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Pascual-Figal D, Bayes-Genis A. Looking for the ideal medication for heart failure with reduced ejection fraction: a narrative review. Front Cardiovasc Med 2024; 11:1439696. [PMID: 39314771 PMCID: PMC11417622 DOI: 10.3389/fcvm.2024.1439696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 08/20/2024] [Indexed: 09/25/2024] Open
Abstract
The main goals of the pharmacological treatment of Heart failure with reduced ejection fraction (HFrEF) are the reduction of mortality and the prevention of hospitalizations. However, other outcomes such as improvements in cardiac remodeling and clinical status, functional capacity and quality of life, should be taken into account. Also, given the significant inter-individual and intra-individual variability of HF, and the fact that patients usually present with comorbidities, an appropriate treatment for HFrEF should exert a clinical benefit in most patient profiles irrespective of their characteristics or the presence of comorbidities, while providing organ protection beyond the cardiovascular system. The aim of this narrative review is to determine which are the proven effects of the guideline-directed treatments for HFrEF on five key clinical outcomes: cardiovascular mortality and hospitalization due to HF, sudden death, reverse cardiac remodeling, renal protection and evidence in hospitalized patients. Publications that fulfilled the pre-established selection criteria were selected and reviewed. Renin-angiotensin system (RAS) inhibitors, namely angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), sodium-glucose co-transporter 2 inhibitors (SGLT2i) show a benefit in terms of mortality and hospitalization rates. ARNI, BB, and MRA have demonstrated a significant positive effect on the incidence of sudden death. ARB, ARNI, BB and SGLT2i have been associated with clear benefits in reverse cardiac remodeling. Additionally, there is consistent evidence of renal protection from ARB, ARNI, and SGLT2i in renal protection and of benefits for hospitalized patients from ARNI and SGLT2i. In conclusion, the combination of drugs that gather most beneficial effects in HFrEF, beyond cardiovascular mortality and hospitalization, would be ideally pursued.
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Affiliation(s)
- Domingo Pascual-Figal
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
- University of Murcia, Murcia, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Antoni Bayes-Genis
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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Buttar C, Alai H, Matanes FN, Cassidy MM, Stencel J, Le Jemtel TH. Full decongestion in acute heart failure therapy. Am J Med Sci 2024; 368:182-189. [PMID: 38880301 DOI: 10.1016/j.amjms.2024.06.002] [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: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
Incomplete decongestion is the main cause of readmission in the early post-discharge period of a hospitalization for acute heart failure. Recent heart failure guidelines have highlighted initiation and rapid up-titration of quadruple therapy with angiotensin receptor neprilysin inhibitor, beta adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor to prevent hospitalizations for heart failure with reduced ejection fraction. However, full decongestion remains the foremost therapeutic goal of hospitalization for heart failure. While early addition of sodium glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists may be helpful, the value of the other therapeutics comes after decongestion is complete.
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Affiliation(s)
- Chandan Buttar
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Hamid Alai
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Faris N Matanes
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Mark M Cassidy
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Jason Stencel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Thierry H Le Jemtel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA.
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3
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Wang X, He M, Jin D, Sun C, Lu H. Effect of SGLT-2 inhibitors on acute kidney injury in patients with heart failure: a systematic review and meta-analysis. Diabetol Metab Syndr 2024; 16:207. [PMID: 39192267 DOI: 10.1186/s13098-024-01446-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Sodium glucose cotransporter-2 (SGLT-2) inhibitors are known to reduce hospitalization and cardiovascular mortality in various heart failure (HF) populations, potentially through enhanced excretion of water and sodium. However, there are concerns regarding the risk of acute kidney injury (AKI) associated with their use. This meta-analysis aimed to unravel the effects of SGLT-2 inhibitors on risk of AKI in a variety of patients with HF. METHODS This study conducted a comprehensive literature search using PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov for studies published up to January 1, 2024. Data were analyzed using both random-effects or fixed-effects models to estimate the overall relative risk (RR) with a 95% confidence interval (CI). RESULTS Our analysis included 25,172 patients with HF from 16 randomized controlled trials. Treatment with SGLT-2 inhibitors led to a 28% reduction in the risk of AKI progression compared to placebo (RR 0.72, 95% CI 0.61-0.85, p<0.0001), without an increased risk of hypotension (RR 1.21, 95% CI 0.87-1.70, p = 0.26) and hypovolemia (RR 2.26, 95% CI: 0.70-7.33, p = 0.17). Notably, SGLT-2 inhibitors significantly decreased AKI in specific subgroups, including patients with HF with reduced ejection fraction (RR 0.59, 95% CI 0.43-0.80, p = 0.0007), those treated with empagliflozin (RR 0.70, 95% CI 0.57-0.88, p = 0.002) or dapagliflozin (RR 0.74, 95% CI 0.57-0.98, p = 0.04), in studies with a follow-up of at least 1 year (RR 0.67, 95% CI 0.55-0.82, p = 0.0001), and in patients aged 65 years or older (RR 0.72, 95% CI 0.61-0.85, p < 0.0001). CONCLUSION Use of SGLT-2 inhibitors did not increase the incidence of AKI regardless of the ejection fraction environment (chronic and acute), type of SGLT-2 inhibitors, or patient age.
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Affiliation(s)
- Xianghong Wang
- Department of Endocrinology and Metabolism, Zhuhai People's Hospital (Zhuhai Clinical Medical College of Jinan University), Zhuhai, China
| | - Meihong He
- The Biomedical Translational Research Institute, Faculty of Medical Science, Jinan University, Guangzhou, China
| | - Donghua Jin
- Department of Intensive Care Unit, The Third People's Hospital of Zhengzhou, Henan, China
| | - Chuanchuan Sun
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hongyun Lu
- Department of Endocrinology and Metabolism, Zhuhai People's Hospital (Zhuhai Clinical Medical College of Jinan University), Zhuhai, China.
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Vaduganathan M, Neuen BL, McCausland F, Jhund PS, Docherty KF, McMurray JJV, Solomon SD. Why Has it Been Challenging to Modify Kidney Disease Progression in Patients With Heart Failure? J Am Coll Cardiol 2024:S0735-1097(24)08242-1. [PMID: 39217561 DOI: 10.1016/j.jacc.2024.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Finnian McCausland
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Kieran F Docherty
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Hamid A, Greene SJ, Mehta A, Butler J, Khan MS. Estimated Glomerular Filtration Rate Slope as an Endpoint in Cardiovascular Trials. Curr Heart Fail Rep 2024; 21:407-416. [PMID: 38795231 DOI: 10.1007/s11897-024-00668-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE OF REVIEW End stage kidney disease can be a slow process and it may be challenging to achieve required follow-up for sufficient events. Therefore, a surrogate kidney endpoint, such as estimated glomerular filtration rate (eGFR) slope maybe attractive to assess the kidney in cardiovascular trials, especially heart failure (HF). RECENT FINDINGS eGFR slope can generate informative results in a shorter follow-up period, has decreased risk of type-2 error, and is less sensitive to eGFR shifts compared with other surrogate kidney endpoints (eGFR decline≥40% or doubling creatinine). However, eGFR slope has its limitations with acute effects, heterogeneity in slope calculation/reporting, and deviations from linearity. eGFR slope is a kidney endpoint which may be well-suited for HF trials. Cross-collaborated guideline recommendations are needed to optimize the use of eGFR slope as a kidney endpoint in patients with HF.
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Affiliation(s)
- Arsalan Hamid
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Ankit Mehta
- Division of Nephrology, Department of Internal Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
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Theodorakopoulou MP, Alexandrou ME, Tsitouridis A, Kamperidis V, Pella E, Xanthopoulos A, Ziakas A, Triposkiadis F, Vassilikos V, Papagianni A, Sarafidis P. Effects of sodium-glucose co-transporter 2 inhibitors on heart failure events in chronic kidney disease: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:329-341. [PMID: 38218589 DOI: 10.1093/ehjcvp/pvae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/05/2023] [Accepted: 01/11/2024] [Indexed: 01/15/2024]
Abstract
AIMS Sodium-glucose co-transporter 2 (SGLT-2) inhibitors significantly reduce the risk for hospitalizations for heart failure (HF) in patients with diabetes, and HF; findings in patients with chronic kidney disease (CKD) are not uniform. We aimed to perform a meta-analysis exploring the effect of SGLT-2 inhibitors on HF events in patients with CKD and across subgroups defined by baseline kidney function. METHODS AND RESULTS A systematic search in major electronic databases was performed. Randomized controlled trials (RCTs) providing data on the effect of SGLT-2 inhibitors on the primary outcome, time to hospitalization or urgent visit for worsening HF in patients with prevalent CKD at baseline or across subgroups stratified by baseline estimated glomerular-filtration-rate (eGFR) were included. Twelve studies (n = 89,191 participants) were included in the meta-analysis. In patients with CKD, treatment with SGLT-2 inhibitors reduced the risk for HF events by 32% compared to placebo [hazard ratio (HR) 0.68; 95% confidence interval (CI) 0.63-0.73]. Reduction in HF events with SGLT-2 inhibitors was more prominent in patients with eGFR <60 ml/min/1.73 m2 (HR 0.68; 95% CI 0.62-0.74) than in those with eGFR ≥60 ml/min/1.73 m2 (HR 0.76; 95% CI 0.69-0.83). Subgroup analysis according to type of SGLT-2 inhibitor showed a consistent treatment effect across all studied agents (p-subgroup-analysis = 0.44). Sensitivity analysis including data from studies including only diabetic patients showed an even more pronounced effect in eGFR subgroup <60 ml/min/1.73 m2 (HR 0.62; 95% CI 0.54-0.70). CONCLUSION Treatment with SGLT-2 inhibitors led to a significant reduction in HF events in patients with CKD. Such findings may change the landscape of prevention of HF events in patients with advanced CKD. PROSPERO Registration number CRD42022382857.
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Affiliation(s)
- Marieta P Theodorakopoulou
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki GR54642, Greece
| | - Maria-Eleni Alexandrou
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki GR54642, Greece
| | - Alexandros Tsitouridis
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki GR54642, Greece
| | - Vasileios Kamperidis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eva Pella
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki GR54642, Greece
| | | | - Antonios Ziakas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Vassilios Vassilikos
- Third Department of Cardiology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Papagianni
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki GR54642, Greece
| | - Pantelis Sarafidis
- First Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki GR54642, Greece
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Yu PL, Yu Y, Li S, Mu BC, Nan MH, Pang M. Dapagliflozin in heart failure and type 2 diabetes: Efficacy, cardiac and renal effects, safety. World J Diabetes 2024; 15:1518-1530. [PMID: 39099807 PMCID: PMC11292345 DOI: 10.4239/wjd.v15.i7.1518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/12/2024] [Accepted: 05/14/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Heart failure (HF), especially HF with reduced ejection fraction (HFrEF), presents complex challenges, particularly in the aging population where it often coexists with type 2 diabetes mellitus (T2DM). AIM To analyze the effect of dapagliflozin treatment on cardiac, renal function, and safety in patients with HFrEF combined with T2DM. METHODS Patients with T2DM complicated with HFrEF who underwent treatment in our hospital from February 2018 to March 2023 were retrospectively analyzed as the subjects of this study. The propensity score matching method was used, and a total of 102 eligible samples were scaled. The clinical efficacy of the two groups was evaluated at the end of the treatment, comparing the results of blood glucose, insulin, cardiac function, markers of myocardial injury, renal function indexes, and 6-min walk test (6MWT) before and after the treatment. We compared the occurrence of adverse effects on the treatment process of the two groups of patients. The incidence of adverse outcomes in patients within six months of treatment was counted. RESULTS The overall clinical efficacy rate of patients in the study group was significantly higher than that of patients in the control group (P = 0.013). After treatment, the pancreatic beta-cell function index, left ventricular ejection fraction, and glomerular filtration rate of patients in the study group were significantly higher than control group (P < 0.001), while their fasting plasma glucose, 2-h postprandial glucose, glycosylated hemoglobin, insulin resistance index, left ventricular end-systolic diameter, left ventricular end-diastolic diameter, cardiac troponin I, creatine kinase-MB, N-terminal pro b-type natriuretic peptide, serum creatinine, and blood urea nitrogen were significantly lower than those of the control group. After treatment, patients in the study group had a significantly higher 6MWT than those in the control group (P < 0.001). Hypoglycemic reaction (P = 0.647), urinary tract infection (P = 0.558), gastrointestinal adverse effect (P = 0.307), respiratory disturbance (P = 0.558), and angioedema (P = 0.647) were not statistically different. There was no significant difference between the incidence of adverse outcomes between the two groups (P = 0.250). CONCLUSION Dapagliflozin significantly enhances clinical efficacy, cardiac and renal function, and ambulatory capacity in patients with HFrEF and T2DM without an increased risk of adverse effects or outcomes.
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Affiliation(s)
- Pei-Ling Yu
- The Second Department of Cardiology, The Second Affiliated Hospital of Liaoning Hospital of Traditional Chinese Medicine, Shenyang 110034, Liaoning Province, China
| | - You Yu
- The Second Department of Cardiology, The Second Affiliated Hospital of Liaoning Hospital of Traditional Chinese Medicine, Shenyang 110034, Liaoning Province, China
| | - Shuang Li
- The Second Department of Cardiology, The Second Affiliated Hospital of Liaoning Hospital of Traditional Chinese Medicine, Shenyang 110034, Liaoning Province, China
| | - Bai-Chen Mu
- The Second Department of Cardiology, The Second Affiliated Hospital of Liaoning Hospital of Traditional Chinese Medicine, Shenyang 110034, Liaoning Province, China
| | - Ming-Hua Nan
- The Second Department of Cardiology, The Second Affiliated Hospital of Liaoning Hospital of Traditional Chinese Medicine, Shenyang 110034, Liaoning Province, China
| | - Min Pang
- Department of Outpatient, The Second Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang 110034, Liaoning Province, China
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Usman MS, Bhatt DL, Hameed I, Anker SD, Cheng AYY, Hernandez AF, Jones WS, Khan MS, Petrie MC, Udell JA, Friede T, Butler J. Effect of SGLT2 inhibitors on heart failure outcomes and cardiovascular death across the cardiometabolic disease spectrum: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2024; 12:447-461. [PMID: 38768620 DOI: 10.1016/s2213-8587(24)00102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors have been studied in patients with heart failure, type 2 diabetes, chronic kidney disease, atherosclerotic cardiovascular disease, and acute myocardial infarction. Individual trials were powered to study composite outcomes in one disease state. We aimed to evaluate the treatment effect of SGLT2 inhibitors on specific clinical endpoints across multiple demographic and disease subgroups. METHODS In this systematic review and meta-analysis, we queried online databases (PubMed, Cochrane CENTRAL, and SCOPUS) up to Feb 10, 2024, for primary and secondary analyses of large trials (n>1000) of SGLT2 inhibitors in patients with heart failure, type 2 diabetes, chronic kidney disease, and atherosclerotic cardiovascular disease (including acute myocardial infarction). Outcomes studied included composite of first hospitalisation for heart failure or cardiovascular death, first hospitalisation for heart failure, cardiovascular death, total (first and recurrent) hospitalisation for heart failure, and all-cause mortality. Effect sizes were pooled using random-effects models. This study is registered with PROSPERO, CRD42024513836. FINDINGS We included 15 trials (N=100 952). Compared with placebo, SGLT2 inhibitors reduced the risk of first hospitalisation for heart failure by 29% in patients with heart failure (hazard ratio [HR] 0·71 [95% CI 0·67-0·77]), 28% in patients with type 2 diabetes (0·72 [0·67-0·77]), 32% in patients with chronic kidney disease (0·68 [0·61-0·77]), and 28% in patients with atherosclerotic cardiovascular disease (0·72 [0·66-0·79]). SGLT2 inhibitors reduced cardiovascular death by 14% in patients with heart failure (HR 0·86 [95% CI 0·79-0·93]), 15% in patients with type 2 diabetes (0·85 [0·79-0·91]), 11% in patients with chronic kidney disease (0·89 [0·82-0·96]), and 13% in patients with atherosclerotic cardiovascular disease (0·87 [0·78-0·97]). The benefit of SGLT2 inhibitors on both first hospitalisation for heart failure and cardiovascular death was consistent across the majority of the 51 subgroups studied. Notable exceptions included acute myocardial infarction (22% reduction in first hospitalisation for heart failure; no effect on cardiovascular death) and heart failure with preserved ejection fraction (26% reduction in first hospitalisation for heart failure; no effect on cardiovascular death). INTERPRETATION SGLT2 inhibitors reduced heart failure events and cardiovascular death in patients with heart failure, type 2 diabetes, chronic kidney disease, and atherosclerotic cardiovascular disease. These effects were consistent across a wide range of subgroups within these populations. This supports the eligibility of a large population with cardiorenal-metabolic diseases for treatment with SGLT2 inhibitors. FUNDING None.
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Affiliation(s)
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ishaque Hameed
- Department of Medicine, Medstar Health, Baltimore, MD, USA
| | - Stefan D Anker
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, German Heart Center Charité, Charité-University Medicine Berlin, Corporate Member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; BIH Center for Regenerative Therapies (BCRT), Charité-University Medicine Berlin, Corporate Member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
| | - Alice Y Y Cheng
- Department of Medicine, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - William Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor Scott and White Health, Dallas, TX, USA; Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
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Choi CH, Singh S, Cheung AT, Vanneman M, Madhok J. Prolonged Postoperative Euglycemic Diabetic Ketoacidosis in a Lung Transplant Recipient With Preoperative SGLT2 Inhibitor Use. J Cardiothorac Vasc Anesth 2024; 38:1539-1542. [PMID: 38637210 DOI: 10.1053/j.jvca.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Christine H Choi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Shivani Singh
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Albert T Cheung
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew Vanneman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jai Madhok
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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10
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Zhou Z, Yao X. Safety assessment of dapagliflozin: Real-world adverse event analysis based on the FAERS database from 2012 to 2023. Heliyon 2024; 10:e33306. [PMID: 39022025 PMCID: PMC11253505 DOI: 10.1016/j.heliyon.2024.e33306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/20/2024] Open
Abstract
Background Dapagliflozin possesses the capacity to cure a wide range of diseases, however, there are many adverse events (AEs) that have not yet been acknowledged or recorded. Aim Safety assessment of dapagliflozin based on the Food and Drug Administration Adverse Event Reporting System (FAERS) database, to explore differences between the reported AEs to provide a overview of the safety profile of dapagliflozin. Methods We extracted data from the United States FAERS database, including from the fourth quarter of 2012 to the third quarter of 2023. Reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and empirical Bayesian geometric average (EBGM) were used to evaluate the relationship between dapagliflozin and its associated AEs. Results A total of 13,593,946 case reports were gathered from the Food and Drug Administration Adverse Event Reporting System database for this investigation. Among these, there were 44,506 episodes of adverse events that were associated with dapagliflozin. Included in the analysis were 341 preferred words and 2 system organ classes that showed statistical significance according to all four methods simultaneously. The system organ classes encompassed illnesses related to metabolism and nutrition, as well as problems affecting the renal and urinary systems. PT levels were screened for adverse drug reaction signals including scrotal gangrene, scrotal cellulitis, perineal cellulitis, diabetic ketoacidosis, and pancreatitis. Conclusion The majority of our findings aligned with the specification, however, certain novel indicators of AEs such as acute pancreatitis were not accounted for. The analysis of the AE signals may provide support for clinical monitoring and risk identification of dapagliflozin. Due to the inherent limitations of FAERS data, well-designed studies are required to demonstrate the safety of dapagliflozin.
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Affiliation(s)
- Zhengxi Zhou
- Department of Urology, Ningbo Mingzhou Hospital, Zhejiang, China
| | - Xiaotian Yao
- The Division of Nephrology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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11
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Battistoni I, Pongetti G, Falchetti E, Giannini I, Olivieri R, Gioacchini F, Bonelli P, Contadini D, Scappini L, Flori M, Giovagnoli A, De Maria R, Marini M. Safety and Efficacy of Dapagliflozin in Patients with Heart Failure with Reduced Ejection Fraction: Multicentre Retrospective Study on Echocardiographic Parameters and Biomarkers of Heart Congestion. J Clin Med 2024; 13:3522. [PMID: 38930049 PMCID: PMC11204467 DOI: 10.3390/jcm13123522] [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: 05/19/2024] [Revised: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: Dapagliflozin has shown efficacy in clinical trials in patients with heart failure and reduced ejection fraction (HFrEF). However, real-world data on its use and outcomes in routine clinical practice are limited. We aimed to evaluate the utilisation and safety profile of dapagliflozin in a real-world population of HFrEF patients within the Marche region. Methods: Nine cardiology departments within the Marche region retrospectively included HFrEF patients who were initiated on dapagliflozin therapy in an outpatient setting. Data on medical history, comorbidities, echocardiographic parameters, and laboratory tests were collected at baseline and after 6 months. Telephone follow-up interviews were conducted at 1 and 3 months to assess adverse events. We defined the composite endpoint score as meeting at least 50% of four objective measures of improvement among: weight loss, NYHA decrease, ≥50% Natriuretic peptides (NP) decrease, and guideline/directed medical therapy (GDMT) up titration. Results: We included 95 HFrEF patients aged 66 ± 12 years, 82% were men, 48% had ischemic heart disease, and 20% had diabetes. At six months, glomerular filtration rate declined (p = 0.03) and natriuretic peptides levels decreased, on average, by 23% (p < 0.001). Echocardiographic measurements revealed a decrease in pulmonary artery pressure (p < 0.001) and E/e' (p < 0.001). In terms of drug therapy, furosemide dosage decreased (p = 0.001), and the percentage of the target dose achieved for angiotensin receptor-neprilysin inhibitors increased (p = 0.003). By multivariable Cox regression, after adjustment for age, sex, the presence of diabetes/prediabetes, and HF duration, higher baseline Hb concentrations (HR 1.347, 95% CI 1.038-1.746, p = 0.025), and eGFR levels (HR 1.016, 95% CI 1.000-1.033, p = 0.46). Conclusions: In a real-life HFrEF population, dapagliflozin therapy is safe and well-tolerated, improves echocardiographic parameters and biomarkers of congestion, and can also facilitate the titration of drugs with a prognostic impact.
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Affiliation(s)
- Ilaria Battistoni
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, 60100 Ancona, Italy; (G.P.); (M.M.)
| | - Giulia Pongetti
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, 60100 Ancona, Italy; (G.P.); (M.M.)
| | - Elena Falchetti
- Cardiology Department, Senigallia Hospital, 60019 Senigallia, Italy;
| | - Irene Giannini
- Department of Cardiology, Camerino-Hospital, 62032 Camerino, Italy;
| | - Roberto Olivieri
- Cardiology Unit, Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy (L.S.)
| | | | - Paolo Bonelli
- Department of Cardiology, Cardiac Intensive Care Unit, Centre of Telemedicine, Italian National Research Centre on Aging (INRCA), 60127 Ancona, Italy;
| | - Daniele Contadini
- Cardiology Division, Ospedale Provinciale AREA VASTA 3, 62100 Piediripa, Italy;
| | - Lorena Scappini
- Cardiology Unit, Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy (L.S.)
| | - Marco Flori
- U.O.C. Cardiology-Utic Ospedale della Misericordia Urbino AST Pesaro-Urbino, 61029 Urbino, Italy;
| | | | | | - Marco Marini
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, 60100 Ancona, Italy; (G.P.); (M.M.)
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Arévalo-Lorido JC, Carretero-Gomez J, Rubini A, Félix-Redondo FJ, Robles Pérez Monteoliva NR, Hernández González M, Vázquez Jarén E, Cancho-Castellanos B, González Fernández R, Fernández-Bergés D. Temporal trends on the prevalence of renal disease and outcomes among patients with diabetes mellitus hospitalized by heart failure: findings from INCAex. Expert Rev Endocrinol Metab 2024:1-11. [PMID: 38866705 DOI: 10.1080/17446651.2024.2365769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/26/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND To assess 20-year time trends in the prevalence of diabetes mellitus (DM) among inpatients with heart failure (HF) and the influence of coexisting DM and kidney disease (KD) on outcomes. RESEARCH DESIGN AND METHODS A retrospective study of patients was admitted due to HF, during the period 2000/2019. The period of follow-up was divided into three intervals according to the European Medical Agency approval of newer hypoglycemic drugs. We analyzed in-hospital mortality and outcomes during the follow-up period. RESULTS A total of 4959 patients were included. Over time, prevalence of DM was significantly raising among women with HF (50 to 53.2%) and descending among men (50% to 46.8%, p = 0.02). Total mortality and readmissions were higher in patients with DM during the and second periods. However, no significant differences were found in the third-one (HR 1.14, 95% CI 0.94-1.39, p = 0.181). A protector role of oral hypoglycemic medications was observed in this last period. According to the presence of KD, the patients with both DM and KD were who presented most of the events. CONCLUSIONS Over the time analyzed, the prevalence of DM raised among women and decreased among men. DM influenced the prognosis of HF except in the third period when more protective hypoglycemic drugs started to be used.
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Affiliation(s)
| | | | - Alessia Rubini
- Servicio Extremeño de Salud, Unidad de Investigación Área Salud Don Benito-Villanueva, Villanueva de la Serena, Badajoz, Spain
- Unidad de investigaci'ón (GRIMEX), Villanueva de la Serena, Badajoz, Spain
| | - Francisco Javier Félix-Redondo
- Servicio Extremeño de Salud, Unidad de Investigación Área Salud Don Benito-Villanueva, Villanueva de la Serena, Badajoz, Spain
| | - Nicolás Roberto Robles Pérez Monteoliva
- Unidad de investigaci'ón (GRIMEX), Villanueva de la Serena, Badajoz, Spain
- Unidad de Hipertensión Arterial, Servicio de Nefrología, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Miriam Hernández González
- Servicio Extremeño de Salud, Unidad de Investigación Área Salud Don Benito-Villanueva, Villanueva de la Serena, Badajoz, Spain
- Unidad de investigaci'ón (GRIMEX), Villanueva de la Serena, Badajoz, Spain
| | - Elena Vázquez Jarén
- Servicio Extremeño de Salud, Unidad de Investigación Área Salud Don Benito-Villanueva, Villanueva de la Serena, Badajoz, Spain
| | - Bárbara Cancho-Castellanos
- Unidad de investigaci'ón (GRIMEX), Villanueva de la Serena, Badajoz, Spain
- Unidad de Hipertensión Arterial, Servicio de Nefrología, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Reyes González Fernández
- Unidad de investigaci'ón (GRIMEX), Villanueva de la Serena, Badajoz, Spain
- Servicio de Cardiología, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Daniel Fernández-Bergés
- Servicio Extremeño de Salud, Unidad de Investigación Área Salud Don Benito-Villanueva, Villanueva de la Serena, Badajoz, Spain
- Unidad de investigaci'ón (GRIMEX), Villanueva de la Serena, Badajoz, Spain
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13
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Locatelli F, Paoletti E, Ravera M, Pucci Bella G, Del Vecchio L. Can we effectively manage chronic kidney disease with a precision-based pharmacotherapy plan? Where are we? Expert Opin Pharmacother 2024; 25:1145-1161. [PMID: 38940769 DOI: 10.1080/14656566.2024.2374039] [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: 04/22/2024] [Accepted: 06/25/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION In recent years, thanks to significant advances in basic science and biotechnologies, nephrology has witnessed a deeper understanding of the mechanisms leading to various conditions associated with or causing kidney disease, opening new perspectives for developing specific treatments. These new possibilities have brought increased challenges to physicians, who face with a new complexity in disease characterization and selection the right treatment for individual patients. AREAS COVERED We chose four therapeutic situations: anaemia in chronic kidney disease (CKD), heart failure in CKD, IgA nephropathy (IgAN) and membranous nephropathy (MN). The literature search was made through PubMed. EXPERT OPINION Anaemia management remains challenging in CKD; a personalized therapeutic approach is often needed. Identifying patients who could benefit from a specific therapy is also an important goal for patients with CKD and heart failure with reduced ejection fraction. Several new treatments are under clinical development for IgAN; interestingly, they target specifically the pathogenetic mechanisms of the disease. The understanding of MN pathogenesis as an autoimmune disease and the discovery of several autoantibodies allows a better characterization of patients. High-sensible techniques for lymphocyte counting open the possibility of more personalized use of anti CD20 therapies.
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Affiliation(s)
- Francesco Locatelli
- Past Director, Department of Nephrology and Dialysis, A Manzoni Hospital, Lecco, Italy
| | - Ernesto Paoletti
- Department of Nephrology and Dialysis, ASL 1 Imperiese - Stabilimento Ospedaliero di Imperia, Imperia, Liguria, Italy
| | - Maura Ravera
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Giulio Pucci Bella
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
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Kodur N, Tang WHW. Non-cardiac comorbidities in heart failure: an update on diagnostic and management strategies. Minerva Med 2024; 115:337-353. [PMID: 38899946 DOI: 10.23736/s0026-4806.24.09070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Managing non-cardiac comorbidities in heart failure (HF) requires a tailored approach that addresses each patient's specific conditions and needs. Regular communication and coordination among healthcare providers is crucial to providing the best possible care for these patients. Poorly controlled hypertension contributes to left ventricular remodeling and diastolic dysfunction, emphasizing the importance of optimal blood pressure control while avoiding adverse effects. Among HF patients with diabetes, SGLT2 inhibitors and mineralocorticoid receptor antagonists have shown promise in reducing HF-related morbidity and mortality. Chronic kidney disease exacerbates HF and vice versa, forming the vicious cardiorenal syndrome, so disease-modifying therapies should be maintained in HF patients with comorbid CKD, even with transient changes in kidney function. Anemia in HF patients may be multifactorial, and there is growing evidence for the benefit of intravenous iron supplementation in HF patients with iron deficiency with or without anemia. Obesity, although a risk factor for HF, paradoxically offers a better prognosis once HF is established, though developing treatment strategies may improve symptoms and cardiac performance. In HF patients with stroke and atrial fibrillation, anticoagulation therapy is recommended. Among HF patients with sleep-disordered breathing, continuous positive airway pressure may improve sleep quality. Chronic obstructive pulmonary disease often coexists with HF, and many patients can tolerate cardioselective beta-blockers. Cancer patients with comorbid HF require careful consideration of cardiotoxicity risks associated with cancer therapies. Depression is underdiagnosed in HF patients and significantly impacts prognosis. Cognitive impairment is prevalent in HF patients and impacts their self-care and overall quality of life.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - W H Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA -
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Natale P, Tunnicliffe DJ, Toyama T, Palmer SC, Saglimbene VM, Ruospo M, Gargano L, Stallone G, Gesualdo L, Strippoli GF. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors for people with chronic kidney disease and diabetes. Cochrane Database Syst Rev 2024; 5:CD015588. [PMID: 38770818 PMCID: PMC11106805 DOI: 10.1002/14651858.cd015588.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Diabetes is associated with high risks of premature chronic kidney disease (CKD), cardiovascular diseases, cardiovascular death and impaired quality of life. People with diabetes are more likely to develop kidney impairment, and approximately one in three adults with diabetes have CKD. People with CKD and diabetes experience a substantially higher risk of cardiovascular outcomes. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors have shown potential effects in preventing kidney and cardiovascular outcomes in people with CKD and diabetes. However, new trials are emerging rapidly, and evidence synthesis is essential to summarising cumulative evidence. OBJECTIVES This review aimed to assess the benefits and harms of SGLT2 inhibitors for people with CKD and diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2023 using a search strategy designed by an Information Specialist. Studies in the Register are continually identified through regular searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled studies were eligible if they evaluated SGLT2 inhibitors versus placebo, standard care or other glucose-lowering agents in people with CKD and diabetes. CKD includes all stages (from 1 to 5), including dialysis patients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the study risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The primary review outcomes were all-cause death, 3-point and 4-point major adverse cardiovascular events (MACE), fatal or nonfatal myocardial infarction (MI), fatal or nonfatal stroke, and kidney failure. MAIN RESULTS Fifty-three studies randomising 65,241 people with CKD and diabetes were included. SGLT2 inhibitors with or without other background treatments were compared to placebo, standard care, sulfonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, or insulin. In the majority of domains, the risks of bias in the included studies were low or unclear. No studies evaluated the treatment in children or in people treated with dialysis. No studies compared SGLT2 inhibitors with glucagon-like peptide-1 receptor agonists or tirzepatide. Compared to placebo, SGLT2 inhibitors decreased the risk of all-cause death (20 studies, 44,397 participants: RR 0.85, 95% CI 0.78 to 0.94; I2 = 0%; high certainty) and cardiovascular death (16 studies, 43,792 participants: RR 0.83, 95% CI 0.74 to 0.93; I2 = 29%; high certainty). Compared to placebo, SGLT2 inhibitors probably make little or no difference to the risk of fatal or nonfatal MI (2 studies, 13,726 participants: RR 0.95, 95% CI 0.80 to 1.14; I2 = 24%; moderate certainty), and fatal or nonfatal stroke (2 studies, 13,726 participants: RR 1.07, 95% CI 0.88 to 1.30; I2 = 0%; moderate certainty). Compared to placebo, SGLT2 inhibitors probably decrease 3-point MACE (7 studies, 38,320 participants: RR 0.89, 95% CI 0.81 to 0.98; I2 = 46%; moderate certainty), and 4-point MACE (4 studies, 23,539 participants: RR 0.82, 95% CI 0.70 to 0.96; I2 = 77%; moderate certainty), and decrease hospital admission due to heart failure (6 studies, 28,339 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 17%; high certainty). Compared to placebo, SGLT2 inhibitors may decrease creatinine clearance (1 study, 132 participants: MD -2.63 mL/min, 95% CI -5.19 to -0.07; low certainty) and probably decrease the doubling of serum creatinine (2 studies, 12,647 participants: RR 0.70, 95% CI 0.56 to 0.89; I2 = 53%; moderate certainty). SGLT2 inhibitors decrease the risk of kidney failure (6 studies, 11,232 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 0%; high certainty), and kidney composite outcomes (generally reported as kidney failure, kidney death with or without ≥ 40% decrease in estimated glomerular filtration rate (eGFR)) (7 studies, 36,380 participants: RR 0.68, 95% CI 0.59 to 0.78; I2 = 25%; high certainty) compared to placebo. Compared to placebo, SGLT2 inhibitors incur less hypoglycaemia (16 studies, 28,322 participants: RR 0.93, 95% CI 0.89 to 0.98; I2 = 0%; high certainty), and hypoglycaemia requiring third-party assistance (14 studies, 26,478 participants: RR 0.75, 95% CI 0.65 to 0.88; I2 = 0%; high certainty), and probably decrease the withdrawal from treatment due to adverse events (15 studies, 16,622 participants: RR 0.94, 95% CI 0.82 to 1.08; I2 = 16%; moderate certainty). The effects of SGLT2 inhibitors on eGFR, amputation and fracture were uncertain. No studies evaluated the effects of treatment on fatigue, life participation, or lactic acidosis. The effects of SGLT2 inhibitors compared to standard care alone, sulfonylurea, DPP-4 inhibitors, or insulin were uncertain. AUTHORS' CONCLUSIONS SGLT2 inhibitors alone or added to standard care decrease all-cause death, cardiovascular death, and kidney failure and probably decrease major cardiovascular events while incurring less hypoglycaemia compared to placebo in people with CKD and diabetes.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Tadashi Toyama
- Department of Nephrology, Kanazawa University, Kanazawa, Japan
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Letizia Gargano
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Gippini A, Prado A. Earlier onset of treatment improves the nephroprotective effect of dapagliflozin. Nefrologia 2024; 44:431-433. [PMID: 39002997 DOI: 10.1016/j.nefroe.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 07/15/2024] Open
Affiliation(s)
- Antonio Gippini
- Endocrinologist, Endocrinology Service, Hospitalary Complex Ourense, National Health System, Spain.
| | - Alberto Prado
- Pharmacist, Master in Statistics, Cardiovascular Renal Metabolism (CVRM), Medical Department, AstraZeneca, Spain
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17
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Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [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] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
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Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
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18
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Kondo T, Jhund PS, Gasparyan SB, Yang M, Claggett BL, McCausland FR, Tolomeo P, Vadagunathan M, Heerspink HJL, Solomon SD, McMurray JJV. A hierarchical kidney outcome using win statistics in patients with heart failure from the DAPA-HF and DELIVER trials. Nat Med 2024; 30:1432-1439. [PMID: 38710952 PMCID: PMC11108780 DOI: 10.1038/s41591-024-02941-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 05/08/2024]
Abstract
Win statistics offer a new approach to the analysis of outcomes in clinical trials, allowing the combination of time-to-event and longitudinal measurements and taking into account the clinical importance of the components of composite outcomes, as well as their relative timing. We examined this approach in a post hoc analysis of two trials that compared dapagliflozin to placebo in patients with heart failure and reduced ejection fraction (DAPA-HF) and mildly reduced or preserved ejection fraction (DELIVER). The effect of dapagliflozin on a hierarchical composite kidney outcome was assessed, including the following: (1) all-cause mortality; (2) end-stage kidney disease; (3) a decline in estimated glomerular filtration rate (eGFR) of ≥57%; (4) a decline in eGFR of ≥50%; (5) a decline in eGFR of ≥40%; and (6) participant-level eGFR slope. For this outcome, the win ratio was 1.10 (95% confidence interval (CI) = 1.06-1.15) in the combined dataset, 1.08 (95% CI = 1.01-1.16) in the DAPA-HF trial and 1.12 (95% CI = 1.05-1.18) in the DELIVER trial; that is, dapagliflozin was superior to placebo in both trials. The benefits of treatment were consistent in participants with and without baseline kidney disease, and with and without type 2 diabetes. In heart failure trials, win statistics may provide the statistical power to evaluate the effect of treatments on kidney as well as cardiovascular outcomes.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Samvel B Gasparyan
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Finnian R McCausland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Tolomeo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Muthiah Vadagunathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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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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20
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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21
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Shiau CH, Tsau LY, Kao CC, Peng YC, Bai CH, Wu JC, Hou WH. Efficacy and safety of sodium-glucose cotransporter-2 inhibitors in patients with chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2024; 56:1359-1381. [PMID: 37752340 DOI: 10.1007/s11255-023-03789-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE Owing to the pharmacological mechanism, sodium-glucose cotransporter 2 inhibitors (SGLT2is) may be less effective in patients with reduced renal functions, but no systematic review or meta-analysis addressed chronic kidney disease (CKD) patients specifically. We aimed to assess the efficacy and safety of SGLT2is in CKD patients. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials. Mean difference (MD) were pooled for the decline of glomerular filtration rate (eGFR) and change in urine albumin-to-creatinine ratio (uACR). Hazard ratio (HR) and rate ratio (RR) were pooled for composite of renal outcomes and adverse effects. RESULTS Thirty articles were identified. Overall MD in rate of eGFR decline was 0.02 (P = 0.05), with a borderline significant difference favoring SGLT2is, while the change in uACR from baseline was - 141.34 mg/g and hazard ratio of composite renal outcomes was 0.64 significantly favoring SGLT2is. Subgroup analyses showed that the long-term renal function, participants with baseline macroalbuminuria, and stage 4 CKD patients had significantly slower eGFR decline rate in SGLT2is compared to the placebo group. Risks of genital mycotic infection and ketoacidosis were significantly higher among the SGLT2is group than placebo. CONCLUSION For CKD patients, no matter diabetic or non-diabetic, our study showed potential renoprotective effects favoring SGLT2is in overall and long-term phase, and in patients with macroalbuminuria or stage 4 CKD. However, only slight increased risk of adverse effects among the SGLT2is group is observed. Therefore, we concluded that in CKD patients, prescribing SGLT2is was safe and had renal benefits.
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Affiliation(s)
- Chu-Hsuan Shiau
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Yun Tsau
- Graduate Institute of Clinical Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yu-Ching Peng
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Jeng-Cheng Wu
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan.
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan.
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan.
- Department of Education and Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Wen-Hsuan Hou
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- International Ph.D. Program in Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan.
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22
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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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23
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Sharma A, Inzucchi SE, Testani JM, Ofstad AP, Fitchett D, Mattheus M, Verma S, Zannad F, Wanner C, Kraus BJ. Kidney and heart failure events are bidirectionally associated in patients with type 2 diabetes and cardiovascular disease. ESC Heart Fail 2024; 11:737-747. [PMID: 38155446 DOI: 10.1002/ehf2.14601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/07/2023] [Accepted: 10/31/2023] [Indexed: 12/30/2023] Open
Abstract
AIMS This study aimed to evaluate the bidirectional relationship between kidney and cardiovascular (CV) events in trial participants with type 2 diabetes and CV disease. METHODS AND RESULTS Post hoc analyses of EMPA-REG OUTCOME using Cox regression models were performed to assess the association of baseline factors with risk of a kidney event and bidirectional associations of incident kidney events and CV events. Among placebo-treated participants, baseline factors significantly associated with greater kidney event risk included lower baseline estimated glomerular filtration rate, albuminuria, higher uric acid, low-density lipoprotein cholesterol levels, and prior heart failure (HF). Coronary artery disease was not associated with increased risk. In placebo-treated participants, occurrence of an incident non-fatal kidney event increased the subsequent risk of hospitalization for HF (HHF) but not 3-point major adverse CV events (non-fatal stroke, non-fatal myocardial infarction, and CV death). Vice versa, HHF (but not myocardial infarction/stroke) increased the risk of subsequent kidney events. These associations were generally also seen in empagliflozin-treated participants and in the overall population. Interestingly, the risk of kidney events following HHF was not significantly increased in the relatively small number of placebo-treated participants already diagnosed with HF at baseline. CONCLUSIONS These findings demonstrate a bidirectional inter-relationship between HHF and kidney events. Further exploration of this relationship and strategies to optimize the use of therapies to reduce both kidney and HF outcomes is warranted.
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Affiliation(s)
- Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Anne Pernille Ofstad
- Boehringer Ingelheim Norway KS, Asker, Norway
- Oslo Diabetes Research Center, Oslo, Norway
| | - David Fitchett
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Subodh Verma
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Nancy, France
- INSERM 1116, CHRU de Nancy, FCRIN INI-CRCT, Nancy, France
| | - Christoph Wanner
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Bettina J Kraus
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
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24
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Spasovski G, Rroji M, Hristov G, Bushljetikj O, Spahia N, Rambabova Bushletikj I. A New Hope on the Horizon for Kidney and Cardiovascular Protection with SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Mineralocorticoid Receptor Antagonists in Type 2 Diabetic and Chronic Kidney Disease Patients. Metab Syndr Relat Disord 2024; 22:170-178. [PMID: 38386800 DOI: 10.1089/met.2023.0227] [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] [Indexed: 02/24/2024] Open
Abstract
Type 2 diabetes (T2D) is the leading cause of chronic kidney disease (CKD). In addition, the cardiovascular prevalence in diabetic patients is around 32.2%, with a two-fold increased mortality risk compared to those without diabetes. Recent investigations have shed light on the promising cardioprotective and nephroprotective benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and nonsteroidal mineralocorticoid receptor antagonists (nsMRAs) for individuals with T2D. The evidence robustly indicates that SGLT2i and GLP-1RA significantly reduce the risk of CKD and cardiovascular disease (CVD), all while effectively managing blood glucose levels. Furthermore, combining SGLT2i with nsMRAs amplifies the benefits, potentially offering a more profound reduction in cardiovascular and renal outcomes. The data analysis strongly supports the integration of these pharmacological agents in the management strategies for CKD and CVD prevention among T2D patients, highlighting the importance of awareness among nephrologists, especially in regions with limited healthcare resources.
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Affiliation(s)
- Goce Spasovski
- Department of Nephrology, Medical Faculty, University Sts. Cyril and Methodius, Skopje, North Macedonia
| | - Merita Rroji
- Department of Nephrology, University of Medicine of Tirana, Tirana, Albania
| | - Goce Hristov
- Department of Internal Medicine and Diabetes, General Public Hospital Strumica, Strumica, North Macedonia
| | - Oliver Bushljetikj
- Department of Cardiology, Medical Faculty, University Sts. Cyril and Methodius, Skopje, North Macedonia
| | - Nereida Spahia
- Department of Nephrology, University of Medicine of Tirana, Tirana, Albania
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25
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Trochu JN. Chronic heart failure with reduced EF: A decade of major pharmacological innovations. Presse Med 2024; 53:104219. [PMID: 38072123 DOI: 10.1016/j.lpm.2023.104219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/24/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Because of its severity, prevalence, and medical economic importance, heart failure is a chronic disease that is the subject of intense medical research. The aim of this article was to review the therapeutic innovations of the last decade that have been incorporated into the latest international recommendations for the treatment of heart failure. METHOD Review of literature and current guidelines. CONCLUSION The results of the clinical trials reviewed here represent major advances that will have a significant impact on quality of life, survival, rehospitalisation and, for certain treatments, a beneficial joint effect on commonly associated comorbidities such as diabetes and chronic renal failure.
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Affiliation(s)
- Jean-Noël Trochu
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France.
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26
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Ruzzarin A, Muraglia S, Fabris E, Caretta G, Zilio F, Pezzato A, Campo G, Unterhuber M, Donazzan L. Impact of Contrast-Associated Acute Kidney Injury on One-Year Outcomes in Very Elderly STEMI Patients: Insights From a Multicenter Registry in Northern Italy. Angiology 2024:33197241233771. [PMID: 38379162 DOI: 10.1177/00033197241233771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Data about contrast-associated acute kidney injury (CA-AKI) in oldest old (age ≥85 years) ST-elevation myocardial infarction (STEMI) patients are scarce. We evaluated the incidence and the 1-year prognostic impact of CA-AKI in this population. Patients were included in a multicenter real-world registry, and CA-AKI was defined according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Major adverse cardiac and cerebrovascular events (MACCEs) were defined as the composite of all-cause death, stroke, unplanned coronary revascularization, and heart failure hospitalization. The primary outcome was the incidence and impact of CA-AKI on MACCEs at 1 year follow-up. Out of 461 STEMI patients (mean age 88.6 ± 2.9 years), 102 (22.1%) patients developed CA-AKI. Chronic kidney disease was the strongest predictor of CA-AKI (odds ratio [OR]: 4.52, 95% CI: 2.81-7.30, P < .01). The CA-AKI cohort showed a higher risk of MACCEs (adjusted HR: 1.75, 95% CI: 1.13-2.71, P = .01), driven mainly by all-cause death (adjusted hazard ratio [HR]: 2.39, 95% CI: 1.41-4.07, P = .01) and followed by heart failure hospitalization (adjusted HR: 2.01, 95% CI: 1.08-3.76, P = .01). Among oldest old STEMI, CA-AKI was frequent and associated with a higher incidence of MACCEs at 1-year follow-up.
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Affiliation(s)
| | - Simone Muraglia
- Department of Cardiology, Santa Chiara Hospital, Trento, Italy
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy
| | - Giorgio Caretta
- Sant'Andrea Hospital, ASL 5 Regione Liguria, La Spezia, Italy
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento, Italy
| | - Andrea Pezzato
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
| | | | - Luca Donazzan
- Department of Cardiology, San Maurizio Hospital, Bolzano, Italy
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27
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Doi SN, Thune JJ, Nielsen JC, Haarbo J, Videbæk L, Yafasova A, Bruun NE, Gustafsson F, Eiskjær H, Hassager C, Svendsen JH, Høfsten DE, Torp‐Pedersen C, Pehrson S, Køber L, Butt JH. Estimated Glomerular Filtration Rate and Implantable Cardioverter-Defibrillator in Nonischemic Systolic Heart Failure: Extended Follow-Up of DANISH. J Am Heart Assoc 2024; 13:e031977. [PMID: 38293926 PMCID: PMC11056118 DOI: 10.1161/jaha.123.031977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/29/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Patients with heart failure and chronic kidney disease (CKD) may have an increased risk of death from causes competing with arrhythmic death, which could have implications for the efficacy of implantable cardioverter-defibrillators (ICDs). We examined the long-term effects of primary prophylactic ICD implantation, compared with usual care, according to baseline CKD status in an extended follow-up study of DANISH (Danish Study to Assess the Efficacy of ICDs in Patients With Nonischemic Systolic Heart Failure on Mortality). METHODS AND RESULTS In the DANISH trial, 1116 patients with nonischemic heart failure with reduced ejection fraction were randomized to receive an ICD (N=556) or usual care (N=550). Outcomes were analyzed according to CKD status (estimated glomerular filtration rate ≥/<60 mL/min per 1.73 m2) at baseline. In total, 1113 patients had an available estimated glomerular filtration rate measurement at baseline (median estimated glomerular filtration rate 73 mL/min per 1.73 m2), and 316 (28%) had CKD. During a median follow-up of 9.5 years, ICD implantation, compared with usual care, did not reduce the rate of all-cause mortality (no CKD, HR, 0.82 [95% CI, 0.64-1.04]; CKD, HR, 1.02 [95% CI, 0.75-1.38]; Pinteraction=0.31) or cardiovascular death (no CKD, HR, 0.77 [95% CI, 0.58-1.03]; CKD, HR, 1.05 [95% CI, 0.73-1.51]; Pinteraction=0.20), irrespective of baseline CKD status. Similarly, baseline CKD status did not modify the beneficial effects of ICD implantation on sudden cardiovascular death (no CKD, HR, 0.57 [95% CI, 0.32-1.00]; CKD, HR, 0.65 [95% CI, 0.34-1.24]; Pinteraction=0.70). CONCLUSIONS ICD implantation, compared with usual care, did not reduce the overall mortality rate, but it did reduce the rate of sudden cardiovascular death, regardless of baseline kidney function in patients with nonischemic heart failure with reduced ejection fraction. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00542945.
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MESH Headings
- Humans
- Defibrillators, Implantable/adverse effects
- Heart Failure, Systolic/complications
- Heart Failure, Systolic/therapy
- Follow-Up Studies
- Risk Factors
- Glomerular Filtration Rate
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Heart Failure/diagnosis
- Heart Failure/therapy
- Heart Failure/complications
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/therapy
- Ventricular Dysfunction, Left
- Denmark/epidemiology
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Affiliation(s)
- Seiko N. Doi
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Jens Jakob Thune
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital—Bispebjerg and FrederiksbergCopenhagenDenmark
| | - Jens C. Nielsen
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Jens Haarbo
- Department of CardiologyCopenhagen University Hospital—Herlev and GentofteHellerupDenmark
| | - Lars Videbæk
- Department of CardiologyOdense University HospitalSvendborgDenmark
| | - Adelina Yafasova
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Niels E. Bruun
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
- Department of CardiologyAalborg University HospitalAalborgDenmark
- Department of CardiologyZealand University HospitalRoskildeDenmark
| | - Finn Gustafsson
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Hans Eiskjær
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Christian Hassager
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Jesper H. Svendsen
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Dan E. Høfsten
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Christian Torp‐Pedersen
- Department of CardiologyNordsjællands HospitalHillerødDenmark
- Department of Public HealthUniversity of CopenhagenCopenhagenDenmark
| | - Steen Pehrson
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
| | - Lars Køber
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Jawad H. Butt
- Department of CardiologyCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of CardiologyZealand University HospitalRoskildeDenmark
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28
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Berezin AE, Berezina TA. Plausible prediction of renoprotective effects of sodium-glucose cotransporter-2 inhibitors in patients with chronic kidney diseases. J Int Med Res 2024; 52:3000605241227659. [PMID: 38329077 PMCID: PMC10854388 DOI: 10.1177/03000605241227659] [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: 06/28/2023] [Accepted: 12/20/2023] [Indexed: 02/09/2024] Open
Abstract
This narrative review was conducted due to uncertainty in predicting the beneficial impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors on a dip of estimated glomerular filtration rate (eGFR), regardless of albuminuria presence, with the aim of elucidating plausible predictors of kidney function outcome among patients treated with SGLT2 inhibitors. The PubMed and Web of Science databases were searched in May 2023 for relevant articles published in English between 2013 and 2023. A total of 25 full-length scientific publications (comprising 11 large randomized trials and two cohort studies) were included for analysis. The majority of studies demonstrated a limited value of conventional biomarkers, such as initial decline in eGFR, a trajectory of eGFR during SGLT2 inhibitor administration, and urine albumin-to-creatinine ratio (UACR), in prediction of renoprotection. Included studies showed that the tendency to decreased eGFR, UACR, hemoglobin, glycosylated hemoglobin, lipid profile, serum uric acid, inflammatory biomarkers and natriuretic peptides did not predict clinical outcomes in groups without heart failure (HF) treated with SGLT2 inhibitors. In HF groups, biomarkers of inflammation, kidney injury, oxidative stress, mitochondrial dysfunction, ketogenesis, energy metabolism, and adipose tissue dysfunction (adropin and irisin), were detected with the aim of finding potential biomarkers. Biomarkers of adipose tissue dysfunction and inflammation may be promising for predicting SGLT2 inhibitor benefit compared with N-terminal pro-B-type natriuretic peptide and energy metabolism indicators.
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Affiliation(s)
- Alexander E Berezin
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Tetiana A Berezina
- Department of Internal Medicine and Nephrology, VitaCenter, Zaporozhye, Ukraine
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29
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Greene SJ, Butler J, Kosiborod MN. Chapter 3: Clinical Trials of Sodium-Glucose Co-Transporter-2 Inhibitors for Treatment of Heart Failure. Am J Med 2024; 137:S25-S34. [PMID: 38184323 DOI: 10.1016/j.amjmed.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/18/2023] [Indexed: 01/08/2024]
Abstract
Cardiovascular outcomes trials of sodium-glucose co-transporter-2 (SGLT2) inhibitors have demonstrated consistent signals of benefit in terms of both prevention and treatment of heart failure (HF), in patients with and without type 2 diabetes (T2D). In response to growing evidence of the benefits of SGLT2 inhibitors, including increased survival, reduced hospitalizations and improved patient-reported symptoms, functional status, and quality of life, the treatment landscape for HF has evolved. Importantly, these agents have also demonstrated safety and tolerability in individuals with HF across the spectrum of left ventricular ejection fraction, with improvements in clinical and patient-reported outcomes occurring as early as days to weeks after treatment initiation. For patients with heart failure with reduced ejection fraction (HFrEF), SGLT2 inhibitors are now increasingly recognized as foundational disease-modifying therapy. An updated joint guideline from the American College of Cardiology and American Heart Association now recommends including SGLT2 inhibitors for patients with HF across the spectrum of ejection fraction, irrespective of the presence of diabetes, and regardless of background therapy (Class 1 recommendation for HFrEF, Class 2a recommendation for HF with mildly reduced ejection fraction [HFmrEF] and HF with preserved ejection fraction [HFpEF]). The European Society of Cardiology also include a Class I recommendation to use SGLT2 inhibitors for patients with HFrEF to reduce the risk of hospitalization for HF and CV death, irrespective of T2D status. This chapter reviews published clinical trial data about the efficacy and safety of SGLT2 inhibitors among patients with HFrEF, HFpEF, and patients hospitalized for HF.
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Affiliation(s)
- Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, MS.
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Mo; University of Missouri-Kansas City, Kansas City, Mo
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Kerwagen F, Riemer U, Wachter R, von Haehling S, Abdin A, Böhm M, Schulz M, Störk S. Impact of the COVID-19 pandemic on implementation of novel guideline-directed medical therapies for heart failure in Germany: a nationwide retrospective analysis. THE LANCET REGIONAL HEALTH. EUROPE 2023; 35:100778. [PMID: 38023333 PMCID: PMC10652117 DOI: 10.1016/j.lanepe.2023.100778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023]
Abstract
Background Guideline-directed medical therapy (GDMT) is the cornerstone in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) and novel substances such as sacubitril/valsartan (S/V) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) have demonstrated marked clinical benefits. We investigated their implementation into real-world HF care in Germany before, during, and after the COVID-19 pandemic period. Methods The IQVIA LRx data set is based on ∼80% of 73 million people covered by the German statutory health insurance. Prescriptions of S/V were used as a proxy for HFrEF. Time trends were analysed between Q1/2016 and Q2/2023 for prescriptions for S/V alone and in combination therapy with SGLT2i. Findings The number of patients treated with S/V increased from 5260 in Q1/2016 to 351,262 in Q2/2023. The share of patients with combination therapy grew from 0.6% (29 of 5260) to 14.2% (31,128 of 219,762) in Q2/2021, and then showed a steep surge up to 54.8% (192,429 of 351,262) in Q2/2023, coinciding with the release of the European Society of Cardiology (ESC) guidelines for HF in Q3/2021. Women and patients aged >80 years were treated less often with combined therapy than men and younger patients. With the start of the COVID-19 pandemic, the number of patients with new S/V prescriptions dropped by 17.5% within one quarter, i.e., from 26,855 in Q1/2020 to 22,145 in Q2/2020, and returned to pre-pandemic levels only in Q1/2021. Interpretation The COVID-19 pandemic was associated with a 12-month deceleration of S/V uptake in Germany. Following the release of the ESC HF guidelines, the combined prescription of S/V and SGLT2i was readily adopted. Further efforts are needed to fully implement GDMT and strengthen the resilience of healthcare systems during public health crises. Funding Supported by Novartis Pharma GmbH, Nuremberg, Germany.
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Affiliation(s)
- Fabian Kerwagen
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Germany
| | - Uwe Riemer
- Medical Department, Novartis Pharma GmbH, Nuremberg, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Amr Abdin
- Department of Internal Medicine Clinic III, Saarland University Hospital, Homburg/Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine Clinic III, Saarland University Hospital, Homburg/Saar, Germany
| | - Martin Schulz
- Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
- German Institute for Drug Use Evaluation (DAPI), Berlin, Germany
| | - Stefan Störk
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Germany
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Barua S, Conte SM, Cherrett C, Kearney KL, Robson D, Bragg C, Macdonald PS, Muthiah K, Hayward CS. Major adverse kidney events predict reduced survival in ventricular assist device supported patients. ESC Heart Fail 2023; 10:3463-3471. [PMID: 37712126 PMCID: PMC10682875 DOI: 10.1002/ehf2.14533] [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: 07/22/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
AIMS There is limited data describing major adverse kidney events (MAKE) in patients supported with ventricular assist devices (VAD). We aim to describe the association between MAKE and survival, risk factors for MAKE, and renal trajectory in VAD supported patients. METHODS AND RESULTS We conducted a single-centre retrospective analysis of consecutive VAD implants between 2010 and 2019. Baseline demographics, biochemistry, and adverse events were collected for the duration of VAD support. MAKE was defined as the first event to occur of sustained drop (>50%) in estimated glomerular filtration rate (eGFR), progression to stage V chronic kidney disease, initiation or continuation of renal replacement therapy beyond implant admission or death on renal replacement therapy at any time. One-hundred and seventy-three patients were included, median age 56.8 years, 18.5% female, INTERMACS profile 1 or 2 in 75.1%. Thirty-seven patients experienced MAKE. On multivariate analysis, post-implant clinical right ventricular failure and the presence of chronic haemolysis, defined by the presence of schistocytes on blood film analysis, were significantly associated with increased risk of MAKE (adjusted odds ratio 9.88, P < 0.001 and adjusted odds ratio 3.33, P = 0.006, respectively). MAKE was associated with reduced survival (hazard ratio 4.80, P < 0.001). Patients who died or experienced MAKE did not demonstrate the expected transient 3-month improvement in eGFR, seen in other cohorts. CONCLUSIONS MAKE significantly impacts survival. In our cohort, MAKE was predicted by post-implant right ventricular failure and chronic haemolysis. The lack of early eGFR improvement on VAD support may indicate higher risk for MAKE.
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Affiliation(s)
- Sumita Barua
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Sean M. Conte
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- School of MedicineUniversity of Notre Dame AustraliaSydneyAustralia
| | - Callum Cherrett
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
| | - Katherine L. Kearney
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Desiree Robson
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
| | | | - Peter S. Macdonald
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Kavitha Muthiah
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Christopher S. Hayward
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
- Faculty of HealthUniversity of TechnologySydneyAustralia
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32
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Ter Maaten JM, Mebazaa A, Davison B, Edwards C, Adamo M, Arrigo M, Barros M, Biegus J, Čelutkienė J, Čerlinskaitė-Bajorė K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Leopold V, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Tomasoni D, Metra M, Cotter G, Voors AA. Early changes in renal function during rapid up-titration of guideline-directed medical therapy following an admission for acute heart failure. Eur J Heart Fail 2023; 25:2230-2242. [PMID: 37905361 DOI: 10.1002/ejhf.3074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 11/02/2023] Open
Abstract
AIM In this subgroup analysis of STRONG-HF, we explored the association between changes in renal function and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) according to a high-intensity care (HIC) strategy. METHODS AND RESULTS In patients randomized to the HIC arm (n = 542), renal function was assessed at baseline and during follow-up visits. We studied the association with clinical characteristics and outcomes of a decrease in estimated glomerular filtration rate (eGFR) at week 1, defined as ≥15% decrease from baseline. Patients in the usual care group (n = 536) were seen at day 90. The treatment effect of HIC versus usual care was independent of baseline eGFR (p-interaction = 0.4809). A decrease in eGFR within 1 week occurred in 77 (15.5%) patients and was associated with more rales on examination (p = 0.004), and a higher New York Heart Association class at the corresponding visit. Following the decrease in eGFR at 1 week, lower average optimal doses of GDMT were prescribed during follow-up (p = 0.0210) and smaller reductions in N-terminal pro-B-type natriuretic peptide occurred (geometrical mean 0.81 in no eGFR decrease vs 1.12 in GFR decrease, p = 0.0003). The rate of heart failure (HF) readmission or death at 180 days was 12.3% in no eGFR decrease versus 18.5% in eGFR decrease (p = 0.2274) and HF readmissions were 7.8% versus 16.6% (p = 0.0496). CONCLUSIONS In the STRONG-HF study, HIC reduced 180-day HF readmission or death regardless of baseline eGFR. An early decrease in eGFR during rapid up-titration of GDMT was associated with more evidence of congestion, yet lower doses of GDMT during follow-up.
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Affiliation(s)
- Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine 'Carol Davila', Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, Nancy ; INSERM, Défaillance Circulatoire Aigue et Chronique ; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Carolyn S P Lam
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Valentine Leopold
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | | | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital / Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
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Reyes-Farias CI, Reategui-Diaz M, Romani-Romani F, Prokop L. The effect of sodium-glucose cotransporter 2 inhibitors in patients with chronic kidney disease with or without type 2 diabetes mellitus on cardiovascular and renal outcomes: A systematic review and meta-analysis. PLoS One 2023; 18:e0295059. [PMID: 38019892 PMCID: PMC10686459 DOI: 10.1371/journal.pone.0295059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have shown a favorable effect on cardiovascular and renal outcomes in patients with type 2 diabetes mellitus (T2DM). However, their efficacy in patients with chronic kidney disease (CKD) with or without T2DM has not yet been analyzed. OBJECTIVE To assess the cardiovascular and renal effects of SGLT-2 inhibitors in patients with CKD with and without T2DM, including all CKD patients in the current literature. METHODS We searched MEDLINE, EMBASE, CENTRAL and Scopus for randomized controlled trials of SGLT-2 inhibitors that evaluated cardiovascular and kidney outcomes in patients with CKD, or trials in which these patients were a subgroup. We defined 2 primary outcomes: a composite of cardiovascular death or hospitalization for heart failure, and a composite renal outcome. For each outcome, we obtained overall hazard ratios with 95% confidence intervals by using a random effects model. RESULTS We included 14 randomized controlled trials. SGLT-2 inhibitors decreased the hazard for the primary cardiovascular outcome (HR 0.76; [95% CI 0.72-0.79]) and the primary renal outcome (HR 0.69; [95% CI 0.61-0.79]) in patients with CKD with or without T2DM. We did not find significant differences in the subgroup analyses according to diabetes status, baseline eGFR values or the type of SGLT-2 inhibitor used. CONCLUSION In patients with CKD, treatment with SGLT-2 inhibitors in addition to standard therapy conferred protection against cardiovascular and renal outcomes. Further research on patients with non-diabetic CKD should be done to confirm the utility of these medications in this population. (PROSPERO ID: CRD42021275012).
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Affiliation(s)
| | | | | | - Larry Prokop
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, United States of America
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34
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Mentz RJ, Brunton SA, Rangaswami J. Sodium-glucose cotransporter-2 inhibition for heart failure with preserved ejection fraction and chronic kidney disease with or without type 2 diabetes mellitus: a narrative review. Cardiovasc Diabetol 2023; 22:316. [PMID: 37974185 PMCID: PMC10655322 DOI: 10.1186/s12933-023-02023-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Heart failure (HF), chronic kidney disease (CKD), and type 2 diabetes mellitus (T2DM) are common and interrelated conditions, each with a significant burden of disease. HF and kidney disease progress through pathophysiologic pathways that culminate in end-stage disease, for which T2DM is a major risk factor. Intervention within these pathways can disrupt disease processes and improve patient outcomes. Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been investigated in patient populations with combinations of T2DM, CKD, and/or HF. However, until recently, the effect of these agents in patients with HF with preserved ejection fraction (HFpEF) was not well studied. MAIN BODY The aim of this review is to summarize key information regarding the interaction between HFpEF, CKD, and T2DM and discuss the role of SGLT2 inhibition in the management of patients with comorbid HFpEF and CKD, with or without T2DM. Literature was retrieved using Boolean searches for English-language articles in PubMed and Google Scholar and included terms related to SGLT2is, HFpEF, T2DM, and CKD. The reference lists from retrieved articles were also considered. CONCLUSION SGLT2is are efficacious and safe in treating HFpEF in patients with comorbid CKD with and without T2DM. The totality of evidence from clinical trials data suggests there are benefits in using SGLT2is across the spectrum of left ventricular ejection fractions, but there may be a potential for different renal effects in the different ejection fraction groups. Further analysis of these clinical trials has highlighted the need to obtain more accurate phenotypes for patients with HF and CKD to better determine which patients might respond to guideline-directed medical therapies, including SGLT2is. CI confidence interval, EF ejection fraction, eGFR estimated glomerular filtration rate, HF heart failure, HHF hospitalization for HF, HR hazard ratio, LVEF left ventricular ejection fraction, SGLT2i sodium-glucose cotransporter-2 inhibitor, UACR urine albumin-creatinine ratio. a Mean value, unless otherwise stated, b SGLT2i vs. placebo, c Data reanalyzed using more conventional endpoints (≥ 50% sustained decrease in eGFR, and including renal death) (UACR at baseline not stated in trial reports).
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Affiliation(s)
- Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC, 27710, USA.
| | | | - Janani Rangaswami
- Division of Nephrology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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35
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Chatur S, Vaduganathan M, Claggett BL, Mc Causland FR, Desai AS, Jhund PS, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez FA, Shah SJ, Sabatine MS, Kober L, Ponikowski P, Merkely B, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Dapagliflozin in Patients With Heart Failure and Deterioration in Renal Function. J Am Coll Cardiol 2023; 82:1854-1863. [PMID: 37634707 DOI: 10.1016/j.jacc.2023.08.026] [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: 08/07/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors are guideline recommended in the management of heart failure (HF). Although these therapies can be initiated even in patients with comorbid chronic kidney disease, some patients may face deterioration of kidney function over time. OBJECTIVES In this study, the authors sought to examine the safety and efficacy of continuing SGLT2 inhibitors in HF when the estimated glomerular filtration rate (eGFR) falls below thresholds for initiation. METHODS Associations between a deterioration of eGFR to <25 mL/min/1.73 m2, efficacy, and safety outcomes and treatment with dapagliflozin were evaluated in time-updated Cox proportional hazard models in a participant-level pooled analysis of the DAPA-HF (Study to Evaluate the Effect of Dapagliflozin on the Incidence of Worsening Heart Failure or Cardiovascular Death in Patients With Chronic Heart Failure) and DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trials. RESULTS Among 11,007 patients, 347 (3.2%) experienced a deterioration of eGFR to <25 mL/min/1.73 m2 at least once in follow-up. These patients had a higher risk of the primary composite outcome (HR: 1.87; 95% CI: 1.48-2.35; P < 0.001). The risk of the primary outcome was lower with dapagliflozin compared with placebo among patients who did (HR: 0.53; 95% CI: 0.33-0.83) as well as did not (HR: 0.78; 95% CI: 0.72-0.86) experience deterioration of eGFR to <25 mL/min/1.73 m2 (Pinteraction = 0.17). The risk of safety outcomes, including drug discontinuation, was higher among patients with deterioration of eGFR to <25 mL/min/1.73 m2; however, rates remained similar between treatment groups including among those who remained on study drug. CONCLUSIONS Patients with deterioration of eGFR to <25 mL/min/1.73 m2 had elevated risks of cardiovascular outcomes yet appeared to benefit from continuation of dapagliflozin with no excess in safety outcomes between treatment groups. The benefit-to-risk ratio may favor continuation of dapagliflozin treatment in patients with HF experiencing deterioration of kidney function. Study to Evaluate the Effect of Dapagliflozin on the Incidence of Worsening Heart Failure or Cardiovascular Death in Patients With Chronic Heart Failure [DAPA-HF]; NCT03036124; and Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian R Mc Causland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Rudolf A de Boer
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands
| | | | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri, Kansas City, Missouri, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Marc S Sabatine
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; TIMI Study Group, Boston, Massachusetts, USA
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | | | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, Biopharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, Biopharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Bakbak E, Verma S, Krishnaraj A, Quan A, Wang CH, Pan Y, Puar P, Mason T, Verma R, Terenzi DC, Rotstein OD, Yan AT, Connelly KA, Teoh H, Mazer CD, Hess DA. Empagliflozin improves circulating vascular regenerative cell content in people without diabetes with risk factors for adverse cardiac remodeling. Am J Physiol Heart Circ Physiol 2023; 325:H1210-H1222. [PMID: 37773589 DOI: 10.1152/ajpheart.00141.2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023]
Abstract
Sodium glucose-cotransporter 2 (SGLT2) inhibitors have been reported to reduce cardiovascular events and heart failure in people with and without diabetes. These medications have been shown to counter regenerative cell exhaustion in the context of prevalent diabetes. This study sought to determine if empagliflozin attenuates regenerative cell exhaustion in people without diabetes. Peripheral blood mononuclear cells were collected at the baseline and 6-mo visits from individuals randomized to receive empagliflozin (10 mg/day) or placebo who were participating in the EMPA-HEART 2 CardioLink-7 trial. Precursor cell phenotypes were characterized by flow cytometry for cell-surface markers combined with high aldehyde dehydrogenase activity to identify precursor cell subsets with progenitor (ALDHhi) versus mature effector (ALDHlow) cell attributes. Samples from individuals assigned to empagliflozin (n = 25) and placebo (n = 21) were analyzed. At baseline, overall frequencies of primitive progenitor cells (ALDHhiSSClow), monocyte (ALDHhiSSCmid), and granulocyte (ALDHhiSSChi) precursor cells in both groups were similar. At 6 mo, participants randomized to empagliflozin demonstrated increased ALDHhiSSClowCD133+CD34+ proangiogenic cells (P = 0.048), elevated ALDHhiSSCmidCD163+ regenerative monocyte precursors (P = 0.012), and decreased ALDHhiSSCmidCD86 + CD163- proinflammatory monocyte (P = 0.011) polarization compared with placebo. Empagliflozin promoted the recovery of multiple circulating provascular cell subsets in people without diabetes suggesting that the cardiovascular benefits of SGLT2 inhibitors may be attributed in part to the attenuation of vascular regenerative cell exhaustion that is independent of diabetes status.NEW & NOTEWORTHY Using an aldehyde dehydrogenase (ALDH) activity-based flow cytometry assay, we found that empagliflozin treatment for 6 mo was associated with parallel increases in circulating vascular regenerative ALDHhi-CD34/CD133-coexpressing progenitors and decreased proinflammatory ALDHhi-CD14/CD86-coexpressing monocyte precursors in individuals without diabetes but with cardiovascular risk factors. The rejuvenation of the vascular regenerative cell reservoir may represent a mechanism via which sodium glucose-cotransporter 2 (SGLT2) inhibitors limit maladaptive repair and delay the development and progression of cardiovascular diseases.
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Affiliation(s)
- Ehab Bakbak
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Subodh Verma
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aishwarya Krishnaraj
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Chao-Hung Wang
- Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi Pan
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Pankaj Puar
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tamique Mason
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Raj Verma
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Ori D Rotstein
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Andrew T Yan
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Division of Cardiology, St Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kim A Connelly
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Division of Cardiology, St Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David A Hess
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Molecular Medicine Research Laboratories, Robarts Research Institute, London, Ontario, Canada
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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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Roddick AJ, Wonnacott A, Webb D, Watt A, Watson MA, Staplin N, Riding A, Lioudaki E, Kuverji A, Kossi ME, Holmes P, Holloway M, Fraser D, Carvalho C, Burton JO, Bhandari S, Herrington WG, Frankel AH. UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease 2023 UPDATE. BMC Nephrol 2023; 24:310. [PMID: 37880609 PMCID: PMC10598949 DOI: 10.1186/s12882-023-03339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/19/2023] [Indexed: 10/27/2023] Open
Abstract
Large placebo-controlled trials have demonstrated kidney and cardiovascular clinical benefits of SGLT-2 inhibitors. Data from the EMPA-KIDNEY and DELIVER trials and associated meta-analyses triggered an update to the UK Kidney Association Clinical Practice Guideline on Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease. We provide a summary of the full guideline and highlight the rationale for recent updates. The use of SGLT-2 inhibitors in people with specific medical conditions, including type 1 diabetes, kidney transplants, and people admitted to hospital with heart failure is also considered, along with Recommendations for future research and Recommendations for implementation. A full "lay" summary of the guidelines is provided as an appendix to ensure that these guidelines are accessible and understandable to people who are not medical professionals.
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Affiliation(s)
- Alistair J Roddick
- The Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - David Webb
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, UK
| | | | | | - Natalie Staplin
- The Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, UK
| | - Alex Riding
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Apexa Kuverji
- John Walls Renal Unit, Glenfield Hospital, Leicester, UK
| | | | | | - Matt Holloway
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Donald Fraser
- Wales Kidney Research Unit, Cardiff University, Cardiff, UK
| | - Chris Carvalho
- North East London Integrated Care Board, London, UK
- Clinical Effectiveness Group, Queen Mary University of London, London, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Sunil Bhandari
- Hull University Teaching Hospitals NHS Trust and Hull York Medical School, Hull, UK
| | - William G Herrington
- The Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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39
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Ogura A, Izawa KP, Tawa H, Wada M, Kanai M, Kubo I, Makihara A, Yoshikawa R, Matsuda Y. Determinants of Anaerobic Threshold at Each Stage of Renal Dysfunction in Patients With Heart Disease. Am J Cardiol 2023; 205:387-392. [PMID: 37689043 DOI: 10.1016/j.amjcard.2023.07.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 09/11/2023]
Abstract
Patients with heart disease have a low anaerobic threshold (AT), and the determinants of AT may differ, depending on the severity of renal dysfunction. This study aimed to verify the determinants of AT for each stage of renal function in patients with heart disease. We consecutively enrolled 250 patients with heart disease who underwent cardiopulmonary exercise testing in our institution. The patients were divided into 3 groups by their estimated glomerular filtration rate (eGFR): <45, 45 to 59, and ≥60 ml/min/1.73 m2. A multivariate linear regression analysis was performed to evaluate the independent determinants of AT for each group. In total, 201 patients were analyzed. AT decreased with the deterioration of renal function (eGFR <45, 10.9 ± 2.1 vs eGFR 45 to 59, 12.4 ± 2.5 vs eGFR ≥60, 14.0 ± 2.6 ml/min/kg, p <0.001). In the eGFR <45 group, left ventricular ejection fraction and hemoglobin were significantly associated with AT (β = 0.427, p = 0.006 and β = 0.488, p = 0.002, respectively). In the eGFR 45 to 59 and ≥60 groups, ΔPETO2 (end-tidal oxygen partial pressure from rest to AT) showed a significant association with AT (β = 0.576, p <0.001 and β = 0.308, p = 0.003, respectively). The determinants of AT depended on the stage of renal dysfunction in patients with heart disease. In conclusion, in the eGFR <45 group, the determinants of AT were left ventricular ejection fraction and hemoglobin, whereas in the eGFR 45 to 59 and eGFR ≥60 groups, the determinant of AT was ΔPETO2.
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Affiliation(s)
- Asami Ogura
- Departments of Rehabilitation, Sanda City Hospital, Hyogo, Japan; Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | - Kazuhiro P Izawa
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan.
| | - Hideto Tawa
- Departments of Cardiology, Sanda City Hospital, Hyogo, Japan
| | - Masaaki Wada
- Departments of Rehabilitation, Sanda City Hospital, Hyogo, Japan
| | - Masashi Kanai
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | - Ikko Kubo
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | - Ayano Makihara
- Department of Public Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan; Cardiovascular Stroke Renal Project (CRP), Hyogo, Japan
| | | | - Yuichi Matsuda
- Departments of Cardiology, Sanda City Hospital, Hyogo, Japan
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40
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Lv J, Guo L, Wang R, Chen J. Efficacy and Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Nondiabetic Patients with Chronic Kidney Disease: A Review of Recent Evidence. KIDNEY DISEASES (BASEL, SWITZERLAND) 2023; 9:326-341. [PMID: 37901712 PMCID: PMC10601939 DOI: 10.1159/000530395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/20/2023] [Indexed: 10/31/2023]
Abstract
Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) were initially developed as glucose-lowering agents in patients with type-2 diabetes. However, available data from clinical trials and meta-analyses suggest that SGLT2i have pleiotropic benefits in reducing mortality and delaying the progression of chronic kidney disease (CKD) in both diabetic and nondiabetic patients. Thus, we herein review the current evidence regarding the efficacy and safety of SGLT2i in patients with nondiabetic CKD and appraise the recently reported clinical trials that might facilitate the management of CKD in routine clinical practice. Summary The benefits of SGLT2i on nondiabetic CKD are multifactorial and are mediated by a combination of mechanisms. The landmark DAPA-CKD trial revealed that dapagliflozin administered with renin-angiotensin system blockade drugs reduced the risk of a sustained decline (at least 50%) in the estimated glomerular filtration rate, end-stage kidney disease, or death from cardiorenal causes. The recent EMPA-KIDNEY trial showed that empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes. These benefits were consistent in patients with and without diabetes. Moreover, a meta-analysis of DAPA-HF and EMPEROR-Reduced trials confirmed reductions in the combined risk of cardiovascular death or worsening heart failure including composite renal endpoint. Key Messages Considering the robust data available from DAPA-CKD, EMPA-KIDNEY, and other trials such as EMPEROR-Preserved, DIAMOND that included nondiabetic patients, it may be necessary to update current guidelines to include SGLT2i as a first-line therapy for CKD and reevaluate current CKD therapeutic approaches.
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Affiliation(s)
- Junhao Lv
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Luying Guo
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
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Mavrakanas TA, Tsoukas MA, Brophy JM, Sharma A, Gariani K. SGLT-2 inhibitors improve cardiovascular and renal outcomes in patients with CKD: a systematic review and meta-analysis. Sci Rep 2023; 13:15922. [PMID: 37741858 PMCID: PMC10517929 DOI: 10.1038/s41598-023-42989-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/17/2023] [Indexed: 09/25/2023] Open
Abstract
The effect of sodium-glucose co-transporter-2 (SGLT-2) inhibitors on cardiovascular and renal outcomes has not been systematically reviewed across baseline kidney function groups. We conducted a systematic review and meta-analysis of randomized control trials (RCTs) with SGLT-2 inhibitors in patients with and without CKD. We performed a PubMed/Medline search of randomized, placebo-controlled, event-driven outcome trials of SGLT-2 inhibitors versus active or placebo control in patients with and without diabetes from inception to November 2022. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2 (PROSPERO registration CRD4202016054). The primary outcome was cardiovascular death. Secondary outcomes included hospitalization for heart failure, major adverse cardiovascular events, CKD progression, all-cause mortality, treatment discontinuation, and acute kidney injury (AKI). The relative risk (RR) was estimated using a random-effects model. Twelve RCTs were included in this meta-analysis (89,191 patients, including 38,949 with eGFR < 60 ml/min/1.73m2). Use of an SGLT-2 inhibitor in patients with CKD was associated with a lower incidence of cardiovascular death (RR 0.87; 95% CI 0.79-0.95) and of heart failure (RR 0.67; 95% CI 0.61-0.75), compared with placebo. Heart failure risk reduction with SGLT-2 inhibitors was larger among patients with CKD compared with patients without CKD (RR for the interaction 0.87, 95% CI 0.75-1.02, and p-value for interaction 0.08). SGLT-2 inhibitors were associated with a lower incidence of CKD progression among patients with pre-existing CKD: RR 0.77 (95% CI 0.68-0.88), compared with placebo. Among patients with CKD, a lower risk of AKI (RR 0.82; 95% CI 0.72-0.93) and treatment discontinuation was seen with SGLT-2 inhibitors compared with placebo. SGLT-2 inhibitors offer substantial protection against cardiovascular and renal outcomes in patients with CKD. These results strongly advocate in favor of using them in patients with CKD and keeping them as kidney function declines.
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Affiliation(s)
- Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Center Research Institute|CORE|Office 2B.44, 5252 de Maisonneuve West, Montreal, QC, H4A 3S9, Canada.
| | - Michael A Tsoukas
- Division of Endocrinology, McGill University Health Centre, Montreal, QC, Canada
| | - James M Brophy
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
| | - Karim Gariani
- Division of Endocrinology, Diabetes, Nutrition and Patient Therapeutic Education, Geneva University Hospitals, Geneva, GE, Switzerland
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42
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Iacoviello M, Marini M, Gori M, Orso F, Gonzini L, Gorini M, Fenici P, Maggioni AP. DAPA-HF applicability: the point of view of a cardiology setting. Acta Cardiol 2023; 78:840-845. [PMID: 37605991 DOI: 10.1080/00015385.2023.2243130] [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: 02/01/2023] [Revised: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023]
Abstract
Randomised clinical trials, observational studies, and meta-analyses have shown that sodium-glucose cotransporter 2 inhibitors (SGLT2-i) reduce the risk of hospitalisation for heart failure (HF), chronic kidney disease (CKD) progression, and mortality in patients with HF, irrespective of the presence of type 2 diabetes mellitus. However, real-world epidemiology may differ from clinical trial populations, thereby limiting generalisability and delaying the introduction of novel treatments in clinical practice.The aim of the present study was to assess the prevalence of DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) inclusion criteria in a population of HF with reduced ejection fraction (HFrEF) patients enrolled in the Italian Network on Heart Failure (IN-HF) registry.Overall, 3415 IN-HF patients matched the 4744 patients in DAPA-HF, overlapping for most baseline characteristics (e.g. similar average ejection fraction), with a slightly lower prevalence of type 2 diabetes and of HF ischaemic aetiology and a higher percentage of NYHA class II patients. The theoretical eligibility to DAPA-HF in a cardiology setting resulted to be 73%.The availability of an easily accessible database from a large nationwide prospective registry allows to provide insights to clinicians and policy makers on the applicability of the DAPA HF findings to a contemporary population of HFrEF patients followed by cardiologists. It is reasonable to assume that the results of this analysis can be applicable to the entire SGLT2-ir class of drugs.
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Affiliation(s)
- Massimo Iacoviello
- Medical and Surgical Sciences Department, University of Foggia, Foggia, Italy
| | - Marco Marini
- Cardiovascular Sciences Cardiology Department, Ospedali Riuniti, Ancona, Italy
| | - Mauro Gori
- Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Orso
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lucio Gonzini
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Marco Gorini
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Peter Fenici
- Catholic University of the Sacred Heart, School of Medicine and Surgery, Rome, Italy
- Biomagnetism and Clinical Physiology International Center (BACPIC), Rome, Italy
- Medical Affairs, AstraZeneca S.p.A, Milan, Italy
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Sharma A, Ferreira JP, Zannad F, Pocock SJ, Filippatos G, Pfarr E, Petrini M, Kraus BJ, Wanner C, Packer M, Butler J, Anker SD. Cardiac and kidney benefits of empagliflozin in heart failure across the spectrum of kidney function: Insights from the EMPEROR-Preserved trial. Eur J Heart Fail 2023; 25:1337-1348. [PMID: 37062851 DOI: 10.1002/ejhf.2857] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/24/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023] Open
Abstract
AIM In the EMPEROR-Preserved trial, empagliflozin improved clinical outcomes of patients with heart failure (HF) with preserved ejection fraction. In this pre-specified analysis, we aim to study the effect of empagliflozin on cardiovascular and kidney outcomes across the spectrum of kidney function. METHODS AND RESULTS Patients were categorized by the presence or absence of chronic kidney disease (CKD) at baseline (CKD defined by an estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m2 or urine albumin to creatinine ratio >300 mg/g). The primary and key secondary outcomes were (i) a composite of cardiovascular death or first HF hospitalization (primary outcome); (ii) total number of HF hospitalization, (iii) eGFR slope; and a pre-specified exploratory composite kidney outcome including a sustained ≥40% decline in eGFR, chronic dialysis or renal transplant. The median follow-up was 26.2 months. A total of 5988 patients were randomized to empagliflozin or placebo, of whom 3198 (53.5%) had CKD. Irrespective of CKD status, empagliflozin reduced the primary outcome (with CKD: hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.69-0.94; without CKD: HR 0.75, 95% CI 0.60-0.95; interaction p = 0.67) and total (first and recurrent) hospitalizations for HF (with CKD: HR 0.68, 95% CI 0.54-0.86; without CKD: HR 0.89, 95% CI 0.66-1.21; interaction p = 0.17). Empagliflozin slowed the slope of eGFR decline by 1.43 (1.01-1.85) ml/min/1.73 m2 /year in patients with CKD and 1.31 (0.88-1.74) ml/min/1.73 m2 /year in patients without CKD (interaction p = 0.70). Empagliflozin did not reduce the pre-specified kidney outcome in patients with or without CKD (with CKD: HR 0.97, 95% CI 0.71-1.34; without CKD: HR 0.92, 95% CI 0.58-1.48; interaction p = 0.86) but slowed progression to macroalbuminuria and reduced the risk of acute kidney injury. The effect of empagliflozin on the primary composite outcome and the key secondary outcomes was consistent across five baseline eGFR categories (all interaction p >0.05). Empagliflozin was well tolerated independent of CKD status. CONCLUSIONS In EMPEROR-Preserved, empagliflozin had a beneficial effect on the key efficacy outcomes in patients with and without CKD. Overall, the benefit and safety of empagliflozin was consistent across a wide range of kidney function spectrum, down to a baseline eGFR of 20 ml/min/1.73 m2 .
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Affiliation(s)
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Porto, Portugal
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | | | - Bettina J Kraus
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin, Germany
- Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
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44
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Voordes G, Damman K. Sodium-glucose cotransporter 2 inhibitors in heart failure with preserved ejection fraction: Treat the heart, cherish the kidney. Eur J Heart Fail 2023; 25:1349-1351. [PMID: 37403710 DOI: 10.1002/ejhf.2963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023] Open
Affiliation(s)
- Geert Voordes
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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45
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Thomas MC, Neuen BL, Twigg SM, Cooper ME, Badve SV. SGLT2 inhibitors for patients with type 2 diabetes and CKD: a narrative review. Endocr Connect 2023; 12:e230005. [PMID: 37159343 PMCID: PMC10448577 DOI: 10.1530/ec-23-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently emerged as an effective means to protect kidney function in people with type 2 diabetes and chronic kidney disease (CKD). In this review, we explore the role of SGLT2 inhibition in these individuals. SGLT2 inhibitors specifically act to inhibit sodium and glucose reabsorption in the early proximal tubule of the renal nephron. Although originally developed as glucose-lowering agents through their ability to induce glycosuria, it became apparent in cardiovascular outcome trials that the trajectory of kidney function decline was significantly slowed and the incidence of serious falls in kidney function was reduced in participants receiving an SGLT2 inhibitor. These observations have recently led to specific outcome trials in participants with CKD, including DAPA-CKD, CREDENCE and EMPA-KIDNEY, and real-world studies, like CVD-REAL-3, that have confirmed the observation of kidney benefits in this setting. In response, recent KDIGO Guidelines have recommended the use of SGLT2 inhibitors as first-line therapy in patients with CKD, alongside statins, renin-angiotensin-aldosterone system inhibitors and multifactorial risk factor management as indicated. However, SGLT2 inhibitors remain significantly underutilized in the setting of CKD. Indeed, an inertia paradox exists, with patients with more severe disease less likely to receive an SGLT2 inhibitor. Concerns regarding safety appear unfounded, as acute kidney injury, hyperkalaemia, major acute cardiovascular events and cardiac death in patients with CKD appear to be lower following SGLT2 inhibition. The first-in-class indication of dapagliflozin for CKD may begin a new approach to managing kidney disease in type 2 diabetes.
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Affiliation(s)
- Merlin C Thomas
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Stephen M Twigg
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia
- Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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Rolek B, Haber M, Gajewska M, Rogula S, Pietrasik A, Gąsecka A. SGLT2 Inhibitors vs. GLP-1 Agonists to Treat the Heart, the Kidneys and the Brain. J Cardiovasc Dev Dis 2023; 10:322. [PMID: 37623335 PMCID: PMC10455499 DOI: 10.3390/jcdd10080322] [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: 07/09/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/26/2023] Open
Abstract
Sodium glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like-peptide-1 receptor (GLP-1-R) agonists are novel therapeutic agents used for the management of type 2 diabetes mellitus (T2DM). Recently, large-scale randomized clinical trials have been conducted to assess the cardiovascular safety of these medications. The findings of these trials have revealed that both SGLT2 inhibitors and GLP-1-R agonists exhibit favorable cardioprotective effects, including reduction in cardiovascular and all-cause mortality, a decreased risk of chronic kidney disease progression, a decrease in hospitalization for heart failure (HF), an effect shown by SGLT2 inhibitors, and stroke prevention, an effect shown by GLP-1-R agonists. Based on the results from above studies, the European and American Diabetes Associations have issued new recommendations strongly endorsing the use of SGLT2 inhibitors and GLP-1-R agonists in combination with metformin for patients with T2DM who have additional cardiovascular (CV) comorbidities or risk factors. The primary aim of this combined therapy is to prevent CV events. Although both medication groups offer beneficial effects, they demonstrate slightly different profiles. SGLT2 inhibitors have exhibited better effects regarding a reduced incidence of HF, whereas GLP-1-R agonists have shown a reduced risk of CV events, particularly stroke. Moreover, recent European Society of Cardiology as well as American College of Cardiology and American Heart Association guidelines of HF treatment stressed the importance of SGLT2 inhibitor administration in patients with HF regardless of T2DM. In this context, we present and discuss the outcomes of the most recent trials investigating the impact of SGLT2 inhibitors and GLP-1-R agonists on renal and cardiovascular outcomes in patients, both with and without T2DM. Additionally, we explore the synergistic effects of combining SGLT2 inhibitors and GLP-1-R agonists in patients with cardiovascular disease.
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Affiliation(s)
| | | | | | - Sylwester Rogula
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (B.R.); (M.H.); (M.G.); (A.P.); (A.G.)
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Meng J, Huang F, Shi J, Zhang C, Feng L, Wang S, Li H, Guo Y, Hu X, Li X, He W, Cheng J, Wu Y. Integrated biomarker profiling of the metabolome associated with type 2 diabetes mellitus among Tibetan in China. Diabetol Metab Syndr 2023; 15:146. [PMID: 37393287 DOI: 10.1186/s13098-023-01124-8] [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: 05/09/2023] [Accepted: 06/25/2023] [Indexed: 07/03/2023] Open
Abstract
INTRODUCTION Metabolomic signatures of type 2 diabetes mellitus (T2DM) in Tibetan Chinese population, a group with high diabetes burden, remain largely unclear. Identifying the serum metabolite profile of Tibetan T2DM (T-T2DM) individuals may provide novel insights into early T2DM diagnosis and intervention. METHODS Hence, we conducted untargeted metabolomics analysis of plasma samples from a retrospective cohort study with 100 healthy controls and 100 T-T2DM patients by using liquid chromatography-mass spectrometry. RESULTS The T-T2DM group had significant metabolic alterations that are distinct from known diabetes risk indicators, such as body mass index, fasting plasma glucose, and glycosylated hemoglobin levels. The optimal metabolite panels for predicting T-T2DM were selected using a tenfold cross-validation random forest classification model. Compared with the clinical features, the metabolite prediction model provided a better predictive value. We also analyzed the correlation of metabolites with clinical indices and found 10 metabolites that were independently predictive of T-T2DM. CONCLUSION By using the metabolites identified in this study, we may provide stable and accurate biomarkers for early T-T2DM warning and diagnosis. Our study also provides a rich and open-access data resource for optimizing T-T2DM management.
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Affiliation(s)
- Jinli Meng
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Fangfang Huang
- Hubei University of Chinese Medicine, Wuhan, 430065, China
| | - Jing Shi
- Department of Science and Education Section, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Chenghui Zhang
- Department of Endocrinology and Metabolism, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Li Feng
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Suyuan Wang
- Department of Endocrinology and Metabolism, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Hengyan Li
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Yongyue Guo
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Xin Hu
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Xiaomei Li
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Wanlin He
- Department of Radiology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China
| | - Jian Cheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Yunhong Wu
- Department of Endocrinology and Metabolism, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), No. 20, Xi Mian Qiao Heng Jie, Wuhou District, Chengdu, Sichuan, China.
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Dwyer JP, Agiro A, Desai P, Cremisi H. Short-term costs in patients with chronic kidney disease treated with dapagliflozin: a retrospective cohort study. Expert Rev Pharmacoecon Outcomes Res 2023; 23:1057-1066. [PMID: 37540162 DOI: 10.1080/14737167.2023.2237679] [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: 06/06/2023] [Accepted: 07/12/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES This real-world study evaluated the impact of dapagliflozin on short-term medical costs in patients with stage 3 chronic kidney disease (CKD). METHODS This retrospective, observational cohort study used medical and pharmacy claims data from IQVIA PharMetrics Plus. Patients aged ≥18 years with a filled dapagliflozin prescription after stage 3 CKD diagnosis between September 2020 and December 2021 were 1:1 propensity score matched with patients with stage 3 CKD who did not receive dapagliflozin. The primary endpoint was cardiorenal medical costs to payers over 6 months; all-cause medical and pharmacy costs were also analyzed. Within the overall population, there was a new-user subgroup of patients with no sodium-glucose co-transporter-2 use during baseline. RESULTS The new-user subgroup included 503 matched patients per cohort. Mean per-patient cardiorenal medical costs were reduced by 49.0% in the dapagliflozin versus non-dapagliflozin cohort ($3172.15 vs $6219.50; P < 0.001). Mean all-cause medical costs were reduced ($8043.58 vs $12,194.87; P < 0.001) and mean all-cause pharmacy costs were increased ($9056.98 vs $7453.23; P = 0.22). Results were similar for the overall population. CONCLUSION This study showed dapagliflozin was associated with reduced cardiorenal medical costs over 6 months compared with no dapagliflozin treatment in patients with stage 3 CKD, demonstrating real-world medical cost savings.
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Affiliation(s)
- Jamie P Dwyer
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Abiy Agiro
- US Evidence, US Medical Affairs, AstraZeneca, Wilmington, DE, USA
| | - Pooja Desai
- US Renal, US Medical Affairs, AstraZeneca, Wilmington, DE, USA
| | - Henry Cremisi
- US Renal, US Medical Affairs, AstraZeneca, Wilmington, DE, USA
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Jhund PS. Improving heart failure outcomes with sodium-glucose cotransporter 2 inhibitors in different patient groups. Diabetes Obes Metab 2023; 25 Suppl 3:26-32. [PMID: 37334518 PMCID: PMC10946463 DOI: 10.1111/dom.15171] [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: 02/24/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/20/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT-2is) were originally developed for the treatment of hyperglycaemia in type 2 diabetes. Because of regulatory requirements to show the safety of this new class of drugs, a large randomized cardiovascular (CV) outcomes trial was completed but this showed that instead of having a neutral effect on heart failure (HF) outcomes, that these drugs could reduce HF outcomes in this population. Subsequent trials with SGLT-2is have shown that HF hospitalizations are reduced by 30% and CV death or HF hospitalization by 21% in patients with type 2 diabetes. These findings have extended to patients with HF with reduced and mildly reduced or preserved ejection fraction in whom further HF hospitalizations are reduced by 28% and CV death or HF hospitalizations reduced by 23%, and that it is becoming a central therapy for the treatment of HF. Moreover, the benefit in patients with HF is observed regardless of the presence or absence of type 2 diabetes. Similarly, in patients with chronic kidney disease and albuminuria, with and without type 2 diabetes, the benefit of SGLT-2is is clearly seen with a 44% reduction in HF hospitalization and 25% reduction in CV death or HF hospitalization. These trials support the use of SGLT-2is in improving HF outcomes in a broad range of patients, from those with type 2 diabetes, chronic kidney disease and those with pre-existing HF regardless of ejection fraction.
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Affiliation(s)
- Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic HealthUniversity of GlasgowGlasgowUK
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50
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Calderón Montero A. [Evidence of iSGLT2 in the treatment of chronic kidney disease]. Semergen 2023; 49 Suppl 1:102019. [PMID: 37355296 DOI: 10.1016/j.semerg.2023.102019] [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: 12/14/2022] [Accepted: 02/02/2023] [Indexed: 06/26/2023]
Abstract
The prevalence and incidence of chronic kidney disease (CKD) is constantly on the rise and it is foreseeable that in the coming decades it will be the main chronic disease in the developed world. CKD is also one of the main causes of cardiovascular morbidity and mortality, with cardiovascular diseases being the main etiology of CKD, so that one and the other feed back into what is known as the cardiorenal axis. Until five years ago, the only pharmacological treatment that had been shown to modify the course of the disease were inhibitors of the renin angiotensin system. However, in recent years, the development of inhibitors of the sodium glucose cotransporter type2 have led to a revolution in cardiovascular and renal protection, both in diabetic and non-diabetic patients, constituting, at present, the cornerstone in the CKD management.
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