Aptamer proteomics for biomarker discovery in heart failure with reduced ejection fraction

Background

Though current heart failure (HF) biomarkers are highly prognostic, systematically characterizing associations between circulating proteins and risk of subsequent events may improve clinical risk prediction and illuminate new biological pathways. Large-scale assays measuring thousands of proteins now enable unbiased proteomic investigation in clinical trials.

Purpose

To identify and replicate serum proteins associated with HF events in patients with chronic HF with reduced ejection fraction (HFrEF), and to develop and validate a proteomic risk score.

Methods

Serum levels of 4076 proteins were measured at baseline in the ATMOSPHERE (n=1261, 487 events over 6 years) and PARADIGM-HF (n=1257, 287 events over 4 years) trials of chronic HFrEF using a modified aptamer-based proteomics assay. Proteins associated with the primary endpoint, HF hospitalization or cardiovascular death, were identified in the ATMOSPHERE discovery cohort (false discovery rate<0.05) by Cox regression adjusted for age, sex, treatment arm, and anticoagulant use, and replicated in PARADIGM-HF (Bonferroni-corrected p<0.05). A proteomic risk score was derived in ATMOSPHERE using Cox LASSO penalized regression and evaluated in PARADIGM-HF compared to the MAGGIC clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP). For proteins associated with the primary endpoint, pathway analysis was conducted using Ingenuity Pathway analysis and an exploratory two-sample Mendelian randomization was performed using genetic and outcome data from both trials and protein quantitative trait loci from deCODE to infer which identified proteins contribute to HF prognosis.

Results

We identified 377 serum proteins associated with the primary endpoint in ATMOSPHERE and replicated 167 in PARADIGM-HF. Prognostic proteins included known HF biomarkers Growth Differentiation Factor 15, NT-proBNP, and Angiopoietin-2, and also a previously unrecognized HF biomarker: Sushi, Von Willebrand Factor Type A, EGF And Pentraxin Domain Containing 1 (SVEP1) (HR 1.60 [95% CI 1.44–1.79] per standard deviation [SD], p=2x10–17) (Table 1). Proteins related to hepatic fibrosis, granulocyte adhesion, and inhibition of matrix metalloproteinases were over-represented. A 64-protein risk score derived in ATMOSPHERE predicted clinical events in PARADIGM-HF with greater discrimination (c-statistic 0.70) than the MAGGIC clinical score (c-statistic 0.61), NT-proBNP (c-statistic 0.65), or both (c-statistic 0.66) (Figure 1). Genetically predicted levels of NT-proBNP, WISP2, FSTL1, and CTSS were associated with the primary endpoint by Mendelian randomization.

Conclusions

We identify SVEP1, an extracellular matrix protein known to cause inflammation in vascular smooth muscle cells, as a previously unrecognized HF biomarker. A 64-protein score improved risk discrimination compared with NT-proBNP and may assist in identifying high-risk patients for clinical trials or disease management programs.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The ATMOSPHERE and PARADIGM-HF trials were sponsored by Novartis

Interleukin-6 and outcomes in patients recently hospitalized with heart failure and preserved ejection fraction

Introduction

Inflammation may play a role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). Interleukin-6 (IL-6) is an important inflammatory mediator but information about its prognostic relevance in HFpEF is lacking.

Purpose

To examine the association between IL-6 and outcomes in patients with HFpEF.

Methods

We assessed the relationship between IL-6 tertile (T1–3) and all cause death, cardiovascular (CV) death and first HF hospitalisation (HFH) in 340 patients admitted to hospital with HFpEF. The association between log IL-6 and outcomes was examined in a Cox regression model adjusted for MAGGIC risk score and log B-type natriuretic peptide (BNP).

Results

Range of IL-6 (pg/ml) was: T1 (0.71–4.27), T2 (4.28–7.91) and T3 (7.94–236.32). Patients with higher IL-6 were older (73.9 versus 70.3 years), more commonly male (58.4% versus 39.5%) and had higher serum creatinine (117.6 versus 106.5 μmol/l), C-reactive protein ([CRP] 17.4 versus 4.4mg/l), troponin I (6.2 versus 5.0μg/l) and BNP (331.0 versus 254.5pg/ml). Rates of CV death and all-cause mortality, but not HFH, remained significantly higher in T3 versus T1 after adjustment. When modelled as a continuous variable, one log unit increase in IL-6 was associated with higher risk of CV death (HR 1.34 [1.05–1.70]), p=0.02) and all cause death (HR 1.41 [1.13–1.75], p=0.002).

Conclusion

In patients recently hospitalised with decompensated HFpEF, IL-6 is an independent predictor of CV death and all-cause mortality after adjusting for the MAGGIC risk score and BNP. The potential utility of IL-6 as a therapeutic target in HFpEF warrants investigation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Scottish Executive Chief Scientist Office [project grant entitled, “Microvolt T-Wave Alternans in Chronic Heart Failure: A Study of Prevalence and Incremental Prognostic Value” (Ref CZH/4/439)]

Assessing the impact of cardiovascular events on health-related quality of life outcomes in DAPA-HF

Background

Heart failure (HF) patients are at increased risk of cardiovascular (CV) events, including hospitalisation for HF (hHF), myocardial infarction (MI) and stroke, imposing a significant burden on health related quality of life (HRQoL). DAPA-HF was a multinational clinical trial (NCT03036124) investigating the efficacy and safety of dapagliflozin for the treatment of HF with reduced ejection fraction. Patient reported outcomes were collected. The objective of this study was to estimate the impact of CV events on patient HRQoL over time, as assessed through EQ-5D-5L and Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score (TSS) and clinical symptom score (CSS).

Methods

Mixed effects regression models were developed based on pooled individual patient data from DAPA-HF to estimate the impact of hHF, MI and stroke on patient utility (EQ-5D-5L questionnaire responses weighted according to the societal value placed on given health states), and KCCQ TSS score. Utility was estimated using UK-specific tariffs after mapping EQ-5D-5L to EQ-5D-3L values in line with NICE guidance. A subject-specific intercept was incorporated, and estimates were adjusted for the incidence of events occurring within one month prior, two to four months prior, and 4 to 12 months prior to questionnaire completion.

Results

Mean patient baseline utility was 0.716 (95% CI: 0.711, 0.722), with KCCQ TSS 73.6 (73.0, 74.2). The incidence of CV events was consistently associated with reduced patient HRQoL, assessed through either EQ-5D or KCCQ TSS. In the first month following the event, hHF was associated with a 0.083 (0.06, 0.107) reduction in patient utility, and 16.9 (14.5, 19.4) reduction in KCCQ TSS (Fig. 1). Comparing measures, the disease specific measure KCCQ appeared more sensitive than EQ-5D to changes in HRQoL following hHF events and less sensitive to changes following MI and stroke events. Comparing events using the generic EQ-5D measure, at two months post-event, patients with MI and stroke returned to baseline utility; patients with hHF remained below baseline utility at each assessment point for 12 months (Fig. 2); where patients had a mean reduction of 0.02 (0.005, 0.035) utility and 0.5 (−1.1, 2.1) KCCQ-TSS compared to those without an hHF event.

Conclusion

The incidence of cardiovascular events imposes a considerable burden on HRQoL in patients with HFrEF. HF specific events may be better characterised with a disease specific tool, whereas for wider CV events a generic tool may be preferable. The impact of hHF on HRQoL was noteworthy in its persistence across the measures used up to one year. Interventions that reduce the risk of these events have the potential to significantly improve patient quality of life.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

Evaluating the key predictors of health-related quality of life in patients with heart failure and reduced ejection fraction: results from the DAPA-HF trial

Background

The DAPA-HF trial demonstrated that dapagliflozin was superior to placebo at preventing cardiovascular death and hospitalisation for heart failure (hHF) events in patients with chronic heart failure with reduced ejection fraction (HFrEF). The trial also demonstrated a clinically important benefit of dapagliflozin on health-related quality of life (HRQoL). However, key predictors of HRQoL in HFrEF patients remain uncertain. The objective of this study was to determine, using DAPA-HF trial data, the patient characteristics and disease-related events associated with patient HRQoL, measured by health state utility values.

Methods

Mixed effects regression models were developed based on pooled individual patient data from DAPA-HF to determine patient utility estimated from responses to the EQ-5D-5L questionnaire, incorporating a subject specific random intercept. In line with NICE guidance, utility estimates were derived using UK-specific utility tariffs after mapping EQ-5D-5L data to EQ-5D-3L values. Univariable analysis was first undertaken to assess candidate predictors of utility; followed by a multivariable model including statistically significant predictors, e.g. Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) and the incidence hHF events, and controlling for differences in baseline characteristics. All variables were included in a single model to provide independent (adjusted) estimates for each covariable.

Results

19,983 EQ-5D-5L questionnaires from 4,744 patients were included. Mean patient utility at baseline was 0.716 (95% CI: 0.711, 0.722). Univariable analysis demonstrated NYHA, KCCQ-TSS, T2DM, BMI, age, geographic location, non-ischaemic/unknown aetiology and atrial fibrillation were statistically significant in their association with patient utility while prior hHF, race, eGFR and left ventricular ejection fraction were not.

Multivariable analysis results are summarised in Fig. 1. The baseline characteristic with the greatest impact on EQ-5D was KCCQ-TSS quartile, with EQ-5D increasing with KCCQ-TSS and the difference in utility between patients in quartile 1 (lowest score) and quartile 4 (highest score) estimated at 0.233 (0.226, 0.240).

When controlled for baseline characteristics, being post-event was significantly associated with HRQoL; patients who experienced hospitalisation for HF had 0.036 (0.014, 0.058) lower utility on average within one month of the event and 0.025 (0.011, 0.039) lower utility up to one-year after the event. For patients who had stroke or myocardial infarction events there were reductions in utility of 0.206 (0.141, 0.272) and 0.108 (0.039, 0.177) respectively at 1 month.

Conclusion

HF symptoms, measured by the KCCQ, were strongly associated with patient health utility. Therapeutic interventions that can improve HF symptoms have the potential to improve HRQoL and reduce the burden of HF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

Elevated markers of liver function are associated with poorer outcomes in HFREF: an analysis of DAPA-HF

Background

Abnormalities of liver tests in patients with heart failure with reduced ejection fraction (HFrEF) is a well-recognised phenomenon. We examined the prognostic value of measures of liver function in a large contemporary cohort of patients with HFrEF enrolled in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial

Methods

In this post-hoc analysis of the DAPA-HF trial we studied 4625 patients with liver function tests available at baseline. Cox proportional hazards models were used to assess the association between liver tests (total bilirubin, alkaline phosphatase [ALP], alanine transaminase [ALT], aspartate transaminase [AST]) and the Model for End-stage Liver Disease excluding INR (MELD-XI) score (calculated as 5.11 Ln [total bilirubin as mg/dL] + 11.76 Ln [creatinine as mg/dL] + 9.44), and the risk of the primary composite endpoint (hospitalisation or urgent visit for heart failure or cardiovascular death). Models were adjusted for age, sex, race, region, systolic blood pressure, heart rate, LVEF, eGFR, log-transformed NT-proBNP, NYHA class, history of hypertension, stroke, myocardial infarction, atrial fibrillation, heart failure aetiology and randomized treatment to dapagliflozin and stratified by diabetic status at baseline. An interaction term between each measure and the effect of treatment on the primary composite outcome was tested as a fractional polynomial.

Results

Total bilirubin, ALP, and MELD-XI score were associated with a higher risk of all the primary outcome (Figure 1) but not ALT or AST. These relationships persisted after adjustment: total bilirubin per log unit increase (HR=1.46; 95% CI 1.28 – 1.67, p<0.001), ALP per log unit increase (HR=1.39; 95% CI 1.15 – 1.66, p<0.001), MELD-XI per 1 SD increase (HR 1.27; 95% CI 1.13 – 1.42, p<0.001). The effect of dapagliflozin on the primary outcome was not modified by the baseline levels of either total bilirubin, ALP or MELD-XI score (Figure 2)

Conclusions

Higher total bilirubin, ALP and MELD-XI score were independently associated with a higher risk of cardiovascular death or worsening HF and may be useful routinely available biomarkers to assess prognosis. The efficacy of dapagliflozin was the not modified by baseline levels of any of these markers.

Funding Acknowledgement

Type of funding sources: None. Figure 2

Age- and Sex-Specific Rates of Heart Failure and other Adverse Cardiovascular Outcomes in Systemic Sclerosis

Background

Age at disease onset and sex appear to modify the disease course in patients with systemic sclerosis (SSc). Although patients with SSc have a higher risk of adverse cardiovascular outcomes than people without SSc, there are few data on age- and sex-specific risks of heart failure (HF) and other adverse cardiovascular outcomes in patients with SSc.

Objectives

To investigate the long-term rates of HF and other adverse cardiovascular outcomes (including arrhythmias, myocardial infarction, ischemic stroke, venous thromboembolism, and pulmonary hypertension) in a nationwide cohort of patients with SSc compared with the background population according to age and sex, separately.

Methods

Using Danish nationwide registries, all patients >18 years with newly diagnosed SSc (1996–2018) were identified. SSc patients were matched at a 1:4 ratio by age, sex, and comorbidities with controls from the background population without SSc. Rates of outcomes according to age (above/below median age) and sex were compared between cases and controls using Cox regression.

Results

Of the 2,019 patients diagnosed with SSc, 1,569 patients were matched with 6,276 controls from the background population (median age 55 years, 80.4% women). SSc was associated with a higher rate of HF in both women (HR 2.99 [95% CI, 2.18–4.09]) and men (HR 3.01 [1.83–4.95]) (Pfor interaction=0.88), with similar findings for other cardiovascular outcomes.For age interaction, SSc was associated with an increased rate of HF in patients <55 years (HR 4.14 [2.54–6.74]) and ≥55 years (HR 2.74 [1.98–3.78]), with similar effect of younger and older groups on HF (P for interaction=0.21), and other cardiovascular outcomes.

Conclusions

SSc was associated with an increased long-term rate of cardiovascular outcomes compared with a matched background population, with similar extent in different gender and age groups.

Funding Acknowledgement

Type of funding sources: None. Adjusted hazard ratios according to sexAdjusted hazard ratios according to age

Lipoprotein(a) and cardiovascular disease: prediction, attributable risk fraction and estimating benefits from novel interventions

Background

Lipoprotein (a) (Lp(a)) measurement may help guide CVD risk prediction, is thought to be causal in several CVD outcomes, and phase 3 intervention trials of Lp(a) lowering agents are underway. We aimed to investigate the population attributable fraction due to elevated Lp(a) and its utility in CVD risk prediction.

Methods

In 413,724 participants from UK Biobank, associations of serum Lp(a) with composite fatal/nonfatal CVD (n=10,065 events), fatal CVD (n=3247), coronary heart disease (n=16,649), ischaemic stroke (n=3191), and peripheral vascular disease (n=2716) were compared using Cox models. Predictive utility was determined by C-index changes. The population attributable fraction was estimated.

Results

Median Lp(a) was 19.7nmol/L (interquartile interval 7.6–75.3nmol/L). 20.8% had Lp(a) values >100nmol/L; 9.2% had values >175nmol/L. After adjustment for classical risk factors, in participants with no baseline CVD and not taking a statin, 1 standard deviation increment in log Lp(a) was associated with a HR for fatal/nonfatal CVD of 1.09 (95% CI 1.07–1.11). Associations were similar for fatal CVD, coronary heart disease, and peripheral vascular disease. Adding Lp(a) to a prediction model containing traditional CVD risk factors improved the C-index by +0.0017 (95% CI 0.0009, 0.0026). We estimated that having Lp(a) values >100nmol/L accounts for 5.7% of CVD events in the whole cohort. We modelled that an ongoing trial to lower Lp(a) in patients with CVD and Lp(a) above ∼175nmol/L may be expected to reduce CVD risk by 20.3%, assuming causality, and an achieved Lp(a) reduction of 80%.

Conclusions

Population screening for elevated Lp(a) may help to predict CVD and target Lp(a) lowering drugs to those with markedly elevated levels, if such drugs prove efficacious.

Population attributable fractions: Lp(a)

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Chest, Heart, and Stroke Association Scotland and British Heart Foundation

Dapagliflozin reduces the risk of hyperkalaemia in patients with heart failure and reduced ejection fraction: a secondary analysis DAPA-HF

Background

Hyperkalaemia often limits the use of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure and reduced ejection fraction (HFrEF), denying these patients a life-saving therapy.

Purpose

To determine whether treatment with the sodium-glucose cotransporter 2 (SGLT-2) inhibitor dapagliflozin reduces the risk of hyperkalaemia associated with MRA use in patients with HFrEF.

Methods

The risk of developing mild hyperkalaemia (potassium >5.5 mmol/L) and moderate/severe hyperkalaemia (>6.0 mmol/L) was examined in the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF) according to background MRA use, and randomized treatment assignment, by use of Cox regression analyses.

Results

Overall, 3370 (70.1%) patients in DAPA-HF were treated with an MRA. Mild hyperkalaemia and moderate/severe hyperkalaemia occurred in 182 (11.1%) and 23 (1.4%) patients treated with dapagliflozin as compared to 204 (12.6%) and 40 (2.4%) of patients given placebo (Table and Figure). This yielded a hazard ratio (HR) of 0.86 (0.70–1.05) for mild hyperkalaemia and 0.50 (0.29, 0.85) for moderate/severe hyperkalaemia, comparing dapagliflozin to placebo.

Conclusions

Patients with HFrEF and taking a MRA who were randomized to dapagliflozin had half the incidence of moderate/severe hyperkalaemia, compared with those randomized to placebo.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): DAPA-HF study was funded by AstraZeneca

Global differences in heart failure with preserved ejection fraction: the paragon-hf trial

Background

Heart failure with preserved ejection fraction (HFpEF) is a global public health problem with important regional differences. We investigated these differences in the PARAGON-HF trial, the largest, most inclusive global HFpEF trial.

Methods

We studied differences in clinical characteristics, outcomes and regional treatment effects of Sacubitril/Valsartan in 4796 patients with HFpEF from the PARAGON-HF trial, grouped according to geographic region.

Results

Regional differences in patient characteristics and comorbidities were observed (Figure 1): patients from Western Europe were oldest (75±7 years) with the highest prevalence of atrial fibrillation (36%); Central/Eastern European patients were youngest (71±8 years) with the highest prevalence of coronary artery disease (CAD, 49%); North American patients had the highest prevalence of obesity (64%) with metabolic syndrome; Latin American patients were youngest and had a high prevalence of obesity (53%); Asia-Pacific patients had a high prevalence of diabetes (44%) despite low prevalence of obesity (26%). Rates of the primary composite endpoint of total hospitalizations for HF and death from cardiovascular causes was lowest in patients from Central Europe (9 per 100 patient years) and highest in patients from North America (28 per 100 patient years), which was primarily driven by a greater number of total hospitalizations for HF and independent of confounders. In the total population, sacubitril–valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes with no significant heterogeneity in treatment response to sacubitril-valsartan across regions.

Conclusion

This first report on regional differences in the largest prospective global trial in HFpEF suggests substantial regional heterogeneity with respect to phenotype, outcomes and quality of life.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Study funded by Novartis

Effect of sacubitril/valsartan on cognitive function in patients with HFpEF: a prespecified analysis of PARAGON-HF

Background

A theoretical concern has been raised about detrimental effects of sacubitril/valsartan (sac/val) on cognitive function as neprilysin is one of many pathways involved in clearance of amyloid beta peptides from brain tissue.

Purpose

To examine effect of sac/val, compared with valsartan, on cognitive function in patients with heart failure (HF) and preserved ejection fraction (HFpEF).

Methods

In the PARAGON-HF trial, cognitive function was tested in a subgroup of patients at baseline and follow-up, using Mini-Mental State Examination [MMSE] having a maximum score of 30 (higher scores reflect better cognitive function). Change in MMSE score from baseline to 96 wks was a prespecified exploratory endpoint. Other post hoc analyses included “cognitive decline” (fall in MMSE ≥3 pts) and assessment of cognition-related adverse events (AEs).

Results

Among 2895 patients (60% of total) in PARAGON-HF with baseline MMSE measurement, mean (SD) score was 27.4 (3.0) in patients receiving sac/val (1453) and 27.4 (2.9) in patients receiving valsartan (1442). There was no difference between sac/val and valsartan in MMSE score change from baseline to wk 96: sac/val −0.02 (SE 0.07) and valsartan 0.00 (0.07); between-treatment difference −0.02 (95% CI: −0.22 to 0.18); p-value = 0.83. Cognitive decline at 96 weeks occurred in 115 of 1071 evaluable patients (10.7%) in sac/val group and 121 of 1053 patients (11.5%) in valsartan group; risk ratio 0.97 (0.75–1.26), p-value = 0.82. Cognition-related AEs were more frequent, than in PARADIGM-HF (likely as patients in PARAGON-HF were older) but, as in PARADIGM-HF, did not differ between sac/val and comparator treatment (Table).

Conclusions

Cognitive change, measured by MMSE, did not differ between treatment with sac/val & valsartan in patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PARAGON-HF study was funded by Novartis Pharma.

Reduced cognitive function is associated with poor outcomes in HFpEF: a post hoc analysis from PARAGON-HF

Background

Little is known about the prevalence and consequences of cognitive impairment in patients with heart failure and preserved ejection fraction (HFpEF).

Purpose

To describe the prevalence of cognitive impairment in HFpEF and the association between cognitive function and outcomes in patients with HFpEF.

Methods

In the Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction trial (PARAGON-HF), cognitive function was tested in a subgroup of patients at baseline and during follow-up, using the Mini-Mental State Examination [MMSE] which has a maximum score of 30, with a higher score reflecting better cognitive function. Patients were divided into 3 groups according to baseline score: ≤24 representing cognitive impairment, 25–27 reflecting borderline cognitive impairment and ≥28 normal cognition. The primary endpoint used in this analysis was a composite of first heart failure hospitalization (HFH) or cardiovascular death (CVD). We examined the relationship between baseline MMSE score and this outcome, its components and all-cause mortality. We adjusted for other standard prognostic variables, including NT-proBNP (see Table footnote).

Results

Among the 2895 patients (60% of total) in PARAGON-HF with a baseline MMSE measurement, 415 (14.3%) had a score ≤24, 671 (23.2%) a score 25–27 and 1809 (62.5%) a score ≥28. Over a median follow-up of 35 (IQR 30–41) months, the unadjusted and adjusted risks of the primary composite (Table), its components and all-cause death (Figure) were higher in patients with lower baseline MMSE scores.

Conclusions

Even mild cognitive impairment, as measured by the MMSE, is predictive of adverse outcomes in HFpEF

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PARAGON-HF was funded by Novartis Pharma

The effect of dapagliflozin across the spectrum of baseline risk: a post-hoc analysis of DAPA-HF

Background

In DAPA-HF, compared to placebo, the sodium-glucose cotransporter 2 (SGLT-2) inhibitor, dapagliflozin, reduced the risk of cardiovascular death or worsening heart failure in patients with heart failure with reduced ejection fraction (HFrEF). The majority of patients in DAPA-HF reported mild functional limitation, however there is significant heterogeneity in prognosis among these patients.

Purpose

To examine the effect of dapagliflozin compared with placebo across the spectrum of baseline risk in DAPA-HF.

Methods

The primary composite outcome of DAPA-HF was time-to-first cardiovascular death or worsening heart failure event (hospitalization for heart failure or outpatient visit requiring intravenous therapy). We examined whether the effect of dapagliflozin was modified by baseline risk, as determined by the MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) risk score based upon 13 predictive variables giving a potential maximum score of 57. The number needed to treat (NNT) to over a median follow-up of 18.2 months was calculated by applying the overall relative risk reduction in DAPA-HF (26%, 95% CI 15–35) to the proportion of patients with a primary outcome event in the placebo group of each MAGGIC risk score category (defined by quintiles of score).

Results

The MAGGIC risk score was calculable for 4740 of 4744 patients in DAPA-HF. The median score was 22 (range 3–43). The event rate for the primary outcome was 7.2 per 100 patient-years in the lowest risk score quintile and 25.7 in the highest. A 1-point increase in score was associated with an 8% increase in the risk of a primary outcome event (p<0.001). Dapagliflozin, compared to placebo, reduced the risk of the primary outcome across quintiles of the MAGGIC risk score (Figure - Interaction p value=0.69) and when the score was analysed as a continuous variable (Interaction p value=0.56). The NNT to prevent one primary event was 39 (95% CI 29–68) in the lowest quintile of risk scores, compared with 14 (11–25) in the highest quintile (Figure).

Similar results were found for the individual components of the primary composite outcome and for all-cause mortality.

Conclusions

DAPA-HF included patients with a wide spectrum of risk. Treatment with dapagliflozin, compared to placebo, reduced the risk of cardiovascular death or worsening heart failure, irrespective of baseline risk as measured by the MAGGIC risk score.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): DAPA-HF was funded by AstraZeneca

The effect of dapagliflozin in patients with HFrEF and COPD: a post-hoc analysis of DAPA-HF

Background

Chronic obstructive pulmonary disease (COPD) is an important comorbidity in HFrEF, associated with worse outcomes and suboptimal treatment due to under-prescription of beta-blockers. Consequently, additional effective therapies are especially relevant in patients with COPD. In DAPA-HF, compared to placebo, the sodium-glucose cotransporter 2 (SGLT-2) inhibitor, dapagliflozin, reduced risk of cardiovascular (CV) death or worsening heart failure (HF) in patients with HF with reduced ejection fraction (HFrEF).

Purpose

To examine effect of dapagliflozin, compared with placebo, in patients with and without COPD.

Methods

Primary composite outcome of DAPA-HF was time-to-first CV death or worsening HF event (hospitalization for HF or outpatient visit requiring intravenous therapy). We examined whether effect of dapagliflozin was modified by investigator reported COPD at baseline.

Results

Overall, 585 (12.3%) of the 4744 patients randomized had an investigator-reported history of COPD, 299 (12.6%) in dapagliflozin group and 286 (12.1%) in placebo group. Incidence of primary composite outcome, in the placebo group, was higher in patients with COPD than in those without (22.8; 95% CI 18.4–28.3 vs. 14.9; 13.5–16.4) (Table). Hazard ratio (HR) for the effect of dapagliflozin, compared with placebo, on the primary outcome, was consistent in patients with and without COPD (Table); P-value for interaction was 0.467. Findings for other outcomes were similar (Figure).

Conclusions

Patients in DAPA-HF with COPD were at substantially higher risk than those without. Treatment with dapagliflozin, compared to placebo, reduced risk of CV death and worsening HF, similarly, in patients with and without COPD.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): DAPA-HF was funded by AstraZeneca

Effect of socioeconomic deprivation on the population risk of incident heart failure hospitalisation: an analysis of the Renfrew/Paisley Study

BACKGROUND

There are few data describing the effect of socioeconomic deprivation on the risk of developing heart failure (HF).

AIMS

To examine the relationship between socioeconomic deprivation and hospitalisation with HF over 20 years.

METHODS

Between 1972 and 1976, 15,402 individuals, aged 45-64 years, residing in two towns in Scotland, underwent cardiovascular screening. We report hospitalisations with HF over the subsequent 20 years according to Carstairs deprivation category and Social Class.

RESULTS

Following screening, 628 men and women (4.1%) were hospitalised with a primary diagnosis of HF. There was a gradient in the risk of HF hospitalisation with increasing socioeconomic deprivation (P=0.003). Of the most deprived individuals, 6.4% were hospitalised for HF compared to 3.5% of the most affluent group. Cox-proportional Hazard models showed that independent of age, sex and baseline risk factors for cardio-respiratory status, greater socioeconomic deprivation increased the risk of HF admission (P<0.001, overall). The adjusted risk of admission for HF was 39% greater in the most versus least deprived subjects (RR 1.39 95% CI 1.04-2.01; P=0.04).

CONCLUSION

These data show a link between social deprivation and the risk of developing HF, irrespective of baseline cardio-respiratory status and cardiovascular risk factors.