Effect of Dapagliflozin on Heart Failure and Mortality in Type 2 Diabetes Mellitus

Sodium-Glucose Co-transporter-2 Inhibitors in Heart Failure with Preserved Ejection Fraction: A Breakthrough in Improvement of Clinical Outcomes?

The conventional conception of the therapy of heart failure (HF) with reduced ejection fraction has been recently modified by adding sodium-glucose co-transporter-2 (SGLT2) inhibitors to the combination consisting of beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors, with the aim of improving clinical outcomes. It remains unclear whether other sub-populations of patients with HF, having either HF with preserved ejection fraction (HFpEF) or HF with mildly reduced ejection fraction, are relevant candidates for the effective therapeutic intervention that includes SGLT2 inhibitors. The purpose of the narrative review is to elucidate plausible perspectives for the clinical implementation of SGLT2 inhibitors into optimal medical therapy in patients with HFpEF. The authors searched the bibliographic databases (Embase, Medline, and the Web of Science) and the Cochrane Central to find English-written publications satisfying the purpose of this study. The authors included eight studies and two meta-analyses that have been reported as completed and found that there were high heterogeneous data regarding the fact that SGLT2 inhibitors had strict resemblance in their efficacy among patients with HFpEF with and without Type 2 diabetes. Due to the use of unpublished data and findings from the trials ended early, there is a lack of upper left ventricular ejection fraction threshold levels to identify inclusion criteria and no agreement in heart failure with reduced ejection fraction determination. However, the results of the meta-analysis, especially come from subgroups’ analysis, appeared to be relevantly optimistic for use of SGLT2 inhibitors in HFpEF therapy.

Eligibility for dapagliflozin and empagliflozin in a real-world heart failure population

BACKGROUND

We investigated eligibility for dapagliflozin and empagliflozin in a real-world heart failure (HF) cohort based on selection criteria of DAPA-HF, DELIVER, and EMPEROR trials.

METHODS AND RESULTS

Selection criteria were applied to the Swedish HF registry out-patient population according to three scenarios: (i) a "trial scenario" applying all selection criteria; (ii) a "pragmatic scenario" applying the most clinically relevant criteria; (iii) a "label scenario" following the regulatory agencies labels. Of 49,317 patients, 55% had ejection fraction (EF)<40% and were assessed for eligibility based on DAPA-HF and EMPEROR-Reduced, 45% had EF≥40% and were assessed based on EMPEROR-Preserved and DELIVER. Eligibility using trial, pragmatic and label scenarios was: 35%, 61% and 80% for DAPA-HF; 31%, 55% and 81% for EMPEROR-Reduced; 30%, 61% and 74% for DELIVER; 32%, 59% and 75% for EMPEROR-Preserved. Main selection criteria limiting eligibility were HF duration and NT-proBNP. Eligible patients had more severe HF, more comorbidities, higher use of HF treatments and higher mortality/morbidity.

CONCLUSIONS

In a real-world HF setting, eligibility for SGLT2i was similar whether selection criteria from DAPA-HF or EMPEROR-Reduced were applied in HFrEF, or EMPEROR-Preserved or DELIVER in HFpEF. These data might help stakeholders assessing the consequences of future trial eligibility.

Diabetes leading to heart failure and heart failure leading to diabetes: epidemiological and clinical evidence

Type 2 diabetes mellitus (T2DM) is a risk factor that plays a major role in the onset of heart failure (HF) both directly, by impairing cardiac function, and indirectly, through associated diseases such as hypertension, coronary disease, renal dysfunction, obesity, and other metabolic disorders. In a population of HF patients, the presence of T2DM ranged from 20 to 40%, according to the population studied, risk factor characteristics, geographic area, and age, and it is associated with a worse prognosis. Finally, patients with HF, when compared with those without HF, show an increased risk for the onset of T2DM due to several mechanisms that predispose the HF patient to insulin resistance. Despite the epidemiological data confirmed the relationship between T2DM and HF, the exact prevalence of HF in T2DM comes from interventional trials rather than from observational registries aimed to prospectively evaluate the risk of HF occurrence in T2DM population. This review is focused on the vicious cycle linking HF and T2DM, from epidemiological data to prognostic implications.

Knockdown of ILK Alleviates High Glucose-Induced Damage of H9C2 Cells through TLR4/MyD88/NF-κB Pathway

The aim of this study was to explore the role of ILK in an in vitro model of diabetic cardiomyopathy. We used 30 mmol/L high glucose to treat H9C2 cells to construct an in vitro model, knocked down the ILK expression level of H9C2 cells by small interference technology, and detected the activity of antioxidant enzymes and inflammatory factors in the supernatant. The expression levels of SOD1 and IL-1β were detected by immunofluorescence staining. The expression levels of the TLR4/MyD88/NF-κB signaling pathway and its downstream factors were detected by quantitative reverse-transcription polymerase chain reaction (qRT-PCR). Compared with the control group, after high-glucose culture of H9C2 cells, the cell activity decreased, while the apoptosis rate increased, with the TLR4/MyD88/NF-κB signaling pathway activated, thereby inducing oxidative stress and inflammation. Compared with the high-glucose group, the HG+si-ILK group increased cell activity, decreased the apoptosis rate, and inhibited the excessive activation of the TLR4/MyD88/NF-κB signaling pathway, thereby improving oxidative stress and inflammation. Knockdown of ILK expression can protect H9C2 cells from reducing high glucose-induced inflammation, oxidative stress, and apoptosis by inhibiting the TLR4/MyD88/NF-κB signaling pathway.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Benefit of sodium-glucose cotransporter-2 inhibitors on survival outcome is related to the type of heart failure: A meta-analysis

AIMS

This meta-analysis aimed to evaluate the efficacy of sodium-glucose cotransporter-2 (SGLT-2) inhibitors in different types of heart failure (HF).

METHODS

Randomized controlled trials (RCTs) comparing SGLT-2 inhibitors with placebo in patients with HF were searched in PubMed, the Cochrane Library database, and clinicaltrials.gov. A random-effects model was used for evidence synthesis. The primary endpoint was cardiac death.

RESULTS

We included 13 studies (12 RCTs). In patients with HF with preserved ejection fraction (HFpEF), SGLT-2 inhibitors reduced the composite endpoint of cardiac death or rehospitalization because of HF (HHF) (HR: 0.78, 95% CI: 0.70-0.87, I2 = 0%, P < 0.001) and that of HHF (HR: 0.74; 95% CI: 0.64-0.85, I2 = 0%, P < 0.001) but not that of cardiac death (HR: 1.01, 95% CI: 0.80-1.28, I2 = 23.9%, P = 0.943). In patients with HF with reduced EF (HFrEF), SGLT-2 inhibitors reduced the composite endpoint of cardiac death or HHF (HR: 0.75, 95% CI: 0.69-0.82, I2 = 0%, P < 0.001) and the individual endpoints of cardiac death (HR: 0.84, 95% CI: 0.75-0.95, I2 = 0%, P = 0.007) and HHF (HR: 0.69, 95% CI: 0.62-0.77, I2 = 0%, P < 0.001).

CONCLUSIONS

SGLT-2 inhibitors reduced the risk of cardiac death in patients with HFrEF but not in those with HFpEF.

SGLT2 Inhibitors in Diabetic Patients With Cardiovascular Disease or at High Cardiovascular Risk: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To investigate the effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with diabetes with cardiovascular disease (CVD) or at high cardiovascular risk.

Design

Systematic review and meta-analysis of randomized controlled trials (RCTs).

Data sources

Pubmed, Embase, the Cochrane Library, and ClinicalTrial.gov from their inception to August 28, 2021.

Review methods

Randomized control trials (RCTs) assess the effects of SGLT2i in patients with diabetes with cardiovascular disease or at high cardiovascular risk. Primary outcomes included the composite outcome of cardiovascular death (CV death) and hospitalization for heart failure (HHF), HHF, and renal composite outcomes. Secondary outcomes included major adverse cardiovascular events (MACE), CV death, all-cause mortality, and change from the baseline in HbA1c. Additionally, we assessed the effects of treatment in prespecified subgroups on the combined risk of primary and secondary outcomes. These subgroups were based on history of heart failure (HF), estimated glomerular filtration rate (eGFR) levels, and history of hypertension (HTN). A meta-analysis was carried out by using fixed effect models to calculate hazard ratio (HR) or mean difference (MD) between the SGLT2i administrated groups and the control groups.

Results

Four major studies (n = 42,568) were included. Primary outcomes showed that SGLT2i was associated with significantly lower risk of CV death/HHF (HR, 0.90; 95% confidence interval, 0.84 to 0.98; P for heterogeneity = 0.01), HHF (HR, 0.84; 95% CI, 0.73 to 0.98; p = 0.02), and renal composite outcomes (HR, 0.83; 95%CI, 0.74 to 0.92; p = 0.0007) in patients with diabetes with CVD or at high CV risk. Secondary outcome showed that the use of SGLT2i was associated with significant reduction of the HbA1c level (MD, −0.30; 95% CI, −0.36 to −0.23; p < 0.00001). In subgroup analyses, SGLT2i significantly reduced the risk of renal composite outcomes in patients without history of HF (HR, 0.75; 95% CI, 0.62 to 0.91; p = 0.003 < 0.025). No statistically significant differences were observed in other secondary outcomes and subgroup analyses.

Conclusions

The SGLT2i showed benefits on CV death/HHF, HHF, renal composite outcomes, and HbA1c reduction in patients with diabetes with CVD or at high CV risk. The benefits of improving renal composite outcomes were observed only in patients with diabetes without HF history.

Systematic Review Registration

PROSPERO CRD42021227400

Economic Evaluation of Dapagliflozin in the Treatment of Patients With Heart Failure: A Systematic Review

Objective: The objective of this study is to systematically review the economic evaluations of dapagliflozin in the treatment of patients with heart failure (HF) and describe their general and methodological features.

Methods: This systematic review followed the PRISMA guidelines. MEDLINE/PubMed, Website Of Science, Embase, The Cochrane Library, ScienceDirect, CNKI, and Wanfang databases were searched to collect relevant studies, and the retrieval time ended on 31 October 2021. Articles on the economic evaluation of dapagliflozin in the treatment of heart failure were included. Secondary studies, incomplete economic indicators, and non-English-language and non-Chinese-language studies were excluded. Standard drug treatment was selected as the comparison. Basic characteristics, methods, and main results were extracted and analyzed systematically.

Result: A total of eight studies were identified, and the overall quality was accepted, which were performed in nine developed countries (Austria, United States, Korea, Japan, Singapore, Spanish, Germany, and United Kingdom) and three developing countries (the Philippines, Thailand, and China). With the exception of the Philippines, the remaining countries considered that dapagliflozin was cost effective. In the analyses of all included studies, the incremental cost-effectiveness ratios were most sensitive to the cost of dapagliflozin, cardiovascular mortality, the duration of dapagliflozin effectiveness, and the probability of HF hospitalization.

Conclusion: Dapagliflozin in the treatment of patients with heart failure with reduced ejection fraction was considered cost effective. Further studies are needed to evaluate the comprehensive value of dapagliflozin on HF.

Comparative Efficacy of Dapagliflozin and Empagliflozin of a Fixed Dose in Heart Failure: A Network Meta-Analysis

Background

The efficacy of dapagliflozin and empagliflozin in sodium-glucose cotransport-2 inhibitors (SGLT-2i) in patients with heart failure (HF) has been discovered. However, which drug could improve varied prognostic outcomes has not been elucidated. Hence, we compared their efficacies on the prognostic improvement of HF.

Methods

Databases including PubMed, EMBASE, Scopus, Google Scholars, and the Cochrane Library were searched for all related randomized controlled trials (RCTs) published from inception to 13 October 2021. Network meta-analyses were performed to generate matrices to show the effect size for pairwise comparison regarding all the interventions.

Results

Eventually a total of 11 RCTs were included in this study. For the primary endpoints, dapagliflozin was comparable with empagliflozin in hospitalization for HF, and empagliflozin (OR=0.70, 95%CI: 0.59–0.84) decreased the risk of exacerbation of HF over dapagliflozin. For the secondary endpoints, dapagliflozin was comparable with empagliflozin in cardiovascular (CV) death /hospitalization for HF, and for CV death, dapagliflozin (OR=0.78, 95%CI: 0.65–0.92) significantly reduced mortality over the placebo. For the tertiary endpoints, dapagliflozin (OR=0.80, 95%CI: 0.66–0.98) significantly decreased the mortality over empagliflozin in all-cause death, and neither drug significantly increased the risk of hypoglycemia.

Recommendations

Overall, 10 mg/day dapagliflozin may be the optimal recommendation for its premium and comprehensive effect on improving the prognosis of patients with HF compared to 10 mg/day empagliflozin.

Effects of ipragliflozin on left ventricular diastolic function in patients with type 2 diabetes and heart failure with preserved ejection fraction: The EXCEED randomized controlled multicenter study

AIM

We carried out a randomized controlled trial using ipragliflozin. We analyzed changes in diastolic function using echocardiography in patients with type 2 diabetes and heart failure with preserved ejection fraction.

METHODS

We carried out an open-label, multicenter, randomized, two-arm interventional trial. A total of eligible 68 participants were randomly assigned into two groups (ipragliflozin group n = 36; conventional treatment group n = 32). Primary end-points were the change in E/e' and e'. Secondary end-points were other parameters of echocardiography, plasma NT-proBNP level, New York Heart Association class, hemoglobin A1c and blood pressure.

RESULTS

After 24 weeks of follow up, E/e' decreased in both groups (ipragliflozin: 11.0 vs 10.4; conventional treatment 10.5 vs 10.1; multivariate-adjusted P = 0.95). There were no significant differences in the amount of change in E/e', e', echocardiography parameters, plasma NT-proBNP level, New York Heart Association class, hemoglobin A1c and blood pressure between the two groups. In the subgroup analysis, ipragliflozin treatment decreased in left ventricular mass index in patients aged ≥70 years and also decreased in NT-proBNP levels in patients with baseline NT-proBNP ≥400 pg/mL.

CONCLUSIONS

In this randomized controlled study carried out in patients with type 2 diabetes and heart failure with preserved ejection fraction, 24-week ipragliflozin treatment did not improve left ventricular diastolic function compared with conventional treatment. As the subgroup, ipragliflozin treatment decreased in left ventricular mass index in participants aged ≥70 years. Geriatr Gerontol Int 2022; 22: 298-304.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Randomized Controlled Trial of the Hemodynamic Effects of Empagliflozin in Patients With Type 2 Diabetes at High Cardiovascular Risk: The SIMPLE Trial

Treatment with the sodium-glucose cotransporter 2 inhibitor (SGLT-2i) empagliflozin significantly reduces cardiovascular events in patients with type 2 diabetes (T2D); however, the mechanisms behind the reduction in cardiovascular (CV) events are unknown. We investigated whether SGLT-2i treatment affected central hemodynamics during rest and exercise in 34 patients with diabetes in this investigator-initiated, randomized, placebo-controlled, double-blinded trial. The primary end point was change in pulmonary capillary wedge pressure (PCWP) at a submaximal ergometer workload (25 W) after 13 weeks of SGLT-2i treatment (25 mg once daily) compared with placebo. Secondary end points included changes in resting hemodynamics. Baseline and follow-up hemodynamic assessments were performed at rest, submaximal exercise (25 W), and peak exercise using right heart catheterization. Treatment with empagliflozin for 13 weeks in patients with T2D at high CV risk did not reduce left heart filling pressure more than placebo at submaximal exercise. At rest, we observed that empagliflozin reduced PCWP at a magnitude of clinical significance.

The Impact of Novel Anti-Diabetic Medications on CV Outcomes: A New Therapeutic Horizon for Diabetic and Non-Diabetic Cardiac Patients

It is estimated that in the past two decades the number of patients diagnosed with diabetes mellites (DM) has doubled. Despite significant progress in the treatment of cardiovascular disease (CVD), including novel anti-platelet agents, effective lipid-lowering medications, and advanced revascularization techniques, patients with DM still are least twice as likely to die of cardiovascular causes compared with their non-diabetic counterparts, and current guidelines define patients with DM at the highest risk for atherosclerotic cardiovascular disease and major adverse cardiovascular events (MACE). Over the last few years, there has been a breakthrough in anti-diabetic therapeutics, as two novel anti-diabetic classes have demonstrated cardiovascular benefit with consistently reduced MACE, and for some agents, also improvement in heart failure status as well as reduced cardiovascular and all-cause mortality. These include the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists. The benefits of these medications are thought to be derived not only from their anti-diabetic effect but also from additional mechanisms. The purpose of this review is to provide the everyday clinician a detailed review of the various agents within each class with regard to their specific characteristics and the effects on MACE and cardiovascular outcomes.

Soluble Epoxide Hydrolase Inhibition Protected against Diabetic Cardiomyopathy through Inducing Autophagy and Reducing Apoptosis Relying on Nrf2 Upregulation and Transcription Activation

Background

Many patients with diabetes die from diabetic cardiomyopathy (DCM); however, effective strategies for the prevention or treatment of DCM have not yet been clarified.

Methods

Leptin receptor-deficient (db/db) mice were treated with either the soluble epoxide hydrolase (sEH) inhibitor AUDA or vehicle alone. A virus carrying Nrf2 shRNA was used to manipulate Nrf2 expression in db/db mice. Cardiac structures and functions were analyzed using echocardiography and hemodynamic examinations. Primary cardiomyocytes cultured under high glucose and high fat (HGHF) conditions were used to conduct in vitro loss-of-function assays after culture in the presence or absence of AUDA (1 μM). Fluorescence microscopy-based detection of mCherry-GFP-LC3 was performed to assess autophagic flux.

Results

The sEH inhibitor AUDA significantly attenuated ventricular remodeling and ameliorated cardiac dysfunction in db/db mice. Interestingly, AUDA upregulated Nrf2 expression and promoted its nuclear translocation in db/db mice and the HGHF-treated cardiomyocytes. Additionally, AUDA increased autophagy and decreased apoptosis in db/db mice heart. Furthermore, the administration of AUDA promoted autophagic flux and elevated LC3-II protein level in the presence of bafilomycin A1. However, AUDA-induced autophagy was abolished, and the antiapoptotic effect was partially inhibited upon Nrf2 knockdown.

Conclusion

Our findings suggest that the sEH inhibitor AUDA attenuates cardiac remodeling and dysfunction in DCM via increasing autophagy and reducing apoptosis, which is relevant to activate Nrf2 signaling pathway.

Cardiac mechanisms of the beneficial effects of SGLT2 inhibitors in heart failure: Evidence for potential off-target effects

Sodium glucose cotransporter 2 inhibitors (SGLT2i) constitute a promising drug treatment for heart failure patients with either preserved or reduced ejection fraction. Whereas SGLT2i were originally developed to target SGLT2 in the kidney to facilitate glucosuria in diabetic patients, it is becoming increasingly clear that these drugs also have important effects outside of the kidney. In this review we summarize the literature on cardiac effects of SGLT2i, focussing on pro-inflammatory and oxidative stress processes, ion transport mechanisms controlling sodium and calcium homeostasis and metabolic/mitochondrial pathways. These mechanisms are particularly important as disturbances in these pathways result in endothelial dysfunction, diastolic dysfunction, cardiac stiffness, and cardiac arrhythmias that together contribute to heart failure. We review the findings that support the concept that SGLT2i directly and beneficially interfere with inflammation, oxidative stress, ionic homeostasis, and metabolism within the cardiac cell. However, given the very low levels of SGLT2 in cardiac cells, the evidence suggests that SGLT2-independent effects of this class of drugs likely occurs via off-target effects in the myocardium. Thus, while there is still much to be understood about the various factors which determine how SGLT2i affect cardiac cells, much of the research clearly demonstrates that direct cardiac effects of these SGLT2i exist, albeit mediated via SGLT2-independent pathways, and these pathways may play a role in explaining the beneficial effects of SGLT2 inhibitors in heart failure.

Immunometabolic Mechanisms of Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is increasing in prevalence worldwide, already accounting for at least half of all heart failure (HF). As most patients with HFpEF are obese with metabolic syndrome, metabolic stress has been implicated in syndrome pathogenesis. Recently, compelling evidence for bidirectional crosstalk between metabolic stress and chronic inflammation has emerged, and alterations in systemic and cardiac immune responses are held to participate in HFpEF pathophysiology. Indeed, based on both preclinical and clinical evidence, comorbidity-driven systemic inflammation, coupled with metabolic stress, have been implicated together in HFpEF pathogenesis. As metabolic alterations impact immune function(s) in HFpEF, major changes in immune cell metabolism are also recognized in HFpEF and in HFpEF-predisposing conditions. Both arms of immunity - innate and adaptive - are implicated in the cardiomyocyte response in HFpEF. Indeed, we submit that crosstalk among adipose tissue, the immune system, and the heart represents a critical component of HFpEF pathobiology. Here, we review recent evidence in support of immunometabolic mechanisms as drivers of HFpEF pathogenesis, discuss pivotal biological mechanisms underlying the syndrome, and highlight questions requiring additional inquiry.

Dapagliflozin attenuates cholesterol overloading-induced injury in mice hepatocytes with type 2 diabetes mellitus (T2DM) via eliminating oxidative damages

Cholesterol overloading-induced damages on hepatocytes cause liver dysfunctions, which further damages cholesterol metabolism and results in visceral fat accumulation in patients with type 2 diabetes mellitus (T2DM). The sodium-glucose cotransporter 2 (SGLT2) inhibitor Dapagliflozin has been reported to regulate cholesterol levels in T2DM patients, but the underlying mechanisms have not been studied. In the present study, we initially established in vivo T2DM mice models, and our results showed that both free cholesterol (FC) and cholesteryl ester (CE) were accumulated, while the pro-proliferation associated genes were downregulated in T2DM mice liver tissues, which were reversed by Dapagliflozin co-treatment. Similarly, the mice primary hepatocytes were loaded with cholesterol to establish in vitro models, and we expectedly found that Dapagliflozin attenuated cholesterol-overloading induced cytotoxicity and cellular senescence in the hepatocytes. Then, we noticed that oxidative damages occurred in T2DM mice liver tissues and cholesterol treated hepatocytes, which could be suppressed by Dapagliflozin. Also, elimination of Reactive Oxygen Species (ROS) by N-acetyl-L-cysteine (NAC) recovered cellular functions of hepatocytes in vitro and in vivo. Furthermore, the potential underlying mechanisms were uncovered, and our data suggested that Dapagliflozin activated the anti-oxidant Nrf2/HO-1 pathway in mice hepatocytes, and silencing of Nrf2 abrogated the protective effects of Dapagliflozin on cholesterol-overloaded hepatocytes. Collectively, we concluded that Dapagliflozin recovered cholesterol metabolism functions in T2DM mice liver via activating the anti-oxidant Nrf2/HO-1 pathway, and our data supported that Dapagliflozin was a potential therapeutic drug to eliminate cholesterol-induced cytotoxicity during T2DM pathogenesis.

Diabetes mellitus and heart failure: an update on pathophysiology and therapy

Diabetes mellitus (DM) is frequent among heart failure (HF) patients with a further projected increase in prevalence in next years. DM promotes the development of both HF with reduced (HFrEF) and preserved ejection fraction (HFpEF) through different mechanisms. As the general prevalence of both DM and HF is growing worldwide, it is important to define the pathophysiologic mechanisms driving the development of HF in DM patients. These include changes in the cardiac metabolism, mitochondrial dysfunction, impairment in insulin signaling, maladaptive inflammation, coronary microvascular dysfunction, endoplasmic reticulum stress, autophagy suppression, and structural changes, among the main ones. In recent years, novel glucose-lowering treatments, especially sodium-glucose cotransporter 2 inhibitors (SGLT-2is), have shown a strikingly positive impact on the natural history of HF. This has led to a progressive change in choosing SGLT-2is in DM patients at high risk for CV disease, supported by recent guidelines. The knowledge about novel pathophysiological mechanisms linking DM and HF may open the way to the development of new targeted therapies in the future. In this review, we will summarize general aspects dealing with incidence, prevalence, and pathophysiology of DM in HF patients. As well, we discuss the therapeutic targets to reduce the disease burden and the current evidence of glucose-lowering drugs in patients with DM and HF.

Small molecule SWELL1 complex induction improves glycemic control and nonalcoholic fatty liver disease in murine Type 2 diabetes

Type 2 diabetes is associated with insulin resistance, impaired pancreatic β-cell insulin secretion, and nonalcoholic fatty liver disease. Tissue-specific SWELL1 ablation impairs insulin signaling in adipose, skeletal muscle, and endothelium, and impairs β-cell insulin secretion and glycemic control. Here, we show that I_Cl,SWELL and SWELL1 protein are reduced in adipose and β-cells in murine and human diabetes. Combining cryo-electron microscopy, molecular docking, medicinal chemistry, and functional studies, we define a structure activity relationship to rationally-design active derivatives of a SWELL1 channel inhibitor (DCPIB/SN-401), that bind the SWELL1 hexameric complex, restore SWELL1 protein, plasma membrane trafficking, signaling, glycemic control and islet insulin secretion via SWELL1-dependent mechanisms. In vivo, SN-401 restores glycemic control, reduces hepatic steatosis/injury, improves insulin-sensitivity and insulin secretion in murine diabetes. These findings demonstrate that SWELL1 channel modulators improve SWELL1-dependent systemic metabolism in Type 2 diabetes, representing a first-in-class therapeutic approach for diabetes and nonalcoholic fatty liver disease.

Type 2 diabetes is associated with insulin resistance, impaired insulin secretion and liver steatosis. Here the authors report a proof-of-concept study for small molecule SWELL1 modulators as a therapeutic approach to treat diabetes and associated liver steatosis by enhancing systemic insulin-sensitivity and insulin secretion in mice.

Sacubitril/valsartan, sodium‐glucose cotransporter 2 inhibitors, and vericiguat for congestive heart failure therapy

Heart failure is associated with notable morbidity and mortality, and therefore, novel therapies are needed. This minireview focused on the effects and mechanisms of action of sacubitril/valsartan, sodium‐glucose cotransporter 2 inhibitors and vericiguat in heart failure patients. A systematic review of the current literature was conducted. Seventeen randomised clinical trials regarding the effects of these drug classes were included. The mechanism of action of each treatment could improve pathophysiological imbalances present in heart failure. All three drug classes revealed a reduction in hospitalisations for heart failure or death from cardiovascular causes in patients with reduced ejection fraction. Sacubitril/valsartan also reduced hospitalisations and death from cardiovascular causes in patients with mid‐range ejection fraction, but not in patients with preserved ejection fraction. The sodium‐glucose cotransporter 2 inhibitors, sotagliflozin and empagliflozin, reduced hospitalisations and death from cardiovascular causes in heart failure patients with preserved ejection fraction. None of the three drug classes was associated with a higher prevalence of treatment discontinuation due to increases in adverse effects in large‐scale randomised clinical trials compared with placebo. Further studies are required to clarify the extent of effects of these medications in different subpopulations—especially in patients with mid‐range and preserved ejection fraction.

Effects of luseogliflozin on estimated plasma volume in patients with heart failure with preserved ejection fraction

AIMS

Sodium glucose co-transporter 2 inhibitors have diuretic effects in both patients with glycosuria and with natriuresis. We sought to assess the effect of luseogliflozin on estimated plasma volume (ePV) in patients with type 2 diabetes and heart failure with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

This study was a post-hoc analysis of the MUSCAT-HF trial (UMIN000018395), a multicentre, prospective, open-label, randomized controlled trial that assessed the effect of 12 weeks of luseogliflozin (2.5 mg, once daily, n = 83) as compared with voglibose (0.2 mg, three times daily, n = 82) on the reduction in brain natriuretic peptide (BNP) in patients with type 2 diabetes and HFpEF. The analysis compared the change in ePV calculated by the Straus formula from baseline to Weeks 4, 12, and 24, using a mixed-effects model for repeated measures. We also estimated the association between changes in ePV and changes in other clinical parameters, including BNP levels. Luseogliflozin significantly reduced ePV as compared to voglibose at Week 4 {adjusted mean group-difference -6.43% [95% confidence interval (CI): -9.11 to -3.74]}, at Week 12 [-8.73% (95%CI: -11.40 to -6.05)], and at Week 24 [-11.02% (95%CI: -13.71 to -8.33)]. The effect of luseogliflozin on these parameters was mostly consistent across various patient clinical characteristics. The change in ePV at Week 12 was significantly associated with log-transformed BNP (r = 0.197, P = 0.015) and left atrial volume index (r = 0.283, P = 0.019).

CONCLUSIONS

Luseogliflozin significantly reduced ePV in patients with type 2 diabetes and HFpEF, as compared with voglibose. The reduction of intravascular volume by luseogliflozin may provide clinical benefits to patients with type 2 diabetes and HFpEF.

Use of Sodium-Glucose Cotransporter-2 Inhibitors in Clinical Practice for Heart Failure Prevention and Treatment: Beyond Type 2 Diabetes. A Narrative Review

Despite the availability of established treatments, heart failure (HF) is associated with a poor prognosis and its management is suboptimal, highlighting the need for new options for treatment and prevention. Patients with type 2 diabetes (T2D) often experience cardiovascular (CV) complications, with HF being one of the most frequent. Consequently, several CV outcome trials have focused on glucose-lowering therapies and their impact on CV outcomes. An established treatment for T2D, sodium-glucose cotransporter-2 inhibitors (SGLT-2is; canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) have demonstrated beneficial effects on CV outcomes in long-term studies of patients with T2D with established CV disease and/or a broad range of CV risk factors. Recent studies have extended these findings to patients with HF, with and without T2D, finding that SGLT-2is (particularly dapagliflozin and empagliflozin) are effective therapeutic interventions for the treatment and prevention of HF. This narrative review article discusses the use of SGLT-2is in the treatment and prevention of HF in patients with and without T2D. Dapagliflozin was the first SGLT-2i to receive US Food and Drug Administration (FDA) approval for treatment of HF, to reduce the risk of CV death and hospitalization for HF in adults with HF with reduced ejection fraction (HFrEF) with and without T2D. Recently, the FDA also approved empagliflozin for this indication. Given the new HFrEF indications for dapagliflozin and empagliflozin, and the likelihood of similar approvals for other SGLT-2is, cardiology guidelines are beginning to integrate SGLT-2is into a standard-of-care treatment regimen for patients with HFrEF. The utility of SGLT-2is in HF with preserved EF (HFpEF) shows promise based on data from the EMPEROR-Preserved study of empagliflozin in patients with HFpEF. Further clinical trial evidence may lead to more widespread use and further integration of SGLT-2is into standard-of-care regimens for the treatment and management of HF in patients with and without T2D.

Heart failure is a medical condition in which the heart cannot pump enough blood. Several types of drugs have been used to treat heart failure, but these may not work for every patient, and heart failure can get worse over time even with treatment. That is why new drugs are needed to treat and prevent heart failure. People with diabetes (type 2 diabetes) often have other conditions related to the heart (cardiovascular system), heart failure being one of the most common. Because of this, there have been studies (clinical trials) in people with diabetes to see if diabetes drugs can also treat and/or reduce the risk of cardiovascular disease. In clinical trials, a type of diabetes drug, sodium-glucose cotransporter-2 inhibitors (SGLT-2is, including canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin), has helped people with both diabetes and cardiovascular disease. Recent clinical trials of dapagliflozin and empagliflozin showed they were effective for treating and preventing heart failure in people without diabetes as well as in those with diabetes. Based on these studies, the US Food and Drug Administration approved dapagliflozin and empagliflozin for heart failure in patients with or without diabetes. These drugs can be prescribed for adults with or without diabetes to treat and prevent a type of heart failure, heart failure with reduced ejection fraction, in which the heart is too weak to pump enough blood to the body. Several clinical studies are ongoing that will provide more information about these drugs, SGLT-2is, which will help healthcare providers to treat people with heart failure.

Self-Induced Euglycemic Diabetic Ketoacidosis: When to Stop the Drip

Diabetic ketoacidosis (DKA) is a well-known, serious complication that many patients with type 1 and 2 diabetes face due to either a relative or absolute insulin deficiency. Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have gained increased popularity due to their diabetic, cardiovascular, and renal benefits. An associated complication of SGLT2 inhibitors is euglycemic DKA.

A 56-year-old male with a history of type 2 diabetes mellitus and peripheral neuropathy presented with right foot pain secondary to a diabetic foot ulcer. The ulcer was present for one year, but the patient noticed increased pain and purulent discharge over the three days prior to presentation. While being treated inpatient for the foot ulcers, the patient repeatedly refused to receive standard hospital diabetes management of insulin injections. He instead insisted to take his home medications against medical advice, which were metformin and Glyxambi® (empagliflozin/linagliptin, Boehringer Ingelheim, Ingelheim am Rhein, Germany). His diabetic foot ulcer was medically managed with IV antibiotics. 

On day 4 of admission, his anion gap increased to 23 mEq/L, and serum bicarbonate (CO2) decreased to 8 mEq/L, raising concerns of diabetic ketoacidosis. His glucose was 141 mg/dL, his beta-hydroxybutyrate was high at 5.5 mmol/L. An arterial blood gas (ABG) test demonstrated anion gap metabolic acidosis with secondary respiratory alkalosis. A urinalysis demonstrated glucose 1000 mg/dL and ketones of 150 mg/dL. The patient was diagnosed with euglycemic DKA. Due to the patient having normal glucose levels, an insulin drip and a 5% dextrose with 0.45% normal saline drip were started. Basic metabolic profiles were ordered every four hours, with glucose checks every hour. Once the anion gap was closed and his urinary ketones disappeared, the patient transitioned to subcutaneous insulin. He was able to be discharged home with basal subcutaneous insulin and metformin with instructions to avoid SGLT2 inhibitors in the future. 

Unfortunately, there are currently no guidelines from endocrinology or internal medicine societies regarding the management of euglycemic DKA. As the typical DKA diagnostic criteria of elevated blood glucose level are not present, it is easy to overlook euglycemic DKA. As these SGLT2 inhibitors become more prevalent, careful monitoring of all potential side effects as well as the contraindications are prudent to successful management of complex disease states.

Prognostic Benefit of New Drugs for HFrEF: A Systematic Review and Network Meta-Analysis

Background: The new heart failure (HF) therapies of sodium-glucose cotransporter 2 inhibitors (SGLT2i), vericiguat, and omecamtiv mecarbil do not act primarily through the neuro-hormonal blockade, but have shown clinical benefits in patients with HF with reduced ejection fraction (HFrEF). However, their respective efficacies remain unclear. Our aim was to evaluate the relative efficacy of new drugs for HFrEF. Methods: We performed a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing SGLT2i, vericiguat, omecamtiv mecarbil, and placebo in HFrEF patients. The primary endpoint was the composite of cardiovascular death (CVD) or HF hospitalization (CVD-HF); secondary endpoints were CVD, all-cause death, and HF hospitalization (HFH). Results: Twelve RCTs (n = 23,861 patients) were included. A significant reduction in CVD-HF was observed with SGLT2i compared with placebo (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.71–0.83), vericiguat (RR 0.84, 95% CI 0.75–0.93), and omecamtiv mecarbil (RR 0.80, 95% CI 0.72–0.88). No significant difference was observed between vericiguat and omecamtiv mecarbil (RR 0.95, 95% CI 0.87–1.04). SGLT2i were superior to placebo and omecamtiv mecarbil for all individual secondary endpoints (CVD, all-cause death, and HFH), and also to vericiguat for HFH. SGLT2i ranked as the most effective therapy for all endpoints, and vericiguat, omecamtiv mecarbil, and placebo ranked as the second, third, and last options, respectively, for the primary endpoint. Conclusions: In patients with HFrEF on standard-of-care therapy, SGLT2i therapy was associated with a reduced risk of CVD-HF compared to placebo, vericiguat, and omecamtiv mecarbil. Furthermore, SGLT2i were superior to placebo and omecamtiv mecarbil for CVD, all-cause death, and HFH, and also to vericiguat for HFH.

A Systematic Review and Meta-analysis of Randomized Placebo-controlled Trials 1 Year after Starting Sodium-glucose Transporter-2 Inhibitors in Heart Failure Patients with Reduced Ventricular Ejection Fraction

Introduction: The Sodium-Glucose Cotransporter-2 Inhibitor (SGLT-2 inhibitor) is a diabetic medication. Recently, there has been enough evidence of SGLT-2 inhibitors in type 2 diabetes mellitus, driving in an abatement in cardiovascular breakdown hospitalization. To explore SGLT-2 inhibitor in cardiovascular breakdown with lower discharge portion, we led an orderly survey and meta-examination. Strategies: We played out a methodical writing search from various electronic databases. We used keywords:” SGLT-2 inhibitor '' and “Heart Failure.” Inclusion criteria are randomized placebo-controlled trial, one-year follow-up and ejection fraction 40% or less. Composite endpoint is cardiovascular mortality with hospitalization of heart failure. Individual outcomes include all-cause mortality, cardiovascular passing, and cardiovascular breakdown hospitalization. For low heterogeneity scores, results are introduced utilizing a danger proportion (RR) with a 95 percent certainty stretch and statistical analysis using a fixed-effect model. Results: Total of two randomized control trial was selected (DAPA-HF [Dapagliflozin] and EMPEROR-Reduced [Empagliflozin]) with 8,474 patients pooled within our analysis. The results of the composite outcome compared SGLT-2 inhibitor with placebo had significant decrease in the composite of cardiovascular passing with hospitalization of cardiovascular breakdown (RR=0.78 [95% CI, 0.71–0.84], p<0.00001; I2=0%). Result of individual outcome showed significant reduction of all-cause mortality (RR=0.88 [95% CI, 0.79 – 0.98], p=0.03; I2=1%), cardiovascular mortality (RR=0.87 [95% CI, 0.77 – 0.99], p=0.03; I2=0%) and hospitalization of heart failure (RR=0.72 [95% CI, 0.65–0.81], p<0.00001; I2=0%). Conclusion: Within one year of treatment with an SGLT-2 inhibitor, the composite of cardiovascular passing with cardiovascular breakdown hospitalization, all-cause mortality, cardiovascular mortality, and cardiovascular breakdown hospitalization was significantly reduced.

Cardiorenal protection with SGLT2 inhibitors in patients with diabetes mellitus: from biomarkers to clinical outcomes in heart failure and diabetic kidney disease

Type 2 diabetes (T2D) is one of the most common causes of chronic kidney disease (CKD) and cardiovascular (CV) disease. Until recently, glycemic and BP control were the cornerstones for preventing progression of CKD and CV disease associated with T2D. However, there has been a paradigm shift in treatment since the publication of the first clinical trial demonstrating benefits of sodium glucose cotransporter 2 (SGLT2) inhibitors in 2015. SGLT2 inhibitors have been shown to reduce the risk of major adverse CV events and progression of kidney disease in the setting of T2D. However, the elucidation of mechanisms of underlying these clinical benefits is the subject of ongoing investigation. Experimental studies have shown that SGLT2 inhibitors have diverse pleiotropic effects such as modulation of neurohormones such as the renin-angiotensin-aldosterone system, increasing hematocrit, altering energy substrate use, and attenuating systemic inflammation and oxidative stress, all of which have been implicated in the CV and kidney protective effects of SGLT2 inhibitors. In this review, we highlight biomarkers linked with diabetic kidney disease and heart failure and discuss how SGLT2 inhibitor-associated changes potentially mediate the cardiorenal protection observed with these therapies.

Renal Tubular Handling of Glucose and Fructose in Health and Disease

The proximal tubule of the kidney is programmed to reabsorb all filtered glucose and fructose. Glucose is taken up by apical sodium-glucose cotransporters SGLT2 and SGLT1 whereas SGLT5 and potentially SGLT4 and GLUT5 have been implicated in apical fructose uptake. The glucose taken up by the proximal tubule is typically not metabolized but leaves via the basolateral facilitative glucose transporter GLUT2 and is returned to the systemic circulation or used as an energy source by distal tubular segments after basolateral uptake via GLUT1. The proximal tubule generates new glucose in metabolic acidosis and the postabsorptive phase, and fructose serves as an important substrate. In fact, under physiological conditions and intake, fructose taken up by proximal tubules is primarily utilized for gluconeogenesis. In the diabetic kidney, glucose is retained and gluconeogenesis enhanced, the latter in part driven by fructose. This is maladaptive as it sustains hyperglycemia. Moreover, renal glucose retention is coupled to sodium retention through SGLT2 and SGLT1, which induces secondary deleterious effects. SGLT2 inhibitors are new anti-hyperglycemic drugs that can protect the kidneys and heart from failing independent of kidney function and diabetes. Dietary excess of fructose also induces tubular injury. This can be magnified by kidney formation of fructose under pathological conditions. Fructose metabolism is linked to urate formation, which partially accounts for fructose-induced tubular injury, inflammation, and hemodynamic alterations. Fructose metabolism favors glycolysis over mitochondrial respiration as urate suppresses aconitase in the tricarboxylic acid cycle, and has been linked to potentially detrimental aerobic glycolysis (Warburg effect). © 2022 American Physiological Society. Compr Physiol 12:2995-3044, 2022.

The Evolution of Sodium-Glucose Co-Transporter-2 Inhibitors in Heart Failure

Sodium-glucose co-transporter-2 (SGLT2) inhibitors have evolved over the years, based on data from several randomized, double-blinded, placebo-controlled clinical trials. Formerly used primarily for blood sugar control in patients with diabetes, they are now used to decrease the risk of hospitalization for heart failure (HF), or of death from cardiovascular (CV) causes, in patients with heart failure with reduced ejection fraction (HFrEF). They have also been shown to slow the progression of renal disease and prevent death related to renal causes in patients with chronic kidney disease (CKD). They are currently being studied to decrease the risk of HF hospitalization in patients with preserved ejection fraction subtype and have shown positive results. The transition of SGLT2 from a medication used in diabetes to an established HF medication was a result of the hypothesis generated from the analysis of earlier trials in diabetic patients and further testing of this hypothesis in an HF population. By way of this review, we aim to highlight the rationale for the paradigm shift of SGLT2 inhibitors from their use in diabetic patients to their use in all patients with HF, regardless of the presence of diabetes. To support our recommendation, we'll present detailed results of several major clinical trials and a meta-analysis study that led to this discovery, along with clinical indication for the same.

The expanding role of SGLT2 inhibitors beyond glucose-lowering to cardiorenal protection

The kidney plays a major physiological role in glucose homeostasis but also contributes to the pathophysiology of type 2 diabetes (T2D), mediated by renal sodium glucose cotransporters (SGLTs). This recognition led to the development of SGLT2 inhibitors that inhibit proximal renal tubular renal glucose and sodium reabsorption. The glucoretic and natriuretic effect of SGLT2 inhibitors is associated with reductions in HbA1c levels, body weight, systolic blood pressure and triglycerides. Major vascular complications of T2D include cardiovascular disease and chronic kidney disease (CKD). Results from several cardiovascular outcome trials (CVOTs) with these drugs have highlighted benefits in reducing major adverse cardiovascular events by 11%, reducing the risk of cardiovascular death or hospitalization for heart failure (HF) by 23% and reducing the risk of progression of renal disease by 45%. Their cardiorenal benefits are apparent across a range of eGFRs (within CKD1-3 groups) and the presence or absence of ischaemic heart disease, HF or T2D. In patients with HF with reduced ejection fraction (HFrEF), similar risk reductions in cardiovascular death and HF events are also seen; results from studies in patients with HF with preserved ejection fraction (HFpEF) are awaited. Cardiorenal benefits have been recently reported in patients with CKD, regardless of the presence or absence of T2D. Indications for use of SGLT2 inhibitors have extended beyond glucose-lowering to a central role in cardiorenal protection. This review will first explore the mechanisms by which glycaemic control, weight loss and cardiovascular risk factors are modulated therapeutically with SGLT2 inhibitors. Subsequently, we outline putative mechanisms underpinning the cardiorenal benefits seen, including in HF and CKD, in the context of completed and ongoing clinical studies. Treatment strategies with SGLT2 inhibitors in individuals with CKD or HF, with and/or without T2D are increasingly appealing. Combination therapy with complementary therapeutic agents is also explored.

Efficacy and Safety of Dapagliflozin in Heart Failure With Reduced Ejection Fraction According to N-Terminal Pro-B-Type Natriuretic Peptide: Insights From the DAPA-HF Trial

BACKGROUND

Effective therapies for HFrEF usually reduce NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, and it is important to establish whether new treatments are effective across the range of NT-proBNP.

METHODS

We evaluated both these questions in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) trial. Patients in New York Heart Association functional class II to IV with a left ventricular ejection fraction ≤40% and a NT-proBNP level ≥600 pg/mL (≥600 ng/L; ≥400 pg/mL if hospitalized for HF within the previous 12 months or ≥900 pg/mL if atrial fibrillation/flutter) were eligible. The primary outcome was the composite of an episode of worsening HF or cardiovascular death.

RESULTS

Of the 4744 randomized patients, 4742 had an available baseline NT-proBNP measurement (median, 1437 pg/mL [interquartile range, 857-2650 pg/mL]). Compared with placebo, treatment with dapagliflozin significantly reduced NT-proBNP from baseline to 8 months (absolute least-squares mean reduction, -303 pg/mL [95% CI, -457 to -150 pg/mL]; geometric mean ratio, 0.92 [95% CI, 0.88-0.96]). Dapagliflozin reduced the risk of worsening HF or cardiovascular death, irrespective of baseline NT-proBNP quartile; the hazard ratio for dapagliflozin versus placebo, from lowest to highest quartile was 0.43 (95% CI, 0.27-0.67), 0.77 (0.56-1.04), 0.78 (0.60-1.01), and 0.78 (0.64-0.95); P for interaction=0.09. Consistent benefits were observed for all-cause mortality. Compared with placebo, dapagliflozin increased the proportion of patients with a meaningful improvement (≥5 points) in Kansas City Cardiomyopathy Questionnaire total symptom score (P for interaction=0.99) and decreased the proportion with a deterioration ≥5 points (P for interaction=0.87) across baseline NT-proBNP quartiles.

CONCLUSIONS

In patients with HFrEF, dapagliflozin reduced NT-proBNP by 300 pg/mL after 8 months of treatment compared with placebo. In addition, dapagliflozin reduced the risk of worsening HF and death, and improved symptoms, across the spectrum of baseline NT-proBNP levels included in DAPA-HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03036124.

[Dapagliflozin in the prevention and treatment of heart failure]

To substantially reduce the risk of hospitalization and death among subjects with heart failure (HF) and reduced left ventricular ejection fraction, it is necessary to make a comprehensive approach of the different neurohormonal systems that are implied in its etiopathogenesis, including not only sympathetic nervous system, and renin-angiotensin system, but also vasoactive peptides and sodium-glucose transport protein 2. The DAPA-HF trial demonstrated that the addition of dapagliflozin to the standard treatment in HF with reduced left ventricular ejection fraction, markedly decreases the risk of cardiovascular death, HF hospitalization and overall death. In addition, dapagliflozin improves functional class and quality of life. Importantly, the prognostic benefit starts early after initiating treatment with dapagliflozin, regardless baseline therapy or the presence of diabetes. All these evidences make dapagliflozin as one of the mainstays of treatment for the management of HF with reduced left ventricular ejection fraction.

Cardiovascular benefit of SGLT2 inhibitors

Patients with type 2 diabetes mellitus (T2D) are at increased risk of cardiovascular (CV) disease. Sodium glucose cotransporter 2 (SGLT2) inhibitors, also known as gliflozins, are a class of medications used to treat T2D by preventing the reabsorption of glucose filtered through the kidney and thereby facilitating glucose excretion in the urine. Over the past 5 years, many cardiovascular outcome trials (CVOTs) have evaluated the safety and efficacy of SGLT2 inhibitors in preventing CV events. The results of 7 CVOTs have provided solid evidence that the use of SGLT2 in patients with T2D and at high CV risk significantly reduced the risk of death from CV causes. Moreover, in patient with heart failure with reduced ejection fraction, regardless of the presence or absence of T2D, SGLT2 inhibitors use significantly reduced the risk of worsening heart failure and death from CV causes. Although the exact mechanism of the cardiorenal benefit of SGLT2 inhibitors is still unknown, studies have shown that the beneficial effect of these drugs cannot be exclusively explained by their glucose lowering effect, and several possible mechanisms have been proposed. This review will explore the changing role of SGLT2 inhibitors from a diabetes drug to clinical practice guideline-supported therapy for the prevention and treatment of CV diseases, including heart failure.

The pleiotropic cardiovascular effects of sodium-glucose cotransporter-2 inhibitors

PURPOSE OF REVIEW

Throughout the history of medicine, scientists and clinicians have observed unanticipated drug effects leading at times to an entirely new use for a drug class, and other times eliminating them from practice. The sodium-glucose cotransporter-2 (SGLT2) inhibitors are one such class of drugs. These agents were initially studied as diabetic agents and their unanticipated and significant cardiovascular benefit has now created a new class of drugs for an entirely new population. Here we review the pleiotropic cardiovascular effects of SGLT2 inhibitors, the potential mechanisms of action, side effect profile and future directions.

RECENT FINDINGS

Large clinical trials have evaluated the cardiovascular outcomes of SGLT2 inhibitors including myocardial infarction and strokes as well as new onset and worsening systolic heart failure.

SUMMARY

SGLT2 inhibitors are being incorporated into the guidelines for the treatment of heart failure with the goal of preventing heart failure hospitalizations and promoting positive ventricular remodeling in patients with or without diabetes. The reduction in cardiovascular events including cardiovascular death, myocardial infarction, and other atherosclerotic effects appears to be driven by baseline risk with those who have known atherosclerosis seeing a reduction in events but those without disease seeing less benefit.

Diabetes and SGLT2-iss inhibitors in patients with heart failure with preserved or mid-range left ventricular ejection fractions

Diabetic patients frequently develop heart failure with preserved (HFpEF) or mid-range (HFmEF) cardiac ejection fractions. This condition may be secondary to diabetic cardiomyopathy or one of several relevant comorbidities, mainly hypertension. Several mechanisms link diabetes to HFpEF or HFmEF. Among these, non-enzymatic glycation of interstitial proteins, lipotoxicity, and endothelial dysfunction may promote structural damage and ultimate lead to heart failure. Findings from several large-scale trials indicated that treatment with sodium/glucose cotransporter 2 inhibitors (SGLT2-iss) resulted in significant improvements in cardiovascular outcomes in diabetic patients with high cardiovascular risk. However, there is currently some evidence that suggests a clinical advantage of using SGLT2-iss specifically in cases of HFpEF or HFmEF. Preclinical and clinical studies revealed that SGLT2-iss treatment results in a reduction in left ventricular mass and improved diastolic function. While some of the beneficial effects of SGLT2-iss have already been characterized (e.g., increased natriuresis and diuresis as well as reduced blood pressure, plasma volume, and arterial stiffness, and nephron-protective activities), there is increasing evidence suggesting that SGLT2-iss may have direct actions on the heart. These findings include SGLT2-iss-mediated reductions in the expression of hypertrophic foetal genes and diastolic myofilaments stiffness, increases in global phosphorylation of myofilament regulatory proteins (in HFpEF), inhibition of cardiac late sodium channel current and Na⁺/H⁺ exchanger activity, metabolic shifts, and effects on calcium cycling. Preliminary data from previously published studies suggest that SGLT2-iss could be useful for the treatment of HFpEF and HFmEF. Several large ongoing trials, including DELIVER AND EMPEROR -preserved have been designed to evalute the efficacy of SGLT2-iss in improving clinical outcomes in patients diagnosed with HFpEF. The goal of this manuscript is to review the use of SGLT2-iss inhibitors for HFpEF or HFmEF associated with diabetes.

Dapagliflozin: A Review in Symptomatic Heart Failure with Reduced Ejection Fraction

Dapagliflozin [Farxiga^® (USA); Forxiga^® (EU)], a sodium–glucose cotransporter 2 (SGLT2) inhibitor, was recently approved in the USA and the EU for the treatment of adults with symptomatic heart failure with reduced ejection fraction (HFrEF). The cardiovascular (CV) benefits of dapagliflozin were first observed in the DECLARE-TIMI 58 trial, in which dapagliflozin 10 mg/day significantly reduced the risk of CV death or hospitalization for HF in patients with type 2 diabetes mellitus (T2DM) who had or were at risk for atherosclerotic CV disease. In the subsequent DAPA-HF trial, dapagliflozin 10 mg/day in addition to standard of care was associated with a significantly lower risk of worsening HF or CV death than placebo in patients with HFrEF, regardless of the presence or absence of T2DM. The benefits of dapagliflozin also remained consistent regardless of background HF therapies. Dapagliflozin was generally well tolerated, with an overall safety profile consistent with its known safety profile in other indications. In conclusion, dapagliflozin is an effective and generally well-tolerated treatment that represents a valuable new addition to the options available for symptomatic HFrEF.

Heart failure (HF) is a major cause of death and disability. HFrEF occurs when the left ventricular ejection fraction is ≤ 40%. Conventional treatments for HFrEF include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, β-blockers, mineralocorticoid receptor antagonists, hydralazine/isosorbide dinitrate, and ivabradine. Dapagliflozin [Farxiga^® (USA); Forxiga^® (EU)] is an SGLT2 inhibitor originally developed for the treatment of T2DM. It was the first SGLT2 inhibitor to be approved for the treatment of adults with symptomatic HFrEF. When added to standard therapy, dapagliflozin significantly reduced the risk of worsening HF or CV death in patients with HFrEF, regardless of whether or not they had T2DM. Moreover, the beneficial effects of dapagliflozin were seen regardless of patients’ usual HF medications. Dapagliflozin was generally well tolerated and is a valuable option for the treatment of symptomatic HFrEF.

The role of sodium-glucose co-transporter 2 protein inhibitors in heart failure: more than an antidiabetic drug?

INTRODUCTION

Heart failure (HF) places a great burden on both the patient and on medical facilities worldwide, with admission due to worsening HF being one of the leading causes of hospitalization. Optimizing HF in the community remains a challenge, but with appropriate medications, specialist review, and community support, the number of hospital admissions could be reduced. Sodium glucose co-transporter protein 2 (SGLT2) inhibitors have been shown to play a role in patients with heart failure and reduce adverse cardiovascular outcomes. This article seeks to investigate the existing medical literature to understand the role of SGLT2 inhibitors in patients with heart failure with reduced ejection fraction (HFrEF).

AREAS COVERED

An electronic search was undertaken looking at recent literature studying the outcomes of SGLT2 inhibitors on patients with heart failure. No limits were placed on the timing of the publications or the type of article. Keywords and MeSH terms were used, and the results were summarized in the relevant section.

EXPERT OPINION

This study shows that SGLT2 inhibitors are a safe and effective medication in the setting of HFrEF and has been shown to reduce symptoms of heart failure thus improving quality of life and reducing admissions due to heart failure and cardiovascular mortality.

Impact of SGLT2 inhibitors on major clinical events and safety outcomes in heart failure patients: a meta-analysis of randomized clinical trials

BACKGROUND

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) significantly reduce the risk of cardiovascular (CV) and renal adverse events in patients with diabetes mellitus, heart failure (HF) and/or chronic kidney disease. We performed a meta-analysis to explore the impact of several different SGLT2i on all-cause mortality, CV mortality, HF hospitalizations and the combined outcome CV death/HF hospitalization in HF patients across the spectrum of left ventricular ejection fraction (LVEF) phenotypes.

METHODS

A systematic search in MEDLINE database and Cochrane library through March 2021 was performed without limitations. Randomized clinical trials that provided data about the impact of SGLT2i on all-cause mortality, CV mortality, HF hospitalizations or the combined outcome of CV death/HF hospitalization in HF patients were included. A random effects model was used for calculating the effect estimates.

RESULTS

Nine studies (n = 16,723 patients, mean age: 65.9 years, males: 70.7%) were included in the quantitative synthesis. Compared to placebo, SGLT2i use was associated with 14% lower risk of all-cause mortality [hazard ratio (HR) = 0.86, 95% CI: 0.78−0.94,I² = 0, P = 0.0008], 32% lower risk of HF hospitalizations (HR = 0.68, 95% CI: 0.62−0.74,I² = 0, P < 0.001), 14% lower risk of CV mortality (HR = 0.86, 95% CI: 0.77−0.95, I² = 0, P = 0.003) and 26% lower risk of CV death/HF hospitalization (HR = 0.74, 95% CI: 0.68−0.80,I² = 0, P < 0.001). Regarding the safety outcomes, our data revealed no significant differences between SGLT2i and placebo groups in drug related discontinuations, amputations, severe hypoglycemia, hypotension, volume depletion, ketoacidosis and genital infections. By contrast, a protective role of SGLT2i against placebo was found for serious adverse events and acute kidney injury.

CONCLUSIONS

In patients with HF, regardless of LVEF phenotype, all SGLT2i had an excellent safety profile and significantly reduced the risk of all-cause mortality, CV mortality, HF hospitalizations and CV deaths/HF hospitalizations compared to placebo.

Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of death globally. Recently, dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) were approved for treating people with type 2 diabetes mellitus. Although metformin remains the first-line pharmacotherapy for people with type 2 diabetes mellitus, a body of evidence has recently emerged indicating that DPP4i, GLP-1RA and SGLT2i may exert positive effects on patients with known CVD.

OBJECTIVES

To systematically review the available evidence on the benefits and harms of DPP4i, GLP-1RA, and SGLT2i in people with established CVD, using network meta-analysis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and the Conference Proceedings Citation Index on 16 July 2020. We also searched clinical trials registers on 22 August 2020. We did not restrict by language or publication status.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) investigating DPP4i, GLP-1RA, or SGLT2i that included participants with established CVD. Outcome measures of interest were CVD mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, all-cause mortality, hospitalisation for heart failure (HF), and safety outcomes.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened the results of searches to identify eligible studies and extracted study data. We used the GRADE approach to assess the certainty of the evidence. We conducted standard pairwise meta-analyses and network meta-analyses by pooling studies that we assessed to be of substantial homogeneity; subgroup and sensitivity analyses were also pursued to explore how study characteristics and potential effect modifiers could affect the robustness of our review findings. We analysed study data using the odds ratios (ORs) and log odds ratios (LORs) with their respective 95% confidence intervals (CIs) and credible intervals (Crls), where appropriate. We also performed narrative synthesis for included studies that were of substantial heterogeneity and that did not report quantitative data in a usable format, in order to discuss their individual findings and relevance to our review scope.

MAIN RESULTS

We included 31 studies (287 records), of which we pooled data from 20 studies (129,465 participants) for our meta-analysis. The majority of the included studies were at low risk of bias, using Cochrane's tool for assessing risk of bias. Among the 20 pooled studies, six investigated DPP4i, seven studied GLP-1RA, and the remaining seven trials evaluated SGLT2i. All outcome data described below were reported at the longest follow-up duration. 1. DPP4i versus placebo Our review suggests that DPP4i do not reduce any risk of efficacy outcomes: CVD mortality (OR 1.00, 95% CI 0.91 to 1.09; high-certainty evidence), myocardial infarction (OR 0.97, 95% CI 0.88 to 1.08; high-certainty evidence), stroke (OR 1.00, 95% CI 0.87 to 1.14; high-certainty evidence), and all-cause mortality (OR 1.03, 95% CI 0.96 to 1.11; high-certainty evidence). DPP4i probably do not reduce hospitalisation for HF (OR 0.99, 95% CI 0.80 to 1.23; moderate-certainty evidence). DPP4i may not increase the likelihood of worsening renal function (OR 1.08, 95% CI 0.88 to 1.33; low-certainty evidence) and probably do not increase the risk of bone fracture (OR 1.00, 95% CI 0.83 to 1.19; moderate-certainty evidence) or hypoglycaemia (OR 1.11, 95% CI 0.95 to 1.29; moderate-certainty evidence). They are likely to increase the risk of pancreatitis (OR 1.63, 95% CI 1.12 to 2.37; moderate-certainty evidence). 2. GLP-1RA versus placebo Our findings indicate that GLP-1RA reduce the risk of CV mortality (OR 0.87, 95% CI 0.79 to 0.95; high-certainty evidence), all-cause mortality (OR 0.88, 95% CI 0.82 to 0.95; high-certainty evidence), and stroke (OR 0.87, 95% CI 0.77 to 0.98; high-certainty evidence). GLP-1RA probably do not reduce the risk of myocardial infarction (OR 0.89, 95% CI 0.78 to 1.01; moderate-certainty evidence), and hospitalisation for HF (OR 0.95, 95% CI 0.85 to 1.06; high-certainty evidence). GLP-1RA may reduce the risk of worsening renal function (OR 0.61, 95% CI 0.44 to 0.84; low-certainty evidence), but may have no impact on pancreatitis (OR 0.96, 95% CI 0.68 to 1.35; low-certainty evidence). We are uncertain about the effect of GLP-1RA on hypoglycaemia and bone fractures. 3. SGLT2i versus placebo This review shows that SGLT2i probably reduce the risk of CV mortality (OR 0.82, 95% CI 0.70 to 0.95; moderate-certainty evidence), all-cause mortality (OR 0.84, 95% CI 0.74 to 0.96; moderate-certainty evidence), and reduce the risk of HF hospitalisation (OR 0.65, 95% CI 0.59 to 0.71; high-certainty evidence); they do not reduce the risk of myocardial infarction (OR 0.97, 95% CI 0.84 to 1.12; high-certainty evidence) and probably do not reduce the risk of stroke (OR 1.12, 95% CI 0.92 to 1.36; moderate-certainty evidence). In terms of treatment safety, SGLT2i probably reduce the incidence of worsening renal function (OR 0.59, 95% CI 0.43 to 0.82; moderate-certainty evidence), and probably have no effect on hypoglycaemia (OR 0.90, 95% CI 0.75 to 1.07; moderate-certainty evidence) or bone fracture (OR 1.02, 95% CI 0.88 to 1.18; high-certainty evidence), and may have no impact on pancreatitis (OR 0.85, 95% CI 0.39 to 1.86; low-certainty evidence). 4. Network meta-analysis Because we failed to identify direct comparisons between each class of the agents, findings from our network meta-analysis provided limited novel insights. Almost all findings from our network meta-analysis agree with those from the standard meta-analysis. GLP-1RA may not reduce the risk of stroke compared with placebo (OR 0.87, 95% CrI 0.75 to 1.0; moderate-certainty evidence), which showed similar odds estimates and wider 95% Crl compared with standard pairwise meta-analysis. Indirect estimates also supported comparison across all three classes. SGLT2i was ranked the best for CVD and all-cause mortality.

AUTHORS' CONCLUSIONS

Findings from both standard and network meta-analyses of moderate- to high-certainty evidence suggest that GLP-1RA and SGLT2i are likely to reduce the risk of CVD mortality and all-cause mortality in people with established CVD; high-certainty evidence demonstrates that treatment with SGLT2i reduce the risk of hospitalisation for HF, while moderate-certainty evidence likely supports the use of GLP-1RA to reduce fatal and non-fatal stroke. Future studies conducted in the non-diabetic CVD population will reveal the mechanisms behind how these agents improve clinical outcomes irrespective of their glucose-lowering effects.

SGLT2 inhibitors in heart failure with reduced ejection fraction

Sodium - glucose co-transporter 2 (SGLT2) inhibitors reduce blood glucose by inhibiting reabsorption of glucose from the proximal renal tubules. Initial studies showed that apart from reducing blood glucose they also reduce the combined endpoint of myocardial infarction, stroke, and cardiovascular death, hospitalization from heart failure, and occurrence of renal failure in patients with known cardiovascular disease or at high risk of developing cardiovascular disease. Recent studies have shown that these drugs also could be used in patients to treat heart failure or to slow the progression of renal failure, irrespective of whether the patients have diabetes or not. In this review, we discuss the clinical trial evidence for the use of SGLT2 inhibitors for the treatment of patients with heart failure with reduced ejection fraction and for the prevention of heart failure in patients with diabetes who are at high risk of cardiovascular events. We also discuss the plausible mechanisms of action for the cardiovascular beneficial effects of SGLT2 inhibitors. EMPA-REG OUTCOME TRIAL, DECLARE-TIMI 58, CANVAS, VERTIS-CV studies have shown that SGLT2 inhibitors namely empagliflozin, dapagliflozin, canagliflozin and ertugliflozin reduce the chances of hospitalisation in patients who have cardiovascular disease or at high risk of cardiovascular disease. The DAPA-HF study and the EMPEROR-REDUCED TRIAL have further shown that Dapagliflozin and Empagliflozin could be used to treat patients with heart failure, with or without diabetes. SGLT2 inhibitors provide us with a new armamentarium for treatment of patients with a triad of diabetes, heart or renal disease. Their mechanism of action in prevention or treatment of patients with heart failure however still remains speculative.

Effect of Empagliflozin on Worsening Heart Failure Events in Patients With Heart Failure and Preserved Ejection Fraction: EMPEROR-Preserved Trial

BACKGROUND

Empagliflozin reduces the risk of cardiovascular death or hospitalization for heart failure in patients with heart failure with preserved ejection fraction, but additional data are needed about its effect on inpatient and outpatient heart failure events.

METHODS

We randomly assigned 5988 patients with class II through IV heart failure with an ejection fraction of >40% to double-blind treatment with placebo or empagliflozin (10 mg once daily), in addition to usual therapy, for a median of 26 months. We prospectively collected information on inpatient and outpatient events reflecting worsening heart failure and prespecified their analysis in individual and composite end points.

RESULTS

Empagliflozin reduced the combined risk of cardiovascular death, hospitalization for heart failure, or an emergency or urgent heart failure visit requiring intravenous treatment (432 versus 546 patients [empagliflozin versus placebo, respectively]; hazard ratio, 0.77 [95% CI, 0.67-0.87]; P<0.0001). This benefit reached statistical significance at 18 days after randomization. Empagliflozin reduced the total number of heart failure hospitalizations that required intensive care (hazard ratio, 0.71 [95% CI, 0.52-0.96]; P=0.028) and the total number of all hospitalizations that required a vasopressor or positive inotropic drug (hazard ratio, 0.73 [95% CI, 0.55-0.97]; P=0.033). Compared with patients in the placebo group, fewer patients in the empagliflozin group reported outpatient intensification of diuretics (482 versus 610; hazard ratio, 0.76 [95% CI, 0.67-0.86]; P<0.0001), and patients assigned to empagliflozin were 20% to 50% more likely to have a better New York Heart Association functional class, with significant effects at 12 weeks that were maintained for at least 2 years. The benefit on total heart failure hospitalizations was similar in patients with an ejection fraction of >40% to <50% and 50% to <60%, but was attenuated at higher ejection fractions.

CONCLUSIONS

In patients with heart failure with preserved ejection fraction, empagliflozin produced a meaningful, early, and sustained reduction in the risk and severity of a broad range of inpatient and outpatient worsening heart failure events. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03057977.

Empagliflozin in Heart Failure with a Preserved Ejection Fraction

BACKGROUND

Sodium-glucose cotransporter 2 inhibitors reduce the risk of hospitalization for heart failure in patients with heart failure and a reduced ejection fraction, but their effects in patients with heart failure and a preserved ejection fraction are uncertain.

METHODS

In this double-blind trial, we randomly assigned 5988 patients with class II-IV heart failure and an ejection fraction of more than 40% to receive empagliflozin (10 mg once daily) or placebo, in addition to usual therapy. The primary outcome was a composite of cardiovascular death or hospitalization for heart failure.

RESULTS

Over a median of 26.2 months, a primary outcome event occurred in 415 of 2997 patients (13.8%) in the empagliflozin group and in 511 of 2991 patients (17.1%) in the placebo group (hazard ratio, 0.79; 95% confidence interval [CI], 0.69 to 0.90; P<0.001). This effect was mainly related to a lower risk of hospitalization for heart failure in the empagliflozin group. The effects of empagliflozin appeared consistent in patients with or without diabetes. The total number of hospitalizations for heart failure was lower in the empagliflozin group than in the placebo group (407 with empagliflozin and 541 with placebo; hazard ratio, 0.73; 95% CI, 0.61 to 0.88; P<0.001). Uncomplicated genital and urinary tract infections and hypotension were reported more frequently with empagliflozin.

CONCLUSIONS

Empagliflozin reduced the combined risk of cardiovascular death or hospitalization for heart failure in patients with heart failure and a preserved ejection fraction, regardless of the presence or absence of diabetes. (Funded by Boehringer Ingelheim and Eli Lilly; EMPEROR-Preserved ClinicalTrials.gov number, NCT03057951).

Sodium-glucose cotransporter 2 inhibitor effects on heart failure hospitalization and cardiac function: systematic review

AIMS

To systematically review randomized controlled trials assessing effects of sodium-glucose cotransporter 2 inhibitors (SGLT2is) on hospitalization for heart failure (HHF) and cardiac structure/function and explore randomized controlled trial (RCT)-derived evidence for SGLT2i efficacy mechanisms in heart failure (HF).

METHODS AND RESULTS

Systematic searches of Medline and Embase were performed. In seven trials [3730-17 160 patients; low risk of bias (RoB)], SGLT2is significantly reduced the relative risk of HHF by 27-39% vs. placebo, including in two studies in patients with HF with reduced ejection fraction with or without type-2 diabetes mellitus (T2DM). Improvements in conventional cardiovascular risk factors, including glycaemic levels, cannot account for these effects. Five trials (56-105 patients; low RoB) assessed the effects of 6-12 months of SGLT2i treatment on left ventricular structure/function; four reported significant improvements vs. placebo, and one did not. Five trials (low RoB) assessed SGLT2i treatment effects on serum N-terminal pro B-type natriuretic peptide levels; significant reductions vs. placebo were reported after 8-12 months (two studies; 3730-4744 patients) but not ≤12 weeks (three studies; 80-263 patients). Limited available RCT-derived evidence suggests various possible cardioprotective SGLT2i mechanisms, including improved haemodynamics (natriuresis and reduced interstitial fluid without blood volume contraction/neurohormonal activation) and vascular function, enhanced erythropoiesis, reduced tissue sodium and epicardial fat/inflammation, decreased sympathetic tone, and beneficial changes in cellular energetics.

CONCLUSIONS

Sodium-glucose cotransporter 2 inhibitors reduce HHF regardless of T2DM status, and reversal of adverse left ventricular remodelling likely contributes to this efficacy. Hypothesis-driven mechanistic trials remain sparse, although numerous trials are planned or ongoing.

Sodium-glucose cotransporter-2 Inhibitors in Heart Failure: An Updated Systematic Review and Meta-analysis of 13 Randomized Clinical Trials Including 14,618 Patients With Heart Failure

ABSTRACT

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors showed benefit in patients with heart failure. In this updated meta-analysis, we evaluate the therapeutic efficacy and safety of SGLT-2 inhibitors in patients with heart failure. Different electronic databases were searched to find relevant articles. RevMan 5.4 was used for pooling data using a random/fixed-effects model, complemented by several sensitivity and subgroup analyses. A total of 13 randomized clinical trials including 14,618 patients with heart failure were included in analysis among 6797 studies screened. The overall mortality rate was 12.45% in the SGLT-2 group and 14.67% in the placebo group with 18% lower odds of overall mortality [odds ratio (OR), 0.82; confidence interval (CI), 0.75-0.91] in the SGLT-2 group. Odds of cardiovascular mortality was 18% lower (OR, 0.82; CI, 0.74-0.92) in the SGLT-2 group. The odds of hospitalization for heart failure (HHF) was 38% lower during the study period (OR, 0.62; CI, 0.56-0.68) in the SGLT-2 group. In addition, a benefit was seen for composite outcome HHF or mortality and considering subgrouping based on diabetes status, gender, and age groups. Although genital infection was significantly higher in the SGLT-2 group, the occurrence of severe adverse events, hypoglycemia, urinary tract infection, bone fracture, volume depletion, and other renal events did not differ between the 2 groups. Thus, SGLT-2 inhibitors improved cardiovascular outcomes among patients with heart failure with no significant difference in adverse events. Clinical benefit was comparable in diabetic and nondiabetic individuals, males and females, people in younger and older age groups with underlying heart failure, and HF with reduced ejection fraction.