: -4.27 to -1.55; p < 0.001), while the control group showed a non-significant mean change of -0.41 kg/m² (95% CI: -1.08 to 0.26; p = 0.22). The difference in BMI between the two groups was statistically significant (mean difference: 3.42 kg/m², 95% CI: 1.43 to 5.42; p = 0.001). Improvements by at least one NYHA class were observed in 65% of the SEMA group (p < 0.001) compared to 15% of the control group (p = 0.18). The SEMA group also showed a significant increase in 6-minute walk distance (6MWD), with a mean difference of 75 m between the groups at one year (95% CI: 0.53 to 150.02; p = 0.049). NT-proBNP levels significantly decreased in the SEMA group (p < 0.001) compared to the control group (p = 0.78), with a statistically significant difference in NT-proBNP between the groups (p = 0.048). Both improvements in 6MWD and reductions in NT-proBNP were significantly correlated with BMI percentage reductions.

CONCLUSIONS

Semaglutide was associated with significant weight reduction in obese patients with heart failure, accompanied by improved NYHA classification and 6-minute walk distance. Larger, multi-center trials and prospective, randomized controlled trials are warranted. These studies should focus on assessing long-term outcomes, optimizing dosage, and exploring the potential cardiovascular benefits beyond weight reduction.

Semaglutide versus placebo in patients with heart failure and mildly reduced or preserved ejection fraction: a pooled analysis of the SELECT, FLOW, STEP-HFpEF, and STEP-HFpEF DM randomised trials

BACKGROUND

Heart failure with mildly reduced or preserved ejection fraction (hereafter referred to as HFpEF) is the most common type of heart failure and is associated with a high risk of hospitalisation and death, especially in patients with overweight, obesity, or type 2 diabetes. In the STEP-HFpEF and STEP-HFpEF DM trials, semaglutide improved heart failure-related symptoms and physical limitations in participants with HFpEF. Whether semaglutide also reduces clinical heart failure events in this group remains to be established.

METHODS

We conducted a post-hoc pooled, participant-level analysis of four randomised, placebo-controlled trials (SELECT, FLOW, STEP-HFpEF, and STEP-HFpEF DM) to examine the effects of once-weekly subcutaneous semaglutide (2·4 mg in SELECT, STEP-HFpEF, and STEP-HFpEF DM; 1·0 mg in FLOW) on heart failure events. The STEP-HFpEF and STEP-HFpF DM trials enrolled participants with obesity-related HFpEF, the SELECT trial enrolled participants with atherosclerotic cardiovascular disease and overweight or obesity, and the FLOW trial enrolled participants with type 2 diabetes and chronic kidney disease. Hence, for this analysis, we include all participants from the STEP-HFpEF trials and those with an investigator-reported history of HFpEF from SELECT and FLOW. The main outcomes for this analysis were the composite endpoint of time to cardiovascular death or first worsening heart failure event (defined as hospitalisation or urgent visit due to heart failure), time to first worsening heart failure event, and time to cardiovascular death. Efficacy and safety endpoints were analysed with the full analysis set (ie, all participants randomly assigned to treatment, according to the intention-to-treat principle). The SELECT, FLOW, STEP-HFpEF, and STEP-HFpEF DM trials are registered at ClinicalTrials.gov, NCT03574597, NCT03819153, NCT04788511, and NCT04916470, respectively, and all are complete.

FINDINGS

Across the four trials, 3743 (16·8%) of 22 282 participants had a history of HFpEF (1914 assigned to semaglutide and 1829 assigned to placebo). In this group of participants with HFpEF, semaglutide reduced the risk of the combined endpoint of cardiovascular death or heart failure events (103 [5·4%] of 1914 in the semaglutide group had events vs 138 [7·5%] of 1829 in the placebo group; hazard ratio [HR] 0·69 [95% CI 0·53-0·89]; p=0·0045). Semaglutide also reduced the risk of worsening heart failure events (54 [2·8%] vs 86 [4·7%]; HR 0·59 [0·41-0·82]; p=0·0019). No significant effect on cardiovascular death alone was seen (59 [3·1%] vs 67 [3·7%]; HR 0·82 [0·57-1·16]; p=0·25). A lower proportion of patients treated with semaglutide had serious adverse events than did those who were treated with placebo (572 [29·9%] vs 708 [38·7%]).

INTERPRETATION

In patients with HFpEF, semaglutide reduced the risk of the combined endpoint of cardiovascular death or worsening heart failure events, and worsening heart failure events alone, whereas its effect on cardiovascular death alone was not significant. These data support the use of semaglutide as an efficacious therapy to reduce the risk of clinical heart failure events in patients with HFpEF, for whom few treatment options are currently available.

FUNDING

Novo Nordisk.