DAPA-HF trial: dapagliflozin evolves from a glucose-lowering agent to a therapy for heart failure

Heart failure with reduced ejection fraction: Influence of gender on clinical characteristics, cardiac remodeling and neurohormonal response

INTRODUCTION

It is estimated that 30-50% of patients with heart failure (HF) with reduced ejection fraction (HFrEF) are women. This population appears to differ in terms of clinical characteristics, aetiology and treatment optimisation compared to men. Our main objective was to analyse these considerations, the influence of female sex on cardiac remodelling and neurohormonal response, as well as their impact on medium- to long-term prognosis.

METHODS

Retrospective study of a cohort of HFrEF patients from real clinical practice. A comparative analysis was performed between male and female patients.

RESULTS

409 patients were analysed, a total of 106 females (25.4%), with a higher mean age than males (71.4±13.8 vs. 66±11.9; P<.001), higher prevalence of de novo HF (66.6% vs. 51.5%; P=.009), with a shorter HF evolution time (18.4±42.6 vs. 42.8±75.6 months; P=.001). Without significant differences in treatment optimisation, women had better cardiac remodelling at follow-up, as well as better neurohormonal response, with higher percentage reduction of NT-proBNP (-61,9% vs. -54,2%; P<.01), and of CA125 (-63,4% vs. -50,9%; P<.01]. With a median follow-up of 5years, there were no differences in hospital readmissions or HF mortality in both sexes.

CONCLUSIONS

Women with HFrEF have different clinical and aetiological characteristics compared to men. In evolution, they have better cardiac remodelling and neurohormonal response, although this has no impact on prognosis, readmission or mortality due to heart failure.

Comparative Effectiveness of Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors Versus Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) in Heart Failure With Reduced Ejection Fraction: A Systematic Review

Heart failure with reduced ejection fraction (HFrEF) remains a major cause of morbidity and mortality worldwide, despite advancements in pharmacotherapy. Among the most significant recent developments are sodium-glucose co-transporter 2 (SGLT2) inhibitors and angiotensin receptor-neprilysin inhibitors (ARNIs), both of which have demonstrated substantial improvements in clinical outcomes. This systematic review aimed to compare the efficacy, clinical outcomes, and therapeutic value of SGLT2 inhibitors versus ARNIs while also exploring their potential synergistic effects in the treatment of HFrEF. A comprehensive literature search was conducted across PubMed, Scopus, Embase, and Cochrane Central, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included randomized controlled trials published within the last 10 years. Five high-quality studies met the strict inclusion criteria, reflecting the limited but robust available evidence. The results suggest that both drug classes are effective in reducing cardiovascular death and heart failure hospitalizations, with emerging evidence indicating that their combined use may further enhance clinical outcomes. SGLT2 inhibitors have shown consistent benefits across key endpoints, even when used alongside ARNI therapy. The review highlights favorable safety profiles for both drug classes and supports early combination therapy in suitable patient populations. Observations regarding potential synergistic effects emerged from consistent trends across studies rather than being predefined primary outcomes. These findings reinforce current guideline recommendations advocating for multidrug strategies and emphasize the need for future direct comparative trials to optimize treatment sequencing in HFrEF.

Dapagliflozin Attenuates Myocardial Inflammation and Apoptosis after Coronary Microembolization in Rats by Regulating the SIRT1/NF-κB Signaling Pathway

BACKGROUND

Coronary microembolization (CME) often occurs as a serious complication during or after percutaneous coronary intervention (PCI), leading to an impairment in heart function, inflammation, and cell death. Dapagliflozin (DAPA) has been shown to have cardioprotective effects. However, its role and exact mechanism in CME remains unclear.

METHODS

A preclinical CME model was developed via the administration of microspheres into the left ventricle. In an in vitro model, the CME-created microenvironment was observed by using lipopolysaccharide (LPS) with hypoxic induction on H9C2 cardiomyocytes. Before developing both experimental models, DAPA or the sirtuin 1 (SIRT1) inhibitor "EX-527" was administered. Echocardiography, histological examination, and molecular and immunological assays were carried out to assess the levels of cardiac tissue or cardiomyocyte damage, inflammation, and apoptosis.

RESULTS

Heart dysfunction and tissue damage caused by CME can be alleviated by pre-treatment with DAPA, which also reduces myocardial inflammation and apoptosis. Moreover, both experimental studies have depicted that DAPA can upregulate the SIRT1 level and downregulate the acetylation and phosphorylation levels of nuclear factor kappa-B (NF-κB) p65. This effect inhibits the induction of NF-κB signaling and mitigates cardiomyocyte damage. However, DAPA's cardioprotective effect was reversed when co-treated with EX-527.

CONCLUSIONS

DAPA reduces myocardial damage caused by CME by suppressing myocarditis and apoptosis via the SIRT1/NF-κB axis.

Risk of acute renal failure associated with combined use of SGLT2 inhibitors and potentially nephrotoxic drugs: an epidemiological surveillance study based on the FDA adverse event reporting system (FAERS)

BACKGROUND

Limited knowledge exists regarding nephrotoxic risks associated with the combination of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and potentially nephrotoxic drugs. This study evaluates acute renal failure (ARF) events linked to such combinations using data from the FDA Adverse Event Reporting System (FAERS).

METHODS

Signal mining was performed by estimating reporting odds ratios (ROR), with validation through additive, multiplicative, and proportional reporting ratio (PRR) models. Logistic regression assessed mortality risk factors.

RESULTS

Among 4,417,195 reports, 1,636 ARF cases were associated with SGLT2i combinations, primarily involving diuretics, lipid-lowering agents, and anticoagulants. The highest ARF risk was observed with dapagliflozin-cefazolin [ROR adjusted (a) 59.63, 95% CI (9.96, 356.87); ROR adjusted (b) 19.88, 95% CI (1.80, 219.21); additive model (0.53); multiplicative model (8.36); PRR (8.53)]. Consistent associations were found for empagliflozin-allopurinol and canagliflozin-vancomycin. Among single drugs, 12, including canagliflozin, met all four significance criteria for ARF signals. Logistic regression revealed male patients had higher mortality risk (OR = 0.356, p = 0.043).

CONCLUSION

This study confirms prior evidence of ARF associated with the combined use of SGLT2i with diuretics or NSAIDs and identifies new risks with proton pump inhibitors (PPIs), antigout medications, and anticoagulants. Male gender was a significant risk factor.

The Role of SGLT2 Inhibitors in Cardiovascular Management

Cardiovascular disease is a major cause of morbidity and mortality worldwide in patients with type 2 diabetes. Type 2 diabetes confers an elevated risk of developing heart failure and atherosclerotic cardiovascular disease. Until recently, there have been limited options to prevent and reduce the cardiovascular complications of type 2 diabetes. However, recent therapeutic advances have led to the adoption of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in cardiovascular management. Though SGLT2i were originally used for antihyperglycemic treatment, a series of landmark trials found that SGLT2i may confer cardio-protective effects in patients with heart failure and atherosclerotic cardiovascular disease, particularly a reduction in cardiovascular mortality and hospitalizations for heart failure. The cardiovascular benefits of SGLT2i were similarly demonstrated in patients with and without type 2 diabetes. Though previous trials found SGLT2i to be cardio-protective in heart failure with reduced ejection fraction, recent trials demonstrated that SGLT2i may also provide cardiovascular benefits in heart failure with mildly reduced and preserved ejection fraction. These advances have led SGLT2i to become an instrumental component of cardiovascular therapy.

SGLT2 inhibitor downregulates ANGPTL4 to mitigate pathological aging of cardiomyocytes induced by type 2 diabetes

BACKGROUND

Senescence is recognized as a principal risk factor for cardiovascular diseases, with a significant association between the senescence of cardiomyocytes and inferior cardiac function. Furthermore, type 2 diabetes exacerbates this aging process. Sodium-glucose co-transporter 2 inhibitor (SGLT2i) has well-established cardiovascular benefits and, in recent years, has been posited to possess anti-aging properties. However, there are no reported data on their improvement of cardiomyocytes function through the alleviation of aging. Consequently, our study aims to investigate the mechanism by which SGLT2i exerts anti-aging and protective effects at the cardiac level through its action on the FOXO1-ANGPTL4 pathway.

METHODS

To elucidate the underlying functions and mechanisms, we established both in vivo and in vitro disease models, utilizing mice with diabetic cardiomyopathy (DCM) induced by type 2 diabetes mellitus (T2DM) through high-fat diet combined with streptozotocin (STZ) administration, and AC16 human cardiomyocyte cell subjected to stimulation with high glucose (HG) and palmitic acid (PA). These models were employed to assess the changes in the senescence phenotype of cardiomyocytes and cardiac function following treatment with SGLT2i. Concurrently, we identified ANGPTL4, a key factor contributing to senescence in DCM, using RNA sequencing (RNA-seq) technology and bioinformatics methods. We further clarified ANGPTL4 role in promoting pathological aging of cardiomyocytes induced by hyperglycemia and hyperlipidemia through knockdown and overexpression of the factor, as well as analyzed the impact of SGLT2i intervention on ANGPTL4 expression. Additionally, we utilized chromatin immunoprecipitation followed by quantitative real-time PCR (ChIP-qPCR) to confirm that FOXO1 is essential for the transcriptional activation of ANGPTL4.

RESULTS

The therapeutic intervention with SGLT2i alleviated the senescence phenotype in cardiomyocytes of the DCM mouse model constructed by high-fat feeding combined with STZ, as well as in the AC16 model stimulated by HG and PA, while also improving cardiac function in DCM mice. We observed that the knockdown of ANGPTL4, a key senescence-promoting factor in DCM identified through RNA-seq technology and bioinformatics, mitigated the senescence of cardiomyocytes, whereas overexpression of ANGPTL4 exacerbated it. Moreover, SGLT2i improved the senescence phenotype by suppressing the overexpression of ANGPTL4. In fact, we discovered that SGLT2i exert their effects by regulating the upstream transcription factor FOXO1 of ANGPTL4. Under conditions of hyperglycemia and hyperlipidemia, compared to the control group without FOXO1, the overexpression of FOXO1 in conjunction with SGLT2i intervention significantly reduced both ANGPTL4 mRNA and protein levels. This suggests that the FOXO1-ANGPTL4 axis may be a potential target for the cardioprotective effects of SGLT2i.

CONCLUSIONS

Collectively, our study demonstrates that SGLT2i ameliorate the pathological aging of cardiomyocytes induced by a high glucose and high fat metabolic milieu by regulating the interaction between FOXO1 and ANGPTL4, thereby suppressing the transcriptional synthesis of the latter, and consequently restoring cardiac function.

Prognostic value of quality of life and functional status in patients with heart failure: a systematic review and meta-analysis

BACKGROUND

Functional health status is increasingly being recognized as a viable endpoint in heart failure (HF) trials. We sought to assess its prognostic impact and relationship with traditional clinical outcomes in patients with HF.

METHODS

MEDLINE and Cochrane central were searched up to January 2021 for post hoc analyses of trials or observational studies that assessed independent association between baseline health/functional status, and mortality and hospitalization in patients with HF across the range of left ventricular ejection fractions to evaluate the prognostic ability of NYHA class [II, III, IV], KCCQ, MLHFQ, and 6MWD. Hazard ratios (HR) with 95% confidence intervals were pooled.

RESULTS

Twenty-two studies were included. Relative to NYHA I, NYHA class II (HR 1.54 [1.16-2.04]; p < 0.01), NYHA class III (HR 2.08 [1.57-2.77]; p < 0.01), and NYHA class IV (HR 2.53 [1.25-5.12]; p = 0.01) were independently associated with increased risk of mortality. 6MWD (per 10 m) was associated with decreased mortality (HR 0.98 [0.98-0.99]; p < 0.01). A 5-point increase in KCCQ-OSS (HR 0.94 [0.91-0.96]; p < 0.01) was associated with decreased mortality. A high MLHFQ score (> 45) was significantly associated with increased mortality (HR 1.30 [1.14-1.47]; p < 0.01). NHYA class, 6MWD (per 10 m), KCCQ-OSS, and MLHFQ all significantly associated with all-cause mortality in patients with HF.

CONCLUSION

Identifying such patients with poor health status using functional health assessment can offer a complementary assessment of disease burden and trajectory which carries a strong prognostic value.

Mendelian randomization study of sodium-glucose cotransporter 2 inhibitors in cardiac and renal diseases

OBJECTIVE

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) target the reabsorption of sodium and glucose in the kidney proximal tubules to reduce blood sugar levels. However, clinical randomized controlled trials on SGLT2i have yielded inconsistent results, necessitating further research into their efficacy and safety for specific cardiac and renal diseases.

METHODS

"Sodium in urine" was selected as a downstream biomarker of SGLT2i. Single nucleotide polymorphisms were extracted from genome-wide association study data as instrumental variables. Mendelian randomization analysis was then conducted for cardiac and renal diseases and potential adverse events. The causal effects of SGLT2i on these diseases were determined based on inverse variance weighted results, followed by sensitivity and pleiotropy tests.

RESULTS

SGLT2i had a significant protective effect against nephrotic syndrome (odds ratio [OR] 0.0011, 95% confidence interval [CI] 0.000-0.237), chronic glomerulonephritis (OR 0.0002, 95% CI 0.000-0.21), and hypertensive nephropathy (OR 0.0003, 95% CI 0.000-0.785). No causal effects were observed between SGLT2i and cardiac diseases or potential adverse events.

CONCLUSIONS

SGLT2i can act as protective factors against nephrotic syndrome, chronic glomerulonephritis, and hypertensive nephropathy.

Initiation and Up-Titration of Guideline-Based Medications in Hospitalized Acute Heart Failure Patients - A Report From the West Tokyo Heart Failure Registry

BACKGROUND

Despite recommendations from clinical practice guidelines to initiate and titrate guideline-directed medical therapy (GDMT) during their hospitalization, patients with acute heart failure (AHF) are frequently undertreated. In this study we aimed to clarify GDMT implementation and titration rates, as well as the long-term outcomes, in hospitalized AHF patients.

METHODS AND RESULTS

Among 3,164 consecutive hospitalized AHF patients included in a Japanese multicenter registry, 1,400 (44.2%) with ejection fraction ≤40% were analyzed. We assessed GDMT dosage (β-blockers, renin-angiotensin inhibitors, and mineralocorticoid-receptor antagonists) at admission and discharge, examined the contributing factors for up-titration, and evaluated associations between drug initiation/up-titration and 1-year post-discharge all-cause death and rehospitalization for HF via propensity score matching. The mean age of the patients was 71.5 years and 30.7% were female. Overall, 1,051 patients (75.0%) were deemed eligible for GDMT, based on their baseline vital signs, renal function, and electrolyte values. At discharge, only 180 patients (17.1%) received GDMT agents up-titrated to >50% of the maximum titrated dose. Up-titration was associated with a lower risk of 1-year clinical outcomes (adjusted hazard ratio: 0.58, 95% confidence interval: 0.35-0.96). Younger age and higher body mass index were significant predictors of drug up-titration.

CONCLUSIONS

Significant evidence-practice gaps in the use and dose of GDMT remain. Considering the associated favorable outcomes, further efforts to improve its implementation seem crucial.

Sotagliflozin vs Dapagliflozin: A Systematic Review Comparing Cardiovascular Mortality

After the debut of the results of the effect of Sotagliflozin on Cardiovascular Events in Patients with Type 2 Diabetes Post Worsening Heart Failure (SOLOIST-WHF) and Sotagliflozin in Patients With Chronic Kidney Disease and Type 2 Diabetes (SCORED) trials at the American Heart Association's 2020 Scientific session, sotagliflozin became the first drug and the third sodium glucose co-transporter-2 (SGLT-2) inhibitor to be approved for heart failure (HF) across the spectrum of ejection fraction (EF). In light of this recent major U.S. Food and Drug Administration (FDA) approval of sotagliflozin, we conducted a systematic review to compare the cardiovascular mortality rates between sotagliflozin and dapagliflozin in patients with HF. To find relevant articles, we extensively searched major research literature databases and search engines such as PubMed, MEDLINE, PubMed Central, Google Scholar, Embase, and Cochrane Library. We compared the results of significant trials involving sotagliflozin with the trials studying dapagliflozin to provide comprehensive mortality results of both drugs. The results showed that the timely initiation of sotagliflozin in HF cases significantly reduces cardiovascular mortality, hospitalizations, and urgent HF visits. Comparative trials with dapagliflozin indicate enhanced mortality reduction associated with greater initial symptom burden. The results of these major trials cannot be overlooked due to the large size of the combined trials, the randomized design, and the high standards with which they were conducted. The pathophysiology behind the cardioprotection offered by these agents is complex and multifactorial, but it is believed that due to the diuretic-like function, SGLT-2 inhibitors reduce glycemic-related toxicity, promote ketogenesis, and exert antihypertrophic, antifibrotic, and anti-remodeling properties. The benefits of dapagliflozin on cardiovascular death and worsening HF in patients with mildly reduced or preserved EF appeared especially pronounced in those with a greater degree of symptomatic impairment at baseline. Sotagliflozin led to a rise in the count of days patients were alive and not hospitalized (DAOH), which offers an extra patient-centered measure to assess the impact of the disease burden. The data in our article will help future researchers conduct large-scale trials with sotagliflozin to identify and implement it in the treatment of patients with HF as a mortality-reducing drug and to improve the quality of life for patients with HF.

Cardiovascular Diseases: Therapeutic Potential of SGLT-2 Inhibitors

Cardiovascular diseases (CVD) are a global health concern, affecting millions of patients worldwide and being the leading cause of global morbidity and mortality, thus creating a major public health concern. Sodium/glucose cotransporter 2 (SGLT2) inhibitors have emerged as a promising class of medications for managing CVD. Initially developed as antihyperglycemic agents for treating type 2 diabetes, these drugs have demonstrated significant cardiovascular benefits beyond glycemic control. In our paper, we discuss the role of empagliflozin, dapagliflozin, canagliflozin, ertugliflozin, and the relatively recently approved bexagliflozin, the class of SGLT-2 inhibitors, as potential therapeutic targets for cardiovascular diseases. All mentioned SGLT-2 inhibitors have demonstrated significant cardiovascular benefits and renal protection in clinical trials, in patients with or without type 2 diabetes. These novel therapeutic approaches aim to develop more effective treatments that improve patient outcomes and reduce the burden of these conditions. However, the major scientific achievements of recent years and the many new discoveries and mechanisms still require careful attention and additional studies.

A Critical View over the Newest Antidiabetic Molecules in Light of Efficacy-A Systematic Review and Meta-Analysis

The increase in life expectancy without a decrease in the years lived without disability leads to the rise of the population aged over 65 years prone to polypharmacy. The novel antidiabetic drugs can improve this global therapeutic and health problem in patients with diabetes mellitus (DM). We aimed to establish the efficacy (A1c hemoglobin reduction) and safety of the newest antidiabetic drugs (considered so due to their novelty in medical practice use), specifically DPP-4i, SGLT-2i, GLP-1 Ra, and tirzepatide. The present meta-analysis followed the protocol registered at Prospero with the CRD42022330442 registration number. The reduction in HbA1c in the DPP4-i class for tenegliptin was 95% CI -0.54 [-1.1, 0.01], p = 0.06; in the SGLT2-iclass for ipragliflozin 95% CI -0.2 [-0.87, 0.47], p = 0.55; and for tofogliflozin 95% CI 3.13 [-12.02, 18.28], p = 0.69, while for tirzepatide it was 0.15, 95% CI [-0.50, 0.80] (p = 0.65). The guidelines for treatment in type 2 DM are provided from cardiovascular outcome trials that report mainly major adverse cardiovascular events and data about efficacy. The newest antidiabetic non-insulinic drugs are reported to be efficient in lowering HbA1c, but this effect depends between classes, molecules, or patients' age. The newest antidiabetic drugs are proven to be efficient molecules in terms of HbA1c decrease, weight reduction, and safety, but more studies are needed in order to characterize exactly their efficacy and safety profiles.

Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction

Guideline-directed medical therapy (GDMT) is the cornerstone of pharmacological therapy for patients with heart failure with reduced ejection fraction (HFrEF) and consists of the four main drug classes: renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors and sodium glucose cotransporter 2 inhibitors. The recommendation for use of GDMT is based on the results of multiple major randomized controlled trials demonstrating improved clinical outcomes in patients with HFrEF who are maintained on this therapy. The effect is most beneficial when medications from the four main drug classes are used in conjunction. Despite this, there is an underutilization of GDMT, partially due to lack of awareness of how to safely and effectively initiate and titrate these medications. In this review article, we describe the different drug classes included in GDMT and offer an approach to initiation and effective titration in both the inpatient as well as outpatient setting.

6-Shogaol, an Active Component of Ginger, Inhibits p300 Histone Acetyltransferase Activity and Attenuates the Development of Pressure-Overload-Induced Heart Failure

Hypertrophic stress-induced cardiac remodeling is a compensatory mechanism associated with cardiomyocyte hypertrophy and cardiac fibrosis. Continuation of this response eventually leads to heart failure. The histone acetyltransferase p300 plays an important role in the development of heart failure, and may be a target for heart failure therapy. The phenolic phytochemical 6-shogaol, a pungent component of raw ginger, has various bioactive effects; however, its effect on cardiovascular diseases has not been investigated. One micromolar of 6-shogaol suppressed phenylephrine (PE)-induced increases in cardiomyocyte hypertrophy in rat primary cultured cardiomyocytes. In rat primary cultured cardiac fibroblasts, 6-shogaol suppressed transforming growth factor-beta (TGF-β)-induced increases in L-proline incorporation. It also blocked PE- and TGF-β-induced increases in histone H3K9 acetylation in the same cells and in vitro. An in vitro p300-HAT assay revealed that 6-shogaol suppressed histone acetylation. The mice underwent transverse aortic constriction (TAC) surgery, and were administered 0.2 or 1 mg/kg of 6-shogaol daily for 8 weeks. 6-shogaol prevented TAC-induced systolic dysfunction and cardiac hypertrophy in a dose-dependent manner. Furthermore, it also significantly inhibited TAC-induced increases in histone H3K9 acetylation. These results suggest that 6-shogaol may ameliorate heart failure through a variety of mechanisms, including the inhibition of p300-HAT activity.

Dapagliflozin initiation in chronic heart failure patients improves central sleep apnoea

Dapagliflozin decreases central sleep apnoea in central sleep apnoea patients, thereby sparing the initiation of ventilatory therapy https://bit.ly/41e2fm0.

Defining the Phenotypes for Heart Failure With Preserved Ejection Fraction

PURPOSE OF REVIEW

Heart failure with preserved ejection fraction (HFpEF) imposes a significant burden on society and healthcare. The lack in efficacious therapies is likely due to the significant heterogeneity of HFpEF. In this review, we define various phenotypes based on underlying comorbidities or etiologies, discuss phenotypes arrived at by novel methods, and explore therapeutic targets.

RECENT FINDINGS

A few studies have used machine learning methods to uncover sub-phenotypes within HFpEF in an unbiased manner based on clinical features, echocardiographic findings, and biomarker levels. We synthesized the literature and propose three broad phenotypes: (1) young, with few comorbidities, usually obese and with low natriuretic peptide levels, (2) obese with substantive cardiometabolic burden and comorbidities and impaired ventricular relaxation, (3) old, multimorbid, with high rates of atrial fibrillation, renal and coronary artery disease, chronic obstructive pulmonary disease, and left ventricular hypertrophy. We also propose potential therapeutic strategies for these phenotypes.

Direct cardial effects and mechanisms of cardiovascular action of gliflosins

The literature review is devoted to the study of the mechanisms of the cardioprotective action of a new class of glucose-lowering drugs glyflozins, which inhibit the joint transport of sodium and glucose in the proximal renal tubules. Favorable changes in ion transport in cardiomyocytes with the use of these drugs are considered. The inhibition of the activity of the sodium-hydrogen exchanger (NHE) was found, followed by a decrease in the activity of Na+/ Ca2+ exchange on the mitochondrial membranes of the cardiomyocytes, which leads to a decrease in the concentration of Ca2+ in the cytoplasm with a simultaneous increase in mitochondria. This initiates a number of intracellular signaling cascades that contribute to the optimization of mitochondrial homeostasis. The use of glyflozins, apparently, provides a balance between the fusion and fission of mitochondria, which determines the bioenergetic adaptation of the cell to the state of intracellular metabolism, weakens the development of the inflammatory response, fibrosis and oxidative stress in the myocardium, which are activated under conditions of diabetes mellitus. The point of view is discussed, according to which the mechanism of anti-inflammatory action of glyflozins is associated with inhibition of the activity of the NLRP3 inflammasome, which contributes to the progression of myocardial dysfunction and subsequent chronic heart failure. The results of clinical trials and experimental data on the beneficial effect of glyflozins in the development of various phenotypes of heart failure with reduced and preserved ejection fraction are analyzed. The assumption is substantiated about the prospects for wider use of these hypoglycemic drugs in heart failure, which is not limited to diabetes mellitus. The assumptions made require further experimental and clinical studies.

Relationship between oxidative stress and nuclear factor-erythroid-2-related factor 2 signaling in diabetic cardiomyopathy (Review)

Diabetic cardiomyopathy (DCM) is the leading cause of death worldwide, and oxidative stress was discovered to serve an important role in the pathophysiology of the condition. An imbalance between free radicals and antioxidant defenses is known to be associated with cellular dysfunction, leading to the development of various types of cardiac disease. Nuclear factor-erythroid-2-related factor 2 (NRF2) is a transcription factor that controls the basal and inducible expression levels of various antioxidant genes and other cytoprotective phase II detoxifying enzymes, which are ubiquitously expressed in the cardiac system. Kelch-like ECH-associated protein 1 (Keap1) serves as the main intracellular regulator of NRF2. Emerging evidence has revealed that NRF2 is a critical regulator of cardiac homeostasis via the suppression of oxidative stress. The activation of NRF2 was discovered to enhance specific endogenous antioxidant defense factors, one of which is antioxidant response element (ARE), which was subsequently illustrated to detoxify and counteract oxidative stress-associated DCM. The NRF2 signaling pathway is closely associated with the development of various types of cardiac disease, including ischemic heart disease, heart failure, myocardial infarction, atrial fibrillation and myocarditis. Therefore, it is hypothesized that drugs targeting this pathway may be developed to inhibit the activation of NRF2 signaling, thereby preventing the occurrence of DCM and effectively treating the disease.

Dapagliflozin attenuates hypoxia/reoxygenation-caused cardiac dysfunction and oxidative damage through modulation of AMPK

Background

Emerging evidence demonstrated dapagliflozin (DAPA), a sodium-glucose cotransporter 2 inhibitor, prevented various cardiovascular events. However, the detailed mechanisms underlying its cardioprotective properties remained largely unknown.

Results

In the present study, we sought to investigate the effects of DAPA on the cardiac ischemia/reperfusion (I/R) injury. Results from in vitro experiments showed that DAPA induced the phosphorylation of AMPK, resulting in the downregulation of PKC in the cardiac myoblast H9c2 cells following hypoxia/reoxygenation (H/R) condition. We demonstrated that DAPA treatment diminished the H/R-elicited oxidative stress via the AMPK/ PKC/ NADPH oxidase pathway. In addition, DAPA prevented the H/R-induced abnormality of PGC-1α expression, mitochondrial membrane potential, and mitochondrial DNA copy number through AMPK/ PKC/ NADPH oxidase signaling. Besides, DAPA reversed the H/R-induced apoptosis. Furthermore, we demonstrated that DAPA improved the I/R-induced cardiac dysfunction by echocardiography and abrogated the I/R-elicited apoptosis in the myocardium of rats. Also, the administration of DAPA mitigated the production of myocardial infarction markers.

Conclusions

In conclusion, our data suggested that DAPA treatment holds the potential to ameliorate the I/R-elicited oxidative stress and the following cardiac apoptosis via modulation of AMPK, which attenuates the cardiac dysfunction caused by I/R injury.

Beyond the myocardium? SGLT2 inhibitors target peripheral components of reduced oxygen flux in the diabetic patient with heart failure with preserved ejection fraction

Recent cardiovascular outcome trials have highlighted the propensity of the antidiabetic agents, SGLT2 inhibitors (SGLT2is or -flozin drugs), to exert positive clinical outcomes in patients with cardiovascular disease at risk for major adverse cardiovascular events (MACEs). Of interest in cardiac diabetology is the physiological status of the patient with T2DM and heart failure with preserved ejection fraction (HFpEF), a well-examined association. Underlying this pathologic tandem are the effects that long-standing hyperglycemia has on the ability of the HFpEF heart to adequately deliver oxygen. It is believed that shortcomings in oxygen diffusion or utilization and the resulting hypoxia thereafter may play a role in underlying the clinical sequelae of patients with T2DM and HFpEF, with implications in the long-term decline of extra-cardiac tissue. Oxygen consumption is one of the most critical factors in indexing heart failure disease burden, warranting a probe into the role of SGLT2i on oxygen utility in HFpEF and T2DM. We investigated the role of oxygen flux in the patient with T2DM and HFpEF extending beyond the heart with focuses on cellular metabolism, perivascular fibrosis with endothelial dysfunction, hematologic changes, and renal effects with neurohormonal considerations in the patient with HFpEF and T2DM. Moreover, we give a commentary on potential therapeutic targets of these components with SGLT2i to gain insight into disease burden amelioration in patients with HFpEF and T2DM.