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Croset F, Llàcer P, Núñez J, Campos J, García M, Pérez A, Fernández C, Fabregate M, López G, Tello S, Fernández JM, Ruiz R, Manzano L. Loop diuretic down-titration at discharge in patients hospitalized for acute heart failure. ESC Heart Fail 2024; 11:1739-1747. [PMID: 38454739 PMCID: PMC11098660 DOI: 10.1002/ehf2.14749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
AIMS The current literature provides limited guidance on the best diuretic strategy post-hospitalization for acute heart failure (AHF). It is postulated that the efficacy and safety of the outpatient diuretic regimen may be significantly influenced by the degree of fluid overload (FO) encountered during hospitalization. We hypothesize that in patients with more pronounced FO, reducing their regular oral diuretic dosage might be associated with an elevated risk of unfavourable clinical outcomes. METHODS AND RESULTS It was a retrospective observational study of 410 patients hospitalized for AHF in which the dose of furosemide at admission and discharge was collected. Patients were categorized across diuretic dose status into two groups: (i) the down-titration group and (ii) the stable/up-titration group. FO status was evaluated by a clinical congestion score and circulating biomarkers. The endpoint of interest was the composite of time to all-cause death and/or heart failure readmission. A multivariable Cox proportional hazard regression model was constructed to analyse the endpoints. The median age was 86 (78-92) years, 256 (62%) were women, and 80% had heart failure with preserved ejection fraction. After multivariate adjustment, the down-titration furosemide equivalent dose remained not associated with the risk of the combined endpoint in the whole sample (hazard ratio 1.34, 95% confidence interval 0.86-2.06, P = 0.184). The risk of the combination of death and/or worsening heart failure associated with the diuretic strategy at discharge was significantly influenced by FO status, including clinical congestion scores and circulating proxies of FO like BNP and cancer antigen 125. CONCLUSIONS In patients hospitalized for AHF, furosemide down-titration does not imply an increased risk of mortality and/or heart failure readmission. However, FO status modifies the effect of down-titration on the outcome. In patients with severe congestion or residual congestion at discharge, down-titration was associated with an increased risk of mortality and/or heart failure readmission.
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Affiliation(s)
- François Croset
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de Alcalá, IRYCISMadridSpain
| | - Pau Llàcer
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de Alcalá, IRYCISMadridSpain
| | - Julio Núñez
- Department of CardiologyHospital Clínico Universitario, Universitat de València, INCLIVAValenciaSpain
- CIBER CardiovascularMadridSpain
| | - Jorge Campos
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Marina García
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Alberto Pérez
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Cristina Fernández
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Martín Fabregate
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Genoveva López
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Susana Tello
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - José María Fernández
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Raúl Ruiz
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
| | - Luis Manzano
- Department of Internal MedicineHospital Universitario Ramón y Cajal, IRYCISMadridSpain
- Department of Medicine and Medical Specialties, Facultad de Medicina y Ciencias de la SaludUniversidad de Alcalá, IRYCISMadridSpain
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2
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Infeld M. Accelerated physiologic pacing in patients with heart failure with preserved ejection fraction: An argument in support of therapeutic heart rate modulation. Heart Rhythm O2 2024; 5:327-333. [PMID: 38840759 PMCID: PMC11148487 DOI: 10.1016/j.hroo.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Margaret Infeld
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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3
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [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: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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4
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Bonacchi G, Rossi VA, Garofalo M, Mollace R, Uccello G, Pieragnoli P, Checchi L, Perrotta L, Voltolini L, Ricciardi G, Beltrami M. Pathophysiological Link and Treatment Implication of Heart Failure and Preserved Ejection Fraction in Patients with Chronic Kidney Disease. Biomedicines 2024; 12:981. [PMID: 38790943 PMCID: PMC11117953 DOI: 10.3390/biomedicines12050981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) results from a complex interplay of age, genetic, cardiac remodeling, and concomitant comorbidities including hypertension, obesity, diabetes, and chronic kidney disease (CKD). Renal failure is an important comorbidity of HFpEF, as well as a major pathophysiological mechanism for those patients at risk of developing HFpEF. Heart failure (HF) and CKD are intertwined conditions sharing common disease pathways; the so-called "kidney tamponade", explained by an increase in intracapsular pressure caused by fluid retention, is only the latest model to explain renal injury in HF. Recognizing the different phenotypes of HFpEF remains a real challenge; the pathophysiological mechanisms of renal dysfunction may differ across the HF spectrum, as well as the prognostic role. A better understanding of the role of cardiorenal interactions in patients with HF in terms of symptom status, disease progression, and prognosis remains essential in HF management. Historically, patients with HF and CKD have been scarcely represented in clinical trial populations. Current concerns affect the practical approach to HF treatment, and, in this context, physicians are frequently hesitant to prescribe and titrate both new and old treatments. Therefore, the extensive application of HF drugs in diverse HF subtypes with numerous comorbidities and different renal dysfunction etiologies remains a controversial matter of discussion. Numerous recently introduced drugs, such as sodium-glucose-linked transporter 2 inhibitors (SGLT2i), constitute a new therapeutic option for patients with HF and CKD. Because of their protective vascular and hormonal actions, the use of these agents may be safely extended to patients with renal dysfunction in the long term. The present review delves into the phenotype of patients with HFpEF and CKD from a pathophysiological perspective, proposing a treatment approach that suggests a practical stepwise algorithm for the proper application of life-saving therapies in clinical practice.
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Affiliation(s)
- Giacomo Bonacchi
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
| | | | - Manuel Garofalo
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Rocco Mollace
- Department of Experimental Medicine, Tor Vergata University, 00133 Rome, Italy;
- Cardiology Unit, Humanitas Gavazzeni, 24125 Bergamo, Italy
| | - Giuseppe Uccello
- Division of Cardiology, “A. Manzoni” Hospital—ASST Lecco, 23900 Lecco, Italy;
| | - Paolo Pieragnoli
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Checchi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Laura Perrotta
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Voltolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Thoracic Surgery Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Giuseppe Ricciardi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
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5
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Alsalem A, Alsultan MM, Alqarni F, Almangour A, Alsharekh L, Alenazi S, Alzahrani S, Almanqour RA, Alazmi A, Alzahrani A. Real-world evidence of the effects of sodium-glucose co-transporter 2 inhibitors on the dosing of diuretics in patients with heart failure: a retrospective cohort study. Front Pharmacol 2024; 15:1366439. [PMID: 38628646 PMCID: PMC11018970 DOI: 10.3389/fphar.2024.1366439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/07/2024] [Indexed: 04/19/2024] Open
Abstract
Background: Heart failure (HF) was estimated to impact approximately 64 million individuals worldwide in 2017 and is predicted to rise in the coming years. Therefore, the aim of our study was to evaluate the effects of sodium-glucose transport protein 2 (SGLT2) inhibitors on the dosing of diuretics among individuals diagnosed with HF. Methods: A retrospective cohort study was conducted at Security Forces Hospital in Riyadh, Saudi Arabia, between January 2018 and August 2022. The study included adult patients who were diagnosed with heart failure and received dapagliflozin and/or diuretic. A descriptive analysis was conducted to identify significant differences between both groups by using the chi-square test for categorical variables and the Student's t-test for continuous variables. A logistic regression model was also run to identify the odds of each event. Statistical significance was indicated by p values less than .05. Results: Overall reduction in diuretics was reported in 68 patients in the SGLT2 inhibitors plus diuretic therapy group, while in the diuretic therapy group 25 patients reported overall reduction in diuretics (OR = 4.81, 95% [2.74-8.45]). The reduction of the loop dose level was reported by 58 patients in the SGLT2 inhibitors plus diuretic group and by 25 patients in the diuretic group (OR = 3.48, 95% [1.98-6.11]). The discontinuation of thiazide was reported by 16 patients in the SGLT2 inhibitors plus diuretic therapy group, but by only two patients in the diuretic group (OR = 9.04, 95% [2.03-40.19]). After 6 months, ejection fraction was increased by 2.74 in the SGLT2 inhibitors plus diuretic group (p = .0019) and decreased by 2.56 in the diuretic group (p = .0485), both of which were statistically significant. The mean dose changes were decreased by 14.52 in the SGLT2 inhibitors plus diuretic group (p < .0001), which was statistically significant. Conclusion: Treatment with SGLT2 inhibitors plus diuretic significantly reduced the patients' diuretic requirements. Therefore, our finding supports the theoretical concept of minimizing the level of diuretic upon the initiation of SGLT2 inhibitors.
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Affiliation(s)
- Abdulaziz Alsalem
- Department of Pharmacy, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Mohammed M. Alsultan
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Faisal Alqarni
- Department of Pharmacy, Security Forces Hospital, Riyadh, Saudi Arabia
| | | | - Lolwa Alsharekh
- Department of Pharmacy, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Saleem Alenazi
- Department of Cardiology, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Saleh Alzahrani
- Department of Pharmacy, Security Forces Hospital, Riyadh, Saudi Arabia
| | | | - Abdullah Alazmi
- College of Medicine Al-Jouf University, Sakaka, Saudi Arabia
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Vanhentenrijk S, Tang WHW. Renal perturbations with sodium-glucose cotransporter 2 inhibitor in heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:897-899. [PMID: 38501484 DOI: 10.1002/ejhf.3205] [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: 02/18/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Simon Vanhentenrijk
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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7
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Vardeny O. SGLT2 Inhibitors and Diuresis: A Small Piece of the Puzzle. JACC. HEART FAILURE 2024; 12:47-49. [PMID: 37943224 DOI: 10.1016/j.jchf.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA.
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Oka K, Masuda T, Ohara K, Miura M, Morinari M, Misawa K, Miyazawa Y, Akimoto T, Shimada K, Nagata D. Fluid homeostatic action of dapagliflozin in patients with chronic kidney disease: the DAPA-BODY Trial. Front Med (Lausanne) 2023; 10:1287066. [PMID: 38155663 PMCID: PMC10753517 DOI: 10.3389/fmed.2023.1287066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/30/2023] [Indexed: 12/30/2023] Open
Abstract
Sodium glucose cotransporter 2 (SGLT2) inhibitors have both glucose-lowering and diuretic effects. We recently reported that the SGLT2 inhibitor dapagliflozin exerts short-term fluid homeostatic action in patients with chronic kidney disease (CKD). However, the long-term effects of SGLT2 inhibitors on body fluid status in patients with CKD remain unclear. This was a prospective, non-randomized, open-label study that included a dapagliflozin treatment group (n = 73) and a control group (n = 24) who were followed for 6 months. Body fluid volume was measured using a bioimpedance analysis device. The extracellular water-to-total body water ratio (ECW/TBW), a predictor of renal outcomes, was used as a parameter for body fluid status (fluid retention, 0.400 ≤ ECW/TBW). Six-month treatment with dapagliflozin significantly decreased ECW/TBW compared with the control group (-0.65% ± 2.03% vs. 0.97% ± 2.49%, p = 0.0018). Furthermore, dapagliflozin decreased the ECW/TBW in patients with baseline fluid retention, but not in patients without baseline fluid retention (-1.47% ± 1.93% vs. -0.01% ± 1.88%, p = 0.0017). Vasopressin surrogate marker copeptin levels were similar between the control and dapagliflozin groups at 6 months (32.3 ± 33.4 vs. 30.6 ± 30.1 pmol/L, p = 0.8227). However, dapagliflozin significantly increased the change in copeptin levels at 1 week (39.0% ± 41.6%, p = 0.0010), suggesting a compensatory increase in vasopressin secretion to prevent hypovolemia. Renin and aldosterone levels were similar between the control and dapagliflozin groups at 6 months, while epinephrine and norepinephrine (markers of sympathetic nervous system activity) were significantly lower in the dapagliflozin group than in the control group. In conclusion, the SGLT2 inhibitor dapagliflozin ameliorated fluid retention and maintained euvolemic fluid status in patients with CKD, suggesting that SGLT2 inhibitors exert sustained fluid homeostatic actions in patients with various fluid backgrounds. Clinical trial registration: https://www.umin.ac.jp/ctr/, identifier [UMIN000048568].
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Affiliation(s)
- Kentaro Oka
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Ken Ohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Marina Miura
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Masato Morinari
- Department of Internal Medicine, Nasu Minami Hospital, Nasukarasuyama, Tochigi, Japan
| | - Kyohei Misawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Department of Nephrology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Yasuharu Miyazawa
- Department of Internal Medicine, Nasu Minami Hospital, Nasukarasuyama, Tochigi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kazuyuki Shimada
- Department of Cardiology, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Chatur S, Vaduganathan M, Claggett BL, Cunningham JW, Docherty KF, Desai AS, Jhund PS, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CS, Martinez FA, Shah SJ, Petersson M, Langkilde AM, McMurray JJ, Solomon SD. Outpatient Worsening Among Patients With Mildly Reduced and Preserved Ejection Fraction Heart Failure in the DELIVER Trial. Circulation 2023; 148:1735-1745. [PMID: 37632455 PMCID: PMC10664793 DOI: 10.1161/circulationaha.123.066506] [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] [Received: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Hospitalization is recognized as a sentinel event in the disease trajectory of patients with heart failure (HF), but not all patients experiencing clinical decompensation are ultimately hospitalized. Outpatient intensification of diuretics is common in response to symptoms of worsening HF, yet its prognostic and clinical relevance, specifically for patients with HF with mildly reduced or preserved ejection fraction, is uncertain. METHODS In this prespecified analysis of the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure), we assessed the association between various nonfatal worsening HF events (those requiring hospitalization, urgent outpatient visits requiring intravenous HF therapies, and outpatient oral diuretic intensification) and rates of subsequent mortality. We further examined the treatment effect of dapagliflozin on an expanded composite end point of cardiovascular death, HF hospitalization, urgent HF visit, or outpatient oral diuretic intensification. RESULTS In DELIVER, 4532 (72%) patients experienced no worsening HF event, whereas 789 (13%) had outpatient oral diuretic intensification, 86 (1%) required an urgent HF visit, 585 (9%) had an HF hospitalization, and 271 (4%) died of cardiovascular causes as a first presentation. Patients with a first presentation manifesting as outpatient oral diuretic intensification experienced rates of subsequent mortality that were higher (10 [8-12] per 100 patient-years) than those without a worsening HF event (4 [3-4] per 100 patient-years) but similar to rates of subsequent death after an urgent HF visit (10 [6-18] per 100 patient-years). Patients with an HF hospitalization as a first presentation of worsening HF had the highest rates of subsequent death (35 [31-40] per 100 patient-years). The addition of outpatient diuretic intensification to the adjudicated DELIVER primary end point (cardiovascular death, HF hospitalization, or urgent HF visit) increased the overall number of patients experiencing an event from 1122 to 1731 (a 54% increase). Dapagliflozin reduced the need for outpatient diuretic intensification alone (hazard ratio, 0.72 [95% CI, 0.64-0.82]) and when analyzed as a part of an expanded composite end point of worsening HF or cardiovascular death (hazard ratio, 0.76 [95% CI, 0.69-0.84]). CONCLUSIONS In patients with HF with mildly reduced or preserved ejection fraction, worsening HF requiring oral diuretic intensification in ambulatory care was frequent, adversely prognostic, and significantly reduced by dapagliflozin. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03619213.
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Pardeep S. Jhund
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Rudolf A. de Boer
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands (R.A.d.B.)
| | | | | | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
| | - Carolyn S.P. Lam
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
| | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (M.P., A.M.K.)
| | - Anna Maria Langkilde
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands (R.A.d.B.)
- Duke University Medical Center, Durham, NC (A.F.H.)
- Yale School of Medicine, New Haven, CT (S.E.I.)
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
- Universidad Nacional de Córdoba, Argentina (F.A.M.)
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (M.P., A.M.K.)
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
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Escobar C, Pascual-Figal D, Manzano L, Nuñez J, Camafort M. Current Role of SLGT2 Inhibitors in the Management of the Whole Spectrum of Heart Failure: Focus on Dapagliflozin. J Clin Med 2023; 12:6798. [PMID: 37959263 PMCID: PMC10649290 DOI: 10.3390/jcm12216798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Heart failure (HF) is associated with a high morbidity and mortality burden. In light of more recent evidence, SGLT2 inhibitors are currently recommended as first-line therapy in managing patients with HF, regardless of ejection fraction, to reduce HF burden. The DAPA-HF and DELIVER trials, and particularly, the pooled analysis of both studies, have shown that dapagliflozin significantly reduces the risk of cardiovascular death, all-cause death, total HF hospitalizations, and MACE in the whole spectrum of HF, with sustained benefits over time. Recent data have shown that the full implementation of dapagliflozin in clinical practice would translate into a robust reduction in hospitalizations for HF and death in real-life populations. Many pathophysiological mechanisms have been involved in these benefits, particularly the positive effects of dapagliflozin on reversing cardiac (atrial and ventricular) remodeling, reducing cardiac fibrosis and inflammation, and improving endothelial dysfunction. In this manuscript, we reviewed from a practical point of view the role of dapagliflozin in the management of the whole spectrum of patients with HF.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, University Hospital La Paz, 28046 Madrid, Spain
| | - Domingo Pascual-Figal
- Cardiology Department, Hospital Clinico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
- Spanish National Cardiovascular Research Centre (CNIC), 28029 Madrid, Spain
- Department of Medicine, Universidad de Murcia, 30100 Murcia, Spain
| | - Luis Manzano
- Internal Medicine Department, University Hospital Ramon y Cajal, Alcala de Henares University, 28034 Madrid, Spain;
| | - Julio Nuñez
- Cardiology Department, University Hospital Clínico of Valencia, Instituto de Investigación Sanitaria (INCLIVA), 46010 Valencia, Spain;
- CIBER Cardiovascular, 28029 Madrid, Spain
| | - Miguel Camafort
- Internal Medicine Department, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
- CIBER OBN, ISCIII (Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III), 28222 Madrid, Spain
- Working Group of Cardiovascular Risk, Nutrition, and Aging, IDIBAPS (Instituto de Investigaciones Biomédicas August Pi i Sunyer), 08036 Barcelona, Spain
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Lim J, Choi YJ, Kim BS, Rhee TM, Lee HJ, Han KD, Park JB, Na JO, Kim YJ, Lee H, Kim HK. Comparative cardiovascular outcomes in type 2 diabetes patients taking dapagliflozin versus empagliflozin: a nationwide population-based cohort study. Cardiovasc Diabetol 2023; 22:188. [PMID: 37496050 PMCID: PMC10373410 DOI: 10.1186/s12933-023-01911-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/01/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Sodium-glucose co-transporter-2 inhibitors displayed cardiovascular benefits in type 2 diabetes mellitus in previous studies; however, there were some heterogeneities regarding respective cardiovascular outcomes within the class. Furthermore, their efficacies in Asians, females, and those with low cardiovascular risks were under-represented. Thus, we compared the cardiovascular outcomes between new users of dapagliflozin and empagliflozin in a broad range of patients with type 2 diabetes mellitus using a nationwide population-based real-world cohort from Korea. METHODS Korean National Health Insurance registry data between May 2016 and December 2018 were extracted, and an active-comparator new-user design was applied. The primary outcome was a composite of heart failure (HF)-related events (i.e., hospitalization for HF and HF-related death), myocardial infarction, ischemic stroke, and cardiovascular death. The secondary outcomes were individual components of the primary outcome. RESULTS A total of 366,031 new users of dapagliflozin or empagliflozin were identified. After 1:1 nearest-neighbor propensity score matching, 72,752 individuals (mean age approximately 56 years, 42% women) from each group were included in the final analysis, with a follow-up of 150,000 ~ person-years. Approximately 40% of the patients included in the study had type 2 diabetes mellitus as their sole cardiovascular risk factor, with no other risk factors. The risk of the primary outcome was not different significantly between dapagliflozin and empagliflozin users (hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.855-1.006). The risks of secondary outcomes were also similar, with the exception of the risks of HF-related events (HR 0.84, 95% CI 0.714-0.989) and cardiovascular death (HR 0.76, 95% CI 0.618-0.921), which were significantly lower in the dapagliflozin users. CONCLUSIONS This large-scale nationwide population-based real-world cohort study revealed no significant difference in composite cardiovascular outcomes between new users of dapagliflozin and empagliflozin. However, dapagliflozin might be associated with lower risks of hospitalization or death due to HF and cardiovascular death than empagliflozin in Asian patients with type 2 diabetes mellitus.
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Affiliation(s)
- Jaehyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - You-Jung Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bong Sung Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Jun-Bean Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Diagnostic Test Unit Section of Cardiovascular Imaging, Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital,, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea
| | - Jin Oh Na
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yong-Jin Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Diagnostic Test Unit Section of Cardiovascular Imaging, Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital,, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea
| | - Heesun Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, 152, Teheran-ro, Gangnam-gu,, Seoul, Republic of Korea.
| | - Hyung-Kwan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Diagnostic Test Unit Section of Cardiovascular Imaging, Division of Cardiology, Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital,, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea.
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