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Verma S, Dhingra NK, Butler J, Anker SD, Ferreira JP, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Peil B, Nordaby M, Brueckmann M, Pocock SJ, Zannad F, Packer M. Empagliflozin in the treatment of heart failure with reduced ejection fraction in addition to background therapies and therapeutic combinations (EMPEROR-Reduced): a post-hoc analysis of a randomised, double-blind trial. Lancet Diabetes Endocrinol 2022; 10:35-45. [PMID: 34861154 DOI: 10.1016/s2213-8587(21)00292-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is important to evaluate whether a new treatment for heart failure with reduced ejection fraction (HFrEF) provides additive benefit to background foundational treatments. As such, we aimed to evaluate the efficacy and safety of empagliflozin in patients with HFrEF in addition to baseline treatment with specific doses and combinations of disease-modifying therapies. METHODS We performed a post-hoc analysis of the EMPEROR-Reduced randomised, double-blind, parallel-group trial, which took place in 520 centres (hospitals and medical clinics) in 20 countries in Asia, Australia, Europe, North America, and South America. Patients with New York Heart Association (NYHA) classification II-IV with an ejection fraction of 40% or less were randomly assigned (1:1) to receive the addition of either oral empagliflozin 10 mg per day or placebo to background therapy. The primary composite outcome was cardiovascular death and heart failure hospitalisation; the secondary outcome was total heart failure hospital admissions. An extended composite outcome consisted of inpatient and outpatient HFrEF events was also evaluated. Outcomes were analysed according to background use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or angiotensin receptor neprilysin inhibitors (ARNIs), as well as β blockers and mineralocorticoid receptor antagonists (MRAs) at less than 50% or 50% or more of target doses and in various combinations. This study is registered with ClinicalTrials.gov, NCT03057977. FINDINGS In this post-hoc analysis of 3730 patients (mean age 66·8 years [SD 11·0], 893 [23·9%] women; 1863 [49·9%] in the empagliflozin group, 1867 [50·1%] in the placebo group) assessed between March 6, 2017, and May 28, 2020, empagliflozin reduced the risk of the primary outcome (361 in 1863 participants in the empagliflozin group and 462 of 1867 in the placebo group; HR 0·75 [95% CI 0·65-0·86]) regardless of background therapy or its target doses for ACE inhibitors or ARBs at doses of less than 50% of the target dose (HR 0·85 [0·69-1·06]) and for doses of 50% or more of the target dose (HR 0·67 [0·52-0·88]; pinteraction=0·18). A similar result was seen for β blockers at doses of less than 50% of the target dose (HR 0·66 [0·54-0·80]) and for doses of 50% or more of the target dose (HR 0·81 [0·66-1·00]; pinteraction=0·15). Empagliflozin also reduced the risk of the primary outcome irrespective of background use of triple therapy with an ACE inhibitor, ARB, or ARNI plus β blocker plus MRA (given combination HR 0·73 [0·61-0·88]; not given combination HR 0·76 [0·62-0·94]; pinteraction=0·77). Similar patterns of benefit were observed for the secondary and extended composite outcomes. Empagliflozin was well tolerated and rates of hypotension, symptomatic hypotension, and hyperkalaemia were similar across all subgroups. INTERPRETATION Empagliflozin reduced serious heart failure outcomes across doses and combinations of disease-modifying therapies for HFrEF. Clinically, these data suggest that empagliflozin might be considered as a foundational therapy in patients with HFrEF regardless of their existing background therapy. FUNDING Boehringer Ingelheim and Eli Lilly and Company.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Joao Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative- Cardiovascular and Renal Clinical Trialists, Nancy, France; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke- National University of Singapore Medical School, Singapore
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany; Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative- Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA; Imperial College London, London, UK
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152
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Effects of SGLT2 Inhibitors on Atherosclerosis: Lessons from Cardiovascular Clinical Outcomes in Type 2 Diabetic Patients and Basic Researches. J Clin Med 2021; 11:jcm11010137. [PMID: 35011882 PMCID: PMC8745121 DOI: 10.3390/jcm11010137] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 12/16/2022] Open
Abstract
Atherosclerosis-caused cardiovascular diseases (CVD) are the leading cause of mortality in type 2 diabetes mellitus (T2DM). Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective oral drugs for the treatment of T2DM patients. Multiple pre-clinical and clinical studies have indicated that SGLT2 inhibitors not only reduce blood glucose but also confer benefits with regard to body weight, insulin resistance, lipid profiles and blood pressure. Recently, some cardiovascular outcome trials have demonstrated the safety and cardiovascular benefits of SGLT2 inhibitors beyond glycemic control. The SGLT2 inhibitors empagliflozin, canagliflozin, dapagliflozin and ertugliflozin reduce the rates of major adverse cardiovascular events and of hospitalization for heart failure in T2DM patients regardless of CVD. The potential mechanisms of SGLT2 inhibitors on cardioprotection may be involved in improving the function of vascular endothelial cells, suppressing oxidative stress, inhibiting inflammation and regulating autophagy, which further protect from the progression of atherosclerosis. Here, we summarized the pre-clinical and clinical evidence of SGLT2 inhibitors on cardioprotection and discussed the potential molecular mechanisms of SGLT2 inhibitors in preventing the pathogenesis of atherosclerosis and CVD.
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153
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Abstract
Coronary artery disease is the leading cause of death in both men and women, yet adequate control of risk factors can largely reduce the incidence and recurrence of cardiac events. In this review, we discuss various life style and pharmacological measures for both the primary and secondary prevention of coronary artery disease. With a clear understanding of management options, health care providers have an excellent opportunity to educate patients and ameliorate a significant burden of morbidity and mortality.
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Affiliation(s)
- Lindsay Short
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California
| | - Van T. La
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California
| | - Mandira Patel
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California
| | - Ramdas G. Pai
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California,Address for correspondence Ramdas G. Pai, MD UCR School of MedicineRiversideCalifornia
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154
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Jiang Y, Zheng R, Sang H. Cost-Effectiveness of Adding SGLT2 Inhibitors to Standard Treatment for Heart Failure With Reduced Ejection Fraction Patients in China. Front Pharmacol 2021; 12:733681. [PMID: 34858172 PMCID: PMC8631914 DOI: 10.3389/fphar.2021.733681] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/20/2021] [Indexed: 12/11/2022] Open
Abstract
Objective: To evaluate the economics and effectiveness of adding dapagliflozin or empagliflozin to the standard treatment for heart failure (HF) for patients with reduced ejection fraction (HFrEF) in China. Methods: A Markov model was developed to project the clinical and economic outcomes of adding dapagliflozin or empagliflozin to the standard treatment for 66-year-old patients with HFrEF. A cost-utility analysis was performed based mostly on data from the empagliflozin outcome trial in patients with chronic heart failure and a reduced ejection fraction (EMPEROR-Reduced) study and the dapagliflozin and prevention of adverse outcomes in heart failure (DAPA-HF) trial. The primary outcomes were measured via total and incremental costs and quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER). Results: In China, compared to the standard treatment, although adding dapagliflozin to the standard treatment in the treatment of HFrEF was more expensive ($4,870.68 vs. $3,596.25), it was more cost-effective (3.87 QALYs vs. 3.64 QALYs), resulting in an ICER of $5,541.00 per QALY. Similarly, adding empagliflozin was more expensive ($5,021.93 vs. $4,118.86) but more cost-effective (3.66 QALYs vs. 3.53 QALYs), resulting in an ICER of $6,946.69 per QALY. A sensitivity analysis demonstrated the robustness of the model in identifying cardiovascular death as a significant driver of cost-effectiveness. A probabilistic sensitivity analysis indicated that when the willingness-to-pay was $11,008.07 per QALY, the probability of the addition of dapagliflozin or empagliflozin being cost-effective was 70.5 and 55.2%, respectively. A scenario analysis showed that the cost of hospitalization, diabetes status, and time horizon had a greater impact on ICER. Conclusion: Compared with standard treatments with or without empagliflozin, adding dapagliflozin to the standard treatment in the treatment of HFrEF in China was extremely cost-effective.
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Affiliation(s)
- Yaohui Jiang
- Department Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rujie Zheng
- Department Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiqiang Sang
- Department Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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155
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Persson F, Charles M, Povlsen JV, Knudsen ST. Improving frequency of urinary albumin testing in type 2 diabetes in primary care - An analysis of cross-sectional studies in Denmark. Prim Care Diabetes 2021; 15:1007-1011. [PMID: 34284949 DOI: 10.1016/j.pcd.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND To ensure high quality standards in chronic care of type 2 diabetes, it is paramount to ensure regular measurement of clinical risk factors. For prevention of diabetic kidney disease, testing for albuminuria and kidney function is vital. The majority of individuals with type 2 diabetes in Denmark are treated in general practice, and given the recent development of kidney-protective treatments, a renewed focus on renal risk factors is important. OBJECTIVE To assess the frequency of albuminuria and kidney function testing in general practice in Denmark and describe developments over the last decade. The proportion of patients with the recommended annual measurements of albuminuria and kidney function was the primary variable. METHODS We used data from subjects with type 2 diabetes in three cross-sectional general practice studies from 2009 to 2017. RESULTS Data from 5592 individuals were available. Almost all subjects (96-99%) in the studies had annual measurement of kidney function performed. During the combined observation period there was a clear increase in the proportion of subjects that had albuminuria measured, from 57.2% to 68.0% to 82.8%. CONCLUSION The regular assessment of renal risk factors in individuals with type 2 diabetes attending primary care in Denmark has seemingly improved over the last decade. This provides the required base for renal risk assessment and appropriate therapy selection.
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Affiliation(s)
| | - Morten Charles
- Research Unit of General Practice, Aarhus University, Denmark; Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren Tang Knudsen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
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156
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Kim AH, Jang JE, Han J. Current status on the therapeutic strategies for heart failure and diabetic cardiomyopathy. Biomed Pharmacother 2021; 145:112463. [PMID: 34839258 DOI: 10.1016/j.biopha.2021.112463] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a leading cause of disease and death from cardiovascular diseases, with cardiovascular diseases accounting for the highest cases of deaths worldwide. The reality is that the quality-of-life survival for those suffering HF remains poor with 45-60% reported deaths within five years. Furthermore, cardiovascular disease is the foremost cause of mortality and disability in people with type 2 diabetes mellitus (T2DM), with T2DM patients having a two-fold greater risk of developing heart failure. The number of T2DM affected persons only continues to surge as there are more than 400 million adults affected by diabetes and an estimated 64.3 million affected by heart failure globally (1). In order to cater to the demands of modern society, the medical field has continuously improved upon the standards for clinical management and its therapeutic approaches. For this purpose, in this review, we aim to provide an overview of the current updates regarding heart failure, to include both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) and their respective treatments, while also diving further into heart failure and its correlation with diabetes and diabetic cardiomyopathy and their respective therapeutic approaches.
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Affiliation(s)
- Amy Hyein Kim
- Department of Physiology, College of Medicine, Cardiovascular and Metabolic Disease Center, Smart Marine Therapeutics Center, Inje University, Busan 47392, South Korea; Department of Health Sciences and Technology, Graduate School, Inje University, Busan 47392, South Korea
| | - Jung Eun Jang
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, College of Medicine, Cardiovascular and Metabolic Disease Center, Smart Marine Therapeutic Center, Inje University, Busan, South Korea
| | - Jin Han
- Department of Physiology, College of Medicine, Cardiovascular and Metabolic Disease Center, Smart Marine Therapeutics Center, Inje University, Busan 47392, South Korea; Department of Health Sciences and Technology, Graduate School, Inje University, Busan 47392, South Korea.
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157
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Pabel S, Hamdani N, Singh J, Sossalla S. Potential Mechanisms of SGLT2 Inhibitors for the Treatment of Heart Failure With Preserved Ejection Fraction. Front Physiol 2021; 12:752370. [PMID: 34803735 PMCID: PMC8602188 DOI: 10.3389/fphys.2021.752370] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/07/2021] [Indexed: 12/19/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is an unsolved and growing concern in cardiovascular medicine. While no treatment options that improve prognosis in HFpEF patients has been established so far, SGLT2 inhibitors (SGLT2i) are currently being investigated for the treatment of HFpEF patients. SGLT2i have already been shown to mitigate comorbidities associated with HFpEF such as type 2 diabetes and chronic renal disease, however, more recently there has been evidence that they may also directly improve diastolic function. In this article, we discuss some potential beneficial mechanisms of SGLT2i in the pathophysiology of HFpEF with focus on contractile function.
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Affiliation(s)
- Steffen Pabel
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Nazha Hamdani
- Department of Molecular and Experimental Cardiology, Institut für Forschung und Lehre (IFL), Ruhr University Bochum, Bochum, Germany.,Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jagdeep Singh
- The Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Samuel Sossalla
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.,Clinic for Cardiology and Pneumology, Georg-August University Göttingen, DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
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158
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Ezekowitz JA, Zheng Y, Cohen-Solal A, Melenovský V, Escobedo J, Butler J, Hernandez AF, Lam CSP, O'Connor CM, Pieske B, Ponikowski P, Voors AA, deFilippi C, Westerhout CM, McMullan C, Roessig L, Armstrong PW. Hemoglobin and Clinical Outcomes in the Vericiguat Global Study in Patients With Heart Failure and Reduced Ejection Fraction (VICTORIA). Circulation 2021; 144:1489-1499. [PMID: 34432985 DOI: 10.1161/circulationaha.121.056797] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND In the VICTORIA trial (Vericiguat Global Study in Patients with Heart Failure with Reduced Ejection Fraction), anemia occurred more often in patients treated with vericiguat (7.6%) than with placebo (5.7%). We explored the association between vericiguat, randomization hemoglobin, development of anemia, and whether the benefit of vericiguat related to baseline hemoglobin. METHODS Anemia was defined as hemoglobin <13.0 g/dL in men and <12.0 g/dL in women (World Health Organization Anemia). Adverse events reported as anemia were also evaluated. We assessed the risk-adjusted relationship between hemoglobin and hematocrit with the primary outcome (composite of cardiovascular death or heart failure hospitalization) and the time-updated hemoglobin relationship to outcomes. RESULTS At baseline, 1719 (35.7%) patients had World Health Organization anemia; median hemoglobin was 13.4 g/L (25th, 75th percentile: 12.1, 14.7 g/dL). At 16 weeks from randomization, 1643 patients had World Health Organization anemia (284 new for vericiguat and 219 for placebo), which occurred more often with vericiguat than placebo (P<0.001). After 16 weeks, no further decline in hemoglobin occurred over 96 weeks of follow-up and the ratio of hemoglobin/hematocrit remained constant. Overall, adverse event anemia occurred in 342 patients (7.1%). A lower hemoglobin was unrelated to the treatment benefit of vericiguat (versus placebo) on the primary outcome. In addition, analysis of time-updated hemoglobin revealed no association with the treatment effect of vericiguat (versus placebo) on the primary outcome. CONCLUSIONS Anemia was common at randomization and lower hemoglobin was associated with a greater frequency of clinical events. Although vericiguat modestly lowered hemoglobin by 16 weeks, this effect did not further progress nor was it related to the treatment benefit of vericiguat. Registration: URL: https://www.clinicaltrials.gov: Unique identifier: NCT02861534.
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Affiliation(s)
- Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
| | | | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (V.M.)
| | - Jorge Escobedo
- Medical Research Unit on Clinical Epidemiology, Mexican Social Security Institute, Mexico City (J.E.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., C.M.O.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., C.M.O.).,Inova Heart and Vascular Institute, Falls Church, VA (C.M.O., C.D.)
| | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin (B.P.)
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland (P.P.)
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, The Netherlands (A.A.V.)
| | | | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
| | | | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
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159
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Staplin N, Roddick AJ, Emberson J, Reith C, Riding A, Wonnacott A, Kuverji A, Bhandari S, Baigent C, Haynes R, Herrington WG. Net effects of sodium-glucose co-transporter-2 inhibition in different patient groups: a meta-analysis of large placebo-controlled randomized trials. EClinicalMedicine 2021; 41:101163. [PMID: 34765951 PMCID: PMC8571171 DOI: 10.1016/j.eclinm.2021.101163] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/17/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The net absolute effects of sodium-glucose co-transporter-2 (SGLT-2) inhibitors across different patient groups have not been quantified. METHODS We performed a meta-analysis of published large (>500 participants/arm) placebo-controlled SGLT-2 inhibitor trials after systematically searching MEDLINE and Embase databases from inception to 28th August 2021 (PROSPERO 2021 CRD42021240468). FINDINGS Four heart failure trials (n=15,684 participants), four trials in type 2 diabetes mellitus at high atherosclerotic cardiovascular risk (n=42,568), and three trials in chronic kidney disease (n=19,289) were included. Relative risks (RRs) for all cardiovascular, renal and safety outcomes were broadly similar across these three patient groups, and between people with or without diabetes. Overall, compared to placebo, allocation to SGLT-2 inhibition reduced risk of hospitalization for heart failure or cardiovascular death by 23% (RR=0.77, 95%CI 0.73-0.80; n=6658), cardiovascular death by 14% (0.86, 0.81-0.92; n=3962), major adverse cardiovascular events by 11% (0.89, 0.84-0.94; n=5703), kidney disease progression by 36% (0.64, 0.59-0.70; n=2275), acute kidney injury by 30% (0.70, 0.62-0.79; n=1013 events) and severe hypoglycaemia by 13% (0.87, 0.79-0.97; n=1484). There was no effect of SGLT-2 inhibition on risk of non-cardiovascular death (0.93, 0.86-1.01; n=2226), but a net 12% reduction in all-cause mortality remained evident (0.88, 0.84-0.93; n=6188). However, the risk of ketoacidosis was 2-times higher among those allocated SGLT-2 inhibitors compared to placebo (2.03, 1.41-2.93; n=159; absolute excess in people with diabetes ∼0.3/1000 patient years). A small increased risk of urinary tract infection was evident (1.07, 1.02-1.13; n=5384) alongside a known increased risk of mycotic genital infections. Overall, risk of lower limb amputations was increased by 16% (1.16, 1.02-1.31; n=1074), but this risk was largely driven by a single outlying trial (CANVAS). INTERPRETATIONS The relative effects of SGLT-2 inhibition on key safety and efficacy outcomes are consistent across the different studied groups of patient. Consequently, absolute benefits and harms are determined by the absolute baseline risk of particular outcomes, with absolute benefits on mortality and on non-fatal serious cardiac/renal outcomes substantially exceeding the risks of amputation and ketoacidosis in the main patient groups studied to date. FUNDING MRC-UK & KRUK.
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Affiliation(s)
- Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Alistair J. Roddick
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Christina Reith
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Alex Riding
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Apexa Kuverji
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Sunil Bhandari
- Hull University Teaching Hospitals NHS Trust and Hull York Medical School, Hull, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
- Health Data Research UK, University of Oxford, Oxford, UK
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160
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Iacoviello M, Palazzuoli A, Gronda E. Recent advances in pharmacological treatment of heart failure. Eur J Clin Invest 2021; 51:e13624. [PMID: 34043809 PMCID: PMC8596398 DOI: 10.1111/eci.13624] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Over the last years, several trials offered new evidence on heart failure (HF) treatment. DESIGN AND RESULTS For HF with reduced left ventricular ejection fraction, type 2 sodium-glucose cotransporter inhibitors, aside from sacubitril-valsartan, demonstrated extraordinary efficacy in ameliorating patients' prognosis. Some new molecules (eg vericiguat, omecamtiv mecarbil and ferric carboxymaltose) correct iron deficiency and have shown to be capable of furthering reducing the burden of HF hospitalisation. Finally, there is new evidence on the possible therapeutic approaches of HF patients with mid-range or preserved left ventricular ejection fraction. CONCLUSIONS This review aimed to revise the main novelties in the field of HF therapy and focus on how the daily clinical approach to patient treatment is changing.
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Affiliation(s)
- Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Edoardo Gronda
- Dialisi e Trapianto Renale dell'adulto Dipartimento Di Medicina e Specialità Mediche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico di Milano UOC di Nefrologia, Milan, Italy
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161
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Singh AK, Singh R. Do SGLT-2 inhibitors exhibit similar cardiovascular benefit in patients having reduced ejection fraction heart failure with type 2 diabetes, prediabetes and normoglycemia? Diabetes Metab Syndr 2021; 15:102282. [PMID: 34562869 DOI: 10.1016/j.dsx.2021.102282] [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: 08/16/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS We aimed to know whether SGLT-2 inhibitors (SGLT-2I) exhibit similar cardiovascular (CV) benefit in patients having reduced ejection fraction heart failure (HFrEF) with varying degree of glycemia. METHOD We meta-analyzed the trial-level hazard ratio and 95% confidence interval of randomized trials that reported the CV outcomes stratified in to three subgroups of normoglycemia, prediabetes and diabetes. RESULTS This meta-analysis found a significant and similar CV risk reduction in patients with HFrEF without any significant interaction between three subgroups (PIntercation = 0.98). CONCLUSIONS SGLT-2I exhibit similar CV risk reduction in HFrEF, regardless of baseline glycemic status. However, this finding is limited to pooled data from only 2 studies in people without T2DM.
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Affiliation(s)
- Awadhesh Kumar Singh
- Department of Diabetes & Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India.
| | - Ritu Singh
- Department of Diabetes & Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India
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162
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Rosano GMC, Allen LA, Abdin A, Lindenfeld J, O'Meara E, Lam CSP, Lancellotti P, Savarese G, Gottlieb SS, Teerlink J, Wintrich J, Böhm M. Drug Layering in Heart Failure: Phenotype-Guided Initiation. JACC-HEART FAILURE 2021; 9:775-783. [PMID: 34627725 DOI: 10.1016/j.jchf.2021.06.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/11/2022]
Abstract
Medications with proven benefit in patients with heart failure with reduced ejection fraction are recommended, according to prospective large clinical trials, in the stable patient after careful up-titration in a strict sequential order. Although the relevance of careful clinical up-titration is unproven, there is evidence that after recompensation and shortly after hospital discharge, the rate of cardiovascular death and hospitalization is high. Clinical studies provided evidence that the onset of treatment effects is rapid, occurring within 28 days with most of these drugs used, and in some trials, early treatment after discharge or already started in the hospital has provided benefits. Therefore, early treatment without deferring it to the stable outpatient may be useful to reduce cardiac-related events further. This expert opinion proposes treatment layering according to individual patient phenotypes involving heart rate, blood pressure, impaired renal function, and electrolyte disturbances, as well as dedicated subgroups of patients with specific requirements for treatment initiation. This complements other approaches that suggest starting sequential treatment according to the size of treatment effects of drugs, specific cardiac diseases, and patient wishes. Patient phenotyping may guide personalized drug layering in heart failure with reduced ejection fraction that provides the best outcomes, whereas pragmatic clinical trials are warranted to scrutinize the effectiveness of these approaches.
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Affiliation(s)
- Giuseppe M C Rosano
- Centre for Clinical and Basic Research, IRCCS San Raffaele Roma, Rome, Italy
| | - Larry A Allen
- Division of Cardiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Amr Abdin
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Joann Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eileen O'Meara
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Carolyn S P Lam
- Duke-National University of Singapore and National Heart Centre Singapore, Singapore
| | | | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Stephen S Gottlieb
- University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, USA
| | - John Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Jan Wintrich
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
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163
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Young SL, Ryan L, Mullins TP, Flint M, Steane SE, Walton SL, Bielefeldt-Ohmann H, Carter DA, Reichelt ME, Gallo LA. Sotagliflozin, a Dual SGLT1/2 Inhibitor, Improves Cardiac Outcomes in a Normoglycemic Mouse Model of Cardiac Pressure Overload. Front Physiol 2021; 12:738594. [PMID: 34621187 PMCID: PMC8490778 DOI: 10.3389/fphys.2021.738594] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/31/2021] [Indexed: 01/10/2023] Open
Abstract
Selective SGLT2 inhibition reduces the risk of worsening heart failure and cardiovascular death in patients with existing heart failure, irrespective of diabetic status. We aimed to investigate the effects of dual SGLT1/2 inhibition, using sotagliflozin, on cardiac outcomes in normal diet (ND) and high fat diet (HFD) mice with cardiac pressure overload. Five-week-old male C57BL/6J mice were randomized to receive a HFD (60% of calories from fat) or remain on ND for 12 weeks. One week later, transverse aortic constriction (TAC) was employed to induce cardiac pressure-overload (50% increase in right:left carotid pressure versus sham surgery), resulting in left ventricular hypertrophic remodeling and cardiac fibrosis, albeit preserved ejection fraction. At 4 weeks post-TAC, mice were treated for 7 weeks by oral gavage once daily with sotagliflozin (10 mg/kg body weight) or vehicle (0.1% tween 80). In ND mice, treatment with sotagliflozin attenuated cardiac hypertrophy and histological markers of cardiac fibrosis induced by TAC. These benefits were associated with profound diuresis and glucosuria, without shifts toward whole-body fatty acid utilization, increased circulating ketones, nor increased cardiac ketolysis. In HFD mice, sotagliflozin reduced the mildly elevated glucose and insulin levels but did not attenuate cardiac injury induced by TAC. HFD mice had vacuolation of proximal tubular cells, associated with less profound sotagliflozin-induced diuresis and glucosuria, which suggests dampened drug action. We demonstrate the utility of dual SGLT1/2 inhibition in treating cardiac injury induced by pressure overload in normoglycemic mice. Its efficacy in high fat-fed mice with mild hyperglycemia and compromised renal morphology requires further study.
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Affiliation(s)
- Sophia L Young
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia.,Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Lydia Ryan
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia.,Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Thomas P Mullins
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia.,Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Melanie Flint
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Sarah E Steane
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Sarah L Walton
- Cardiovascular Disease Program, Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | | | - David A Carter
- Institute for Molecular Biosciences, The University of Queensland, St Lucia, QLD, Australia
| | - Melissa E Reichelt
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Linda A Gallo
- School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia.,Mater Research Institute-University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
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164
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Dhingra NK, Mistry N, Puar P, Verma R, Anker S, Mazer CD, Verma S. SGLT2 inhibitors and cardiac remodelling: a systematic review and meta-analysis of randomized cardiac magnetic resonance imaging trials. ESC Heart Fail 2021; 8:4693-4700. [PMID: 34623032 PMCID: PMC8712921 DOI: 10.1002/ehf2.13645] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/04/2021] [Accepted: 09/19/2021] [Indexed: 01/09/2023] Open
Abstract
Aims Recent large randomized controlled trials (RCTs) have demonstrated efficacy of sodium‐glucose cotransporter‐2 inhibitors (SGLT2i) in both preventing and treating heart failure (HF). SGLT2i‐induced reversal of left ventricular remodelling has been proposed as a mechanism contributing to this effect. Methods and results We performed a systematic review and meta‐analysis of RCTs to compare SGLT2i versus placebo (treatment duration >3 months) on cardiac remodelling parameters as measured by cardiac magnetic resonance imaging (cMRI) in patients with HF and/or diabetes. The PubMed and ClinicalTrials.gov databases were searched until 15 June 2021. Our primary outcome was change in absolute left ventricular mass (LVM) from baseline to study endpoint. Secondary outcomes included changes in LVM indexed to body surface area, left ventricular end‐systolic volume (LVESV), left ventricular end‐diastolic volume (LVEDV), and left ventricular ejection fraction (LVEF) from baseline to study endpoint. The Cochrane Collaboration's tool was used to assess risk of bias. Five studies representing 408 patients were included. SGLT2i was associated with greater LVM regression compared to placebo (MD, −5.76 g; 95% CI, −10.87 g to −0.64 g, I2 = 73%; overall effect, P < 0.03; four RCTs). Statistical subgroup differences were not observed in our sensitivity analysis focusing on HF with reduced ejection fraction (P = 0.37) and were observed in our sensitivity analysis focusing on diabetes (P < 0.001). SGLT2i was not associated with statistical changes in LV mass indexed to body surface area (I2 = 75%; P = 0.16; five RCTs), LVESV (I2 = 87%; P = 0.07; five RCTs), LVEDV (I2 = 81%; P = 0.20; five RCTs), nor LVEF (I2 = 85%; P = 0.19; five RCTs) versus placebo. Sixty per cent of RCTs had low risk of bias. Conclusions Sodium‐glucose cotransporter‐2 inhibitors treatment was associated with a reduction in left ventricular mass as assessed by cMRI.
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Affiliation(s)
- Nitish K Dhingra
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
| | - Nikhil Mistry
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Pankaj Puar
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
| | - Raj Verma
- North York Diagnostic and Cardiac Centre, Toronto, Ontario, Canada
| | - Stefan Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research, Partner Site Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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165
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[Heart failure with preserved ejection fraction as a model disease for the cardio-pulmonary-renal syndrome : Importance of visceral fat expansion as central pathomechanism]. Internist (Berl) 2021; 62:1141-1152. [PMID: 34613426 DOI: 10.1007/s00108-021-01182-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with diverse underlying etiologies and pathophysiological factors. Obesity and type 2 diabetes mellitus (T2DM), diseases which frequently coexist, induce a cluster of metabolic and nonmetabolic signaling derangements, which promote induction of inflammation, fibrosis and myocyte stiffness, all representing hallmarks of HFpEF. In contrast to other HFpEF risk factors, obesity and T2DM are often associated with the formation of an enlarged visceral adipose tissue (VAT), which is a highly active endocrine organ that can sustainably exacerbate inflammation and fibrotic remodeling of myocardial, renal, and vascular tissues via various paracrine and vasocrine signals. An abnormally large epicardial adipose tissue (EAT) thus not only causes a mechanical constriction of the diastolic filling procedure of the heart but is also associated with an increased release of proinflammatory adipokines that trigger atrial fibrillation and impaired left ventricular contraction parameters. Obese patients with HFpEF therefore belong to a unique HFpEF phenotype with a particularly poor prognosis that could benefit from an EAT-oriented phenotype-specific intervention. In addition to statins and antidiabetic drugs such as metformin, glucagon-like peptide‑1 (GLP-1) receptor agonists and sodium-glucose transporter 2 (SGLT-2) inhibitors could also play an important role.
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166
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Colacci M, Fralick M. Letter to the Editor Response: Sodium-Glucose Cotransporter-2 Inhibitors and Risk of Diabetic Ketoacidosis Among Adults With Type 2 Diabetes: A Systematic Review and Meta-Analysis. Can J Diabetes 2021; 46:110. [DOI: 10.1016/j.jcjd.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
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167
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SGLT2 Inhibitors Increase the Risk of Diabetic Ketoacidosis in Adults with Type 2 Diabetes: Should we be Concerned in People Without Diabetes? Can J Diabetes 2021; 46:109. [DOI: 10.1016/j.jcjd.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022]
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168
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Böhm M, Anker SD, Butler J, Filippatos G, Ferreira JP, Pocock SJ, Mahfoud F, Brueckmann M, Jamal W, Ofstad AP, Schüler E, Ponikowski P, Wanner C, Zannad F, Packer M. Empagliflozin Improves Cardiovascular and Renal Outcomes in Heart Failure Irrespective of Systolic Blood Pressure. J Am Coll Cardiol 2021; 78:1337-1348. [PMID: 34556320 DOI: 10.1016/j.jacc.2021.07.049] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Empagliflozin reduces the risk of cardiovascular death or heart failure (HF) hospitalization in patients with reduced ejection fraction. Its interplay with systolic blood pressure (SBP) is not known. OBJECTIVES The goal of this study was to evaluate the interplay of SBP and the effects of empagliflozin in EMPEROR-Reduced (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction). METHODS Study patients (N = 3,730) were randomly assigned to groups according to SBP at baseline (<110 mm Hg, n = 928; 110-130 mm Hg, n = 1,755; >130 mm Hg, n = 1,047). This study explored the influence of SBP on the effects of empagliflozin on cardiovascular death or HF hospitalization (primary outcome), as well as on total HF hospitalizations, rate of decline in estimated glomerular filtration rate, renal outcomes, and empagliflozin's effects and significance on SBP. RESULTS Over a median of 16 months considering only patients receiving placebo, baseline SBP and the risk of cardiovascular death or hospitalization for HF (P trend = 0.0015) were inversely related. Corrected for placebo, a slight early increase was observed in SBP at <110 mm Hg, no change at 110-130 mm Hg, and a slight reduction at >130 mm Hg. These between-group differences were of borderline significance (P for interaction trend = 0.05-0.10) after 4 and 12 weeks but were not significant later. SBP at baseline did not influence the effect of empagliflozin to reduce the risk of HF events or renal endpoints. When treated with empagliflozin, patients with SBP <110 mm Hg did not have an increased rate of symptomatic hypotension. CONCLUSIONS Empagliflozin was effective and safe, with no meaningful interaction between SBP and the effects of empagliflozin in the EMPEROR-Reduced trial. (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977).
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - João Pedro Ferreira
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Nancy, France Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany; Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Waheed Jamal
- Boehringer Ingelheim International, Ingelheim, Germany
| | | | | | | | - Christoph Wanner
- Medizinische Klinik und Poliklinik 1, Schwerpunkt Nephrologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Nancy, France Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Milton Packer
- Baylor University Medical Center, Dallas, Texas, USA; Imperial College, London, United Kingdom
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169
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Pabel S, Hamdani N, Luedde M, Sossalla S. SGLT2 Inhibitors and Their Mode of Action in Heart Failure-Has the Mystery Been Unravelled? Curr Heart Fail Rep 2021; 18:315-328. [PMID: 34523061 PMCID: PMC8484236 DOI: 10.1007/s11897-021-00529-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW SGLT2 inhibitors (SGLT2i) are new drugs for patients with heart failure (HF) irrespective of diabetes. However, the mechanisms of SGLT2i in HF remain elusive. This article discusses the current clinical evidence for using SGLT2i in different types of heart failure and provides an overview about the possible underlying mechanisms. RECENT FINDINGS Clinical and basic data strongly support and extend the use of SGLT2i in HF. Improvement of conventional secondary risk factors is unlikely to explain the prognostic benefits of these drugs in HF. However, different multidirectional mechanisms of SGLT2i could improve HF status including volume regulation, cardiorenal mechanisms, metabolic effects, improved cardiac remodelling, direct effects on cardiac contractility and ion-homeostasis, reduction of inflammation and oxidative stress as well as an impact on autophagy and adipokines. Further translational studies are needed to determine the mechanisms of SGLT2i in HF. However, basic and clinical evidence encourage the use of SGLT2i in HFrEF and possibly HFpEF.
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Affiliation(s)
- Steffen Pabel
- Department of Internal Medicine II, University Medical Centre Regensburg, Regensburg, Germany
| | - Nazha Hamdani
- Department of Molecular and Experimental Cardiology and Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Mark Luedde
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Samuel Sossalla
- Department of Internal Medicine II, University Medical Centre Regensburg, Regensburg, Germany. .,Clinic for Cardiology and Pneumology, Georg-August University Göttingen, and DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.
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170
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Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors improve blood glucose control by blocking renal glucose reabsorption with little subsequent risk of hypoglycemia. Consequently, there are decreases in plasma volume, body weight, and blood pressure. Additional putative benefits include improved cardiovascular energetics, decreased systemic inflammation, and less renal dysfunction. Multiple cardiovascular outcome trials in diabetic patients have demonstrated this drug class reduces the risk of adverse cardiovascular events. Reductions in heart failure (HF) hospitalization suggested that SGLT2 inhibitors might prove useful for the primary treatment of HF. Two large subsequent trials studying SGLT2 inhibitors in heart failure with reduced ejection fraction (HFrEF) demonstrated a reduction in cardiovascular mortality, HF hospitalizations, and renal-specific adverse events. This medication class is now recognized as a new pillar of therapy for patients with HFrEF. The cardiovascular and HF community await the results of ongoing trials of SGLT2 inhibition in patients with HF with preserved ejection fraction. Expected final online publication date for the Annual Review of Pharmacology and Toxicology, Volume 62 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Kevin S Shah
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah 84132, USA; ,
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah 84132, USA; ,
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171
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Influence of receptor selectivity on benefits from SGLT2 inhibitors in patients with heart failure: a systematic review and head-to-head comparative efficacy network meta-analysis. Clin Res Cardiol 2021; 111:428-439. [PMID: 34498169 PMCID: PMC8971161 DOI: 10.1007/s00392-021-01913-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022]
Abstract
Background Receptor selectivity of sodium-glucose cotransporter-2 inhibitors (SGLT2i) varies greatly between agents. The overall improvement of cardiovascular (CV) outcomes in heart failure (HF) patients varies between trials. We, therefore, evaluated the comparative efficacy of individual SGLT2i and the influence of their respective receptor selectivity thereon. Methods We identified randomized controlled trials investigating the use of SGLT2i in patients with HF—either as the target cohort or as a subgroup of it. Comparators included placebo or any other active treatment. The primary endpoint was the composite of hospitalization for HF or CV death. Secondary outcomes included all-cause mortality, CV mortality, hospitalization for HF, worsening renal function (RF), and the composite of worsening RF or CV death. Evidence was synthesized using network meta-analysis. In addition, the impact of receptor selectivity on outcomes was analysed using meta-regression. Results We identified 18,265 patients included in 22 trials. Compared to placebo, selective and non-selective SGLT2i improved fatal and non-fatal HF events. Head-to-head comparisons suggest superior efficacy with sotagliflozin as compared to dapagliflozin, empagliflozin or ertugliflozin. No significant difference was found between canagliflozin and sotagliflozin. Meta-regression analyses show a decreasing benefit on HF events with increasing receptor selectivity of SGLT2i. In contrast, receptor selectivity did not affect mortality and renal endpoints and no significant difference between individual SGLT2i was noted. Conclusion Our data point towards a class-effect of SGLT2i on mortality and renal outcomes. However, non-selective SGLT2i such as sotagliflozin may be superior to highly selective SGLT2i in terms of HF outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01913-z.
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172
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Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Straße 100, 66421 Homburg, Germany
| | - Michael Böhm
- Universitätsklinikum d. Saarlandes, Direktor d. Klinik für Innere Medizin III, Kirrberger Straße 100\/Geb. 41.1, 66421 Homburg \/ Saar, Germany
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173
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Yap SD, Hamblin PS, Bach L, Ekinci E, Wong R. Sodium glucose co-transporter-2 inhibitor-induced diabetic ketoacidosis following tooth extraction: improving awareness among dental practitioners. Aust Dent J 2021; 66:444-447. [PMID: 34432892 DOI: 10.1111/adj.12872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
Sodium glucose co-transporter-2 inhibitors (SGLT-2i) are a relatively new class of oral glucose lowering agents that improve glycaemic control and also provide significant cardiac and renal benefits. However, SGLT-2i use is associated with a small but significant increased risk of diabetic ketoacidosis (DKA) especially during periods of reduced oral intake such as following dental procedures, bowel preparation for colonoscopy, surgery and concurrent illness. In contrast with typical DKA, in many cases of SGLT2i-associated DKA, the blood glucose is normal or only slightly elevated, giving rise to the term euglycaemic DKA (euDKA). Patients with euDKA often present with non-specific symptoms. Moreover, their normal or only mildly elevated blood glucose levels might lead to delayed diagnosis and treatment and hence potentially life-threatening complications. Not only should patients taking an SGLT-2i be informed about the risk of euDKA, and be provided with SGLT-2i sick day management education, but clinicians should also be alert to this diagnosis.
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Affiliation(s)
- S D Yap
- Eastern Health, Melbourne, Victoria, Australia
| | - P S Hamblin
- Western Health, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - L Bach
- Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - E Ekinci
- University of Melbourne, Melbourne, Victoria, Australia.,Austin Health, Melbourne, Victoria, Australia
| | - R Wong
- Eastern Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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174
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Tsampasian V, Baral R, Chattopadhyay R, Debski M, Joshi SS, Reinhold J, Dweck MR, Garg P, Vassiliou VS. The Role of SGLT2 Inhibitors in Heart Failure: A Systematic Review and Meta-Analysis. Cardiol Res Pract 2021; 2021:9927533. [PMID: 34457360 PMCID: PMC8397556 DOI: 10.1155/2021/9927533] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/13/2021] [Indexed: 01/10/2023] Open
Abstract
AIMS Recent randomised controlled trials (RCTs) have shown a significant prognostic benefit of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the cardiovascular (CV) profile of patients with diabetes. This systematic review and meta-analysis aim to provide a concise evaluation of all the available evidence for the use of these agents in patients with heart failure (HF) regardless of their baseline diabetes status. METHODS AND RESULTS PubMed, Web of Science, and Cochrane library databases were systematically searched from inception until November 20th 2020. Eight studies consisting of 13,275 patients were included in the meta-analysis. For the total population, SGLT2 inhibitors reduced the risk of all-cause mortality (HR: 0.83; 95% CI: 0.75-0.91; I 2 0%), hospitalisation for HF (HR: 0.68; 95% CI: 0.61-0.75; I 2: 0%), CV death (HR: 0.82; 95% CI: 0.74-0.92; I 2: 0%), and hospitalisation for HF or CV death (HR: 0.72; 95% CI: 0.66-0.78; I 2: 0%). Subgroup analyses of the total population according to the diabetes status showed that SGLT2 inhibitors significantly reduced the risk of hospitalisation for HF (HR: 0.68; 95% CI: 0.61, 0.75; I 2: 0%), as well as the risk of hospitalisation for HF or CV death (HR: 0.72; 95% CI: 0.66, 078; I 2: 0%) and CV death (HR: 0.82; 95% CI: 0.74, 0.91; I 2: 0%). CONCLUSIONS The results of this meta-analysis confirm the growing evidence in the literature of the favourable profile of SGLT2 inhibitors in cardiovascular outcomes and mortality in patients with heart failure regardless of the baseline diabetes status. This systematic review has been registered with PROSPERO (CRD42021224777).
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Affiliation(s)
- Vasiliki Tsampasian
- Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Ranu Baral
- Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Rahul Chattopadhyay
- Department of Cardiology, Cambridge University Hospitals, Cambridge, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Maciej Debski
- Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Shruti S Joshi
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Johannes Reinhold
- Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Marc R Dweck
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Pankaj Garg
- Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Vassilios S Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Anker SD, Ponikowski P, Wanner C, Pfarr E, Hauske S, Peil B, Salsali A, Ritter I, Koitka-Weber A, Brueckmann M, Lindenfeld J, Abraham WT. Kidney Function After Initiation and Discontinuation of Empagliflozin in Heart Failure Patients With and Without Type 2 Diabetes: Insights From the EMPERIAL Trials. Circulation 2021; 144:1265-1267. [PMID: 34397263 DOI: 10.1161/circulationaha.121.054669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stefan D Anker
- Department of Cardiology, Charité University, Berlin, Germany (S.D.A., W.T.A.)
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Poland (P.P.)
| | - Christoph Wanner
- Division of Nephrology, Würzburg University Clinic, Wurzburg, Germany (C.W., A.K.-W.)
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany (E.P., B.P.)
| | - Sibylle Hauske
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany (S.H.)
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany (E.P., B.P.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT (A.S.)
- Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Ivana Ritter
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
| | - Audrey Koitka-Weber
- Division of Nephrology, Würzburg University Clinic, Wurzburg, Germany (C.W., A.K.-W.)
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia (A.K.-W.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
- Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany (M.B.)
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.L.)
| | - William T Abraham
- Department of Cardiology, Charité University, Berlin, Germany (S.D.A., W.T.A.)
- Division of Cardiovascular Medicine, The Ohio State University, Columbus (W.T.A.)
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176
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Savarese G, Butler J, Lund LH, Bhatt DL, Anker SD. CARDIOVASCULAR EFFECTS OF NON-INSULIN GLUCOSE-LOWERING AGENTS: A COMPREHENSIVE REVIEW OF TRIAL EVIDENCE AND POTENTIAL CARDIOPROTECTIVE MECHANISMS. Cardiovasc Res 2021; 118:2231-2252. [PMID: 34390570 DOI: 10.1093/cvr/cvab271] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is highly prevalent and associated with a 2-fold increased mortality, mostly explained by cardiovascular diseases. Trial evidence on older glucose-lowering agents such as metformin and sulfonylureas is limited in terms of cardiovascular efficacy. Since 2008, after rosiglitazone was observed to increase the risk of myocardial infarction and heart failure (HF), cardiovascular outcome trials (CVOT) have been required by regulators for licensing new glucose-lowering agents. In the following CVOTs, dipeptidyl peptidase 4 inhibitors (DPP4i) have been shown to be safe but not to improve morbidity/mortality, except for saxagliptin which increased the risk of HF. Several glucagon-like peptide-1 receptor agonists (GLP1-Ra) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been demonstrated to reduce the risk of cardiovascular morbidity and mortality. SGLT2i have shown a class effect for the reduction in risk of HF events in patients with T2DM, leading to trials testing their efficacy/safety in HF regardless of T2DM. In the DAPA-HF and the EMPEROR-Reduced trials dapagliflozin and empagliflozin, respectively, improved cardiovascular mortality/morbidity in patients with HF and reduced ejection fraction (HFrEF), with and without T2DM. Therefore, these drugs are now key part of HFrEF pharmacotherapy. In the SOLOIST-WHF, sotagliflozin reduced cardiovascular mortality/morbidity in patients with T2DM and a recent acute episode of HF regardless of EF. The DELIVER and the EMPEROR-Preserved are testing dapagliflozin and empagliflozin, respectively, in patients with HF with mildly reduced and preserved EF. A strong renal protective role of SGLT2i has also emerged in trials enrolling patients with and without T2DM.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Javed Butler
- University of Mississippi School of Medicine, Jackson, MI, USA
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany
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177
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Persson F, Rossing P, Vart P, Chertow GM, Hou FF, Jongs N, McMurray JJV, Correa-Rotter R, Bajaj HS, Stefansson BV, Toto RD, Langkilde AM, Wheeler DC, Heerspink HJL. Efficacy and Safety of Dapagliflozin by Baseline Glycemic Status: A Prespecified Analysis From the DAPA-CKD Trial. Diabetes Care 2021; 44:1894-1897. [PMID: 34183431 PMCID: PMC8385469 DOI: 10.2337/dc21-0300] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/18/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Dapagliflozin and Prevention of Adverse outcomes in Chronic Kidney Disease (DAPA-CKD) study demonstrated risk reduction for kidney and cardiovascular outcomes with dapagliflozin versus placebo in participants with chronic kidney disease (CKD) with and without diabetes. We compared outcomes according to baseline glycemic status. RESEARCH DESIGN AND METHODS We enrolled participants with CKD, estimated glomerular filtration rate (eGFR) 25-75 mL/min/1.73 m2, and urinary albumin-to-creatinine ratio 200-5,000 mg/g. The primary composite end point was sustained eGFR decline ≥50%, end-stage kidney disease, or kidney or cardiovascular death. RESULTS Of 4,304 participants, 738 had normoglycemia, 660 had prediabetes, and 2,906 had type 2 diabetes. The effect of dapagliflozin on the primary outcome was consistent (P for interaction = 0.19) in normoglycemia (hazard ratio [HR] 0.62 [95% CI 0.39, 1.01]), prediabetes (HR 0.37 [0.21, 0.66]), and type 2 diabetes (HR 0.64 [0.52, 0.79]). We found no evidence for effect modification on any outcome. Adverse events were similar, with no major hypoglycemia or ketoacidosis in participants with normoglycemia or prediabetes. CONCLUSIONS Dapagliflozin safely reduced kidney and cardiovascular events independent of baseline glycemic status.
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Affiliation(s)
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Glenn M Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Ricardo Correa-Rotter
- National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | | | - Bergur V Stefansson
- Late-stage Development, Cardiovascular, Renal and Metabolism, Biopharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Robert D Toto
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anna Maria Langkilde
- Late-stage Development, Cardiovascular, Renal and Metabolism, Biopharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, U.K.,The George Institute for Global Health, Sydney, Australia
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178
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Herrington WG, Savarese G, Haynes R, Marx N, Mellbin L, Lund LH, Dendale P, Seferovic P, Rosano G, Staplin N, Baigent C, Cosentino F. Cardiac, renal, and metabolic effects of sodium-glucose co-transporter 2 inhibitors: a position paper from the European Society of Cardiology ad-hoc task force on sodium-glucose co-transporter 2 inhibitors. Eur J Heart Fail 2021; 23:1260-1275. [PMID: 34184823 DOI: 10.1002/ejhf.2286] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/07/2022] Open
Abstract
In 2015, the first large-scale placebo-controlled trial designed to assess cardiovascular safety of glucose-lowering with sodium-glucose co-transporter 2 (SGLT2) inhibition in type 2 diabetes mellitus raised hypotheses that the class could favourably modify not only risk of atherosclerotic cardiovascular disease, but also hospitalization for heart failure, and the development or worsening of nephropathy. By the start of 2021, results from 10 large SGLT2 inhibitor placebo-controlled clinical outcome trials randomizing ∼71 000 individuals have confirmed that SGLT2 inhibitors can provide clinical benefits for each of these types of outcome in a range of different populations. The cardiovascular and renal benefits of SGLT2 inhibitors appear to be larger than their comparatively modest effect on glycaemic control or glycosuria alone would predict, with three trials recently reporting that clinical benefits extend to individuals without diabetes mellitus who are at risk due to established heart failure, or albuminuric chronic kidney disease. This European Society of Cardiology position paper summarizes reported results from these 10 large clinical outcome trials considering separately each of the different types of cardiorenal benefit, summarizes key molecular and pathophysiological mechanisms, and provides a synopsis of metabolic effects and safety. We also describe ongoing placebo-controlled trials among individuals with heart failure with preserved ejection fraction and among individuals with chronic kidney disease.
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Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
| | - Nikolaus Marx
- Department of Internal Medicine, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Linda Mellbin
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, part of the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute: Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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179
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Nakagaito M, Imamura T, Joho S, Ushijima R, Nakamura M, Kinugawa K. Renoprotective effects of sodium glucose cotransporter 2 inhibitors in type 2 diabetes patients with decompensated heart failure. BMC Cardiovasc Disord 2021; 21:347. [PMID: 34289813 PMCID: PMC8296582 DOI: 10.1186/s12872-021-02163-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitor (SGLT2i) reduces the risk of the composite renal endpoint and weakens the progressive decline in renal function in patients with chronic heart failure (HF). However, a detailed mechanism of SGLT2i on renal function and outcome remains uninvestigated. METHODS We prospectively included 40 type 2 diabetic mellitus (T2DM) patients (median 68 years old, 29 male) who were hospitalized for decompensated HF and received SGLT2i during the index hospitalization. Of them, 24 patients had increases in estimated glomerular filtration rate (eGFR) at 12-month follow-up and 16 had decreases in eGFR. We investigated the baseline factors associating with the improvement in renal function. RESULTS Lower plasma B-type natriuretic peptide (BNP) level and the use of renin-angiotensin system inhibitor (RASI) were independently associated with increases in eGFR during the follow-up period (p < 0.05 for both). Patients with both low plasma BNP levels and uses of RASI achieved significant increases in eGFR irrespective of the baseline HbA1c levels. CONCLUSIONS Lower plasma BNP level and the use of RASI at baseline were the key factors contributing to the renoprotective effects of SGLT2i among patients with decompensated HF and T2DM.
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Affiliation(s)
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Shuji Joho
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Ryuichi Ushijima
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
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180
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Influence of SGLT2 Inhibitor Treatment on Urine Antioxidant Status in Type 2 Diabetic Patients: A Pilot Study. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:5593589. [PMID: 34336104 PMCID: PMC8294983 DOI: 10.1155/2021/5593589] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/10/2021] [Accepted: 06/10/2021] [Indexed: 01/10/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been recognized as potent antioxidant agents. Since SGLT2i are nephroprotective drugs, we aimed to examine the urine antioxidant status in patients with type 2 diabetes mellitus (T2DM). One hundred and one subjects participated in this study, including 37 T2DM patients treated with SGLT2i, 31 T2DM patients not using SGLT2i, and 33 healthy individuals serving as a control group. Total antioxidant capacity (TAC), superoxide dismutase (SOD), manganese superoxide dismutase (MnSOD), free thiol groups (R-SH, sulfhydryl groups), and catalase (CAT) activity, as well as glucose concentration, were assessed in the urine of all participants. Urine SOD and MnSOD activity were significantly higher among T2DM patients treated with SGLT2i than T2DM patients without SGLT2i treatment (p = 0.009 and p = 0.003, respectively) and to the healthy controls (p = 0.002 and p = 0.001, respectively). TAC was significantly lower in patients with T2DM treated with SGLT2i when compared to those not treated and healthy subjects (p = 0.036 and p = 0.019, respectively). It could be hypothesized that the mechanism by which SGLT2i provides nephroprotective effects involves improvement of the SOD antioxidant activity. However, lower TAC might impose higher OS (oxidative stress), and elevation of SOD activity might be a compensatory mechanism.
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181
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Li LF, Ding LL, Zhan ZL, Qiu M. Meta-Analysis on the Safety and Cardiorenal Efficacy of SGLT2 Inhibitors in Patients Without T2DM. Front Cardiovasc Med 2021; 8:690529. [PMID: 34277737 PMCID: PMC8277944 DOI: 10.3389/fcvm.2021.690529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/01/2021] [Indexed: 01/10/2023] Open
Abstract
The cardiorenal benefits of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with type 2 diabetes mellitus (T2DM) are established, whereas those in patients without T2DM are not established. We sought to assess the cardiorenal efficacy and safety of SGLT2 inhibitors in non-T2DM patients by performing a meta-analysis based on the subgroup data of non-T2DM patients from relevant secondary analysis articles in which subgroup analyses were done according to the status of diabetes. Compared to placebo, SGLT2 inhibitors significantly reduced heart failure hospitalization [risk ratio (RR) 0.70, 95% confidence interval (CI) 0.59–0.83] and kidney-specific composite outcome (RR 0.55, 95% CI 0.40–0.75) and increased Kansas City Cardiomyopathy Questionnaire total score by 1.15 (95% CI 1.05–1.25) in patients without T2DM with heart failure (HF) or chronic kidney disease (CKD), whereas gliflozins did not significantly affect cardiovascular death, all-cause mortality, volume depletion, fracture, and amputation in this vulnerable population. There was no event of major hypoglycemia or diabetic ketoacidosis observed in the non-T2DM subgroup in included trials. These findings will further prompt gliflozins to be used for the prevention of HF and renal failure events and for the improvement of life quality in patients without T2DM with HF or CKD.
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Affiliation(s)
- Lu-Feng Li
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Liang-Liang Ding
- Department of Endocrinology, First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Ze-Lin Zhan
- Class 3, Clinical Medicine, Grade 2019, The Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, China
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182
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Affiliation(s)
- Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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183
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Empagliflozin: Verbesserung Herzinsuffizienz unabhängig von Diabetes. AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1331-3300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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184
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Dębska-Kozłowska A, Książczyk M, Lelonek M. Where are we in 2021 with heart failure with reduced ejection fraction?-current outlook and expectations from new promising clinical trials. Heart Fail Rev 2021; 27:419-430. [PMID: 34050489 PMCID: PMC8898246 DOI: 10.1007/s10741-021-10120-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/11/2022]
Abstract
Guideline-directed optimal medical therapy is a well-established therapy in treating patients with heart failure with reduced ejection fraction (HFrEF). Despite clear recommendations, the prognosis in this group of patients is still poor with high mortality. After publishing results of the PARADIGM-HF trial (Prospective Comparison of ARNI-Angiotensin Receptor/Neprilysin Inhibitors-with ACEI-Angiotensin-Converting Enzyme Inhibitor-to Determine Impact on Global Mortality and Morbidity in Heart Failure) clinical investigators accelerated their research. Recently, many new trials have been designed to evaluate the efficacy and safety of promising management, taking into account heterogeneity of population with chronic HFrEF. Determining target doses still poses the biggest problem in standard pharmacotherapy. Implementation of new substances for the HFrEF therapy makes it possible to formulate simple rules of treatment-in most cases, administering a dose of drug in one tablet provides a faster therapeutic effect. The aim of this article is to summarize current knowledge on recently announced findings on novel molecules and to propose a new revolutionary and individualised approach to treatment of HFrEF patients.
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Affiliation(s)
- Agnieszka Dębska-Kozłowska
- Military Medical Academy Memorial Teaching Hospital, Central Veteran Hospital, Medical University of Lodz, Lodz, Poland
| | - Marcin Książczyk
- Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland.
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland
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185
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Ameri P, Bertero E, Maack C, Teerlink JR, Rosano G, Metra M. Medical treatment of heart failure with reduced ejection fraction: the dawn of a new era of personalized treatment? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:539-546. [PMID: 34037742 DOI: 10.1093/ehjcvp/pvab033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/21/2021] [Indexed: 12/19/2022]
Abstract
Recent trials have shown the efficacy of new drugs for the medical therapy of heart failure and reduced ejection fraction (HFrEF). Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduced hospitalizations for HF, HF events, and cardiovascular death in patients with HFrEF or hospitalized for HF. Iron repletion with ferric carboxymaltose (FCM) improved symptoms, functional capacity, and quality of life in chronic HFrEF patients, and decreased the risk of subsequent HF hospitalizations in subjects with acutely decompensated HF. New-generation potassium binders may allow initiation and up-titration of renin-angiotensin-aldosterone system inhibitors (RASi). Lastly, the guanylate cyclase stimulator vericiguat and the myosin activator omecamtiv mecarbil reduced the primary endpoint in two major controlled trials. These results open novel pathways for the treatment of HFrEF. This review discusses new opportunities of an individualized approach to HFrEF pharmacotherapy, where new compounds expand a spectrum of drugs that target primarily neuroendocrine activation. SGLT2i can be safely applied once daily at a fixed dose to the vast majority of patients with HFrEF, including those with moderate renal dysfunction and/or systolic blood pressure as low as 95-100 mmHg. Additional medications are suitable for more specific phenotypes, with ivabradine providing benefit in patients with sinus rhythm and heart rates ≥70 beats per minute, FCM in the presence of iron deficiency, and potassium-lowering agents to implement RASi when hyperkalaemia occurs. Vericiguat and omecamtiv mecarbil also have potential for tailored approaches towards the hemodynamic status. Thus, a new era is starting for a more personalized medical treatment of HFrEF.
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Affiliation(s)
- Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy-IRCCS Italian Cardiology Network.,Department of Internal Medicine, University of Genova, Genova, Italy
| | - Edoardo Bertero
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
| | - Christoph Maack
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy
| | - Marco Metra
- Cardiology Unit, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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186
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Honigberg MC, Zekavat SM, Pirruccello JP, Natarajan P, Vaduganathan M. Cardiovascular and Kidney Outcomes Across the Glycemic Spectrum: Insights From the UK Biobank. J Am Coll Cardiol 2021; 78:453-464. [PMID: 34015477 DOI: 10.1016/j.jacc.2021.05.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment guidelines for prediabetes primarily focus on glycemic control and lifestyle management. Few evidence-based cardiovascular and kidney risk-reduction strategies are available in this population. OBJECTIVES This study sought to characterize cardiovascular and kidney outcomes across the glycemic spectrum. METHODS Among participants in the UK Biobank without prevalent type 1 diabetes, cardiovascular disease, or kidney disease, Cox models tested the association of glycemic exposures (type 2 diabetes [T2D], prediabetes, normoglycemia) with outcomes (atherosclerotic cardiovascular disease [ASCVD], chronic kidney disease [CKD], and heart failure), adjusting for demographic, lifestyle, and cardiometabolic risk factors. RESULTS Among 336,709 individuals (mean age: 56.3 years, 55.4% female), 46,911 (13.9%) had prediabetes and 12,717 (3.8%) had T2D. Over median follow-up of 11.1 years, 6,476 (13.8%) individuals with prediabetes developed ≥1 incident outcome, of whom only 802 (12.4%) developed T2D prior to an incident diagnosis. Prediabetes and T2D were independently associated with ASCVD (prediabetes: adjusted HR [aHR]: 1.11; 95% CI: 1.08-1.15; P < 0.001; T2D: aHR: 1.44; 95% CI: 1.37-1.51; P < 0.001), CKD (prediabetes: aHR: 1.08; 95% CI: 1.02-1.14; P < 0.001; T2D: aHR: 1.57; 95% CI: 1.46-1.69; P < 0.001), and heart failure (prediabetes: aHR: 1.07; 95% CI: 1.01-1.14; P = 0.03; T2D: aHR: 1.25; 95% CI: 1.14-1.37; P < 0.001). Compared with hemoglobin A1c (HbA1c) <5.0%, covariate-adjusted risks increased significantly for ASCVD above HbA1c of 5.4%, CKD above HbA1c of 6.2%, and heart failure above HbA1c of 7.0%. CONCLUSIONS Prediabetes and T2D were associated with ASCVD, CKD, and heart failure, but a substantial gradient of risk was observed across HbA1c levels below the threshold for diabetes. These findings highlight the need to design risk-reduction strategies across the glycemic spectrum.
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Affiliation(s)
- Michael C Honigberg
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| | - Seyedeh M Zekavat
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Computational Biology and Bioinformatics Program, Yale University, New Haven, Connecticut, USA. https://twitter.com/zekavatm
| | - James P Pirruccello
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/jpirruccello
| | - Pradeep Natarajan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/pnatarajanmd
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
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187
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Timely and individualized heart failure management: need for implementation into the new guidelines. Clin Res Cardiol 2021; 110:1150-1158. [PMID: 33983472 PMCID: PMC8117452 DOI: 10.1007/s00392-021-01867-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/30/2021] [Indexed: 01/10/2023]
Abstract
Due to remarkable improvements in heart failure (HF) management over the last 30 years, a significant reduction in mortality and hospitalization rates in HF patients with reduced ejection fraction (HFrEF) has been observed. Currently, the optimization of guideline-directed chronic HF therapy remains the mainstay to further improve outcomes for patients with HFrEF to reduce mortality and HF hospitalization. This includes established device therapies, such as implantable defibrillators and cardiac resynchronization therapies, which improved patients' symptoms and prognosis. Over the last 10 years, new HF drugs have merged targeting various pathways, such as those that simultaneously suppress the renin–angiotensin–aldosterone system and the breakdown of endogenous natriuretic peptides (e.g., sacubitril/valsartan), and those that inhibit the If channel and, thus, reduce heart rate (e.g., ivabradine). Furthermore, the treatment of patient comorbidities (e.g., iron deficiency) has shown to improve functional capacity and to reduce hospitalization rates, when added to standard therapy. More recently, other potential treatment mechanisms have been explored, such as the sodium/glucose co-transporter inhibitors, the guanylate cyclase stimulators and the cardiac myosin activators. In this review, we summarize the novel developments in HFrEF pharmacological and device therapy and discuss their implementation strategies into practice to further improve outcomes.
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188
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Valensi P, Prévost G, Pinto S, Halimi JM, Donal E. The impact of diabetes on heart failure development: The cardio-renal-metabolic connection. Diabetes Res Clin Pract 2021; 175:108831. [PMID: 33895192 DOI: 10.1016/j.diabres.2021.108831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 01/01/2023]
Abstract
Heart failure (HF) and chronic kidney disease (CKD) are often associated in type 2 diabetes (T2D), aggravate each other and exert synergistic effects to increase the risk of cardiac and renal events. The risks of renal worsening in HF patients and HF in CKD patients need to be evaluated to tailor preventive therapy. The recent CV and renal trials enriched our knowledge about the natural history of HF and CKD in T2D and provided evidence for the benefit of sodium-glucose cotransporter 2 inhibitors (SGLT2is) in HF and renal decline prevention. SGLT-2is are the best choice in patients with HFrEF to improve CV prognosis and HF-related outcomes and also to prevent kidney-related outcomes, and in CKD patients to slow down renal failure and also reduce hospitalization for HF and CV death. In both situations the number of patients to treat in order to prevent such events in one patient is lower than in the general T2D population at high CV risk. GLP1-receptor agonists could be an alternative in a patient who is intolerant or has a contraindication to SGLT-2is. A tight collaboration between diabetologists, nephrologists and cardiologists should be encouraged for a holistic and effective strategy to reduce the burden of cardio-renal-metabolic interaction.
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Affiliation(s)
- Paul Valensi
- Unit of Endocrinology-Diabetology-Nutrition, AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Bondy, France.
| | - Gaétan Prévost
- Department of Endocrinology, Diabetes and Metabolic Diseases, Normandie Univ, UNIROUEN, Rouen University Hospital, 76000 Rouen, France
| | - Sara Pinto
- Unit of Endocrinology-Diabetology-Nutrition, AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Bondy, France
| | - Jean-Michel Halimi
- Department of Nephrology, CHU Tours, France and EA4245, Tours University, Tours, France
| | - Erwan Donal
- Department of Cardiology, University of Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France
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189
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Ferrannini G, Savarese G, Rydén L. Sodium-glucose transporter inhibition in heart failure: from an unexpected side effect to a novel treatment possibility. Diabetes Res Clin Pract 2021; 175:108796. [PMID: 33845051 DOI: 10.1016/j.diabres.2021.108796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 12/17/2022]
Abstract
Sodium-glucose transporter-2 inhibitors (SGLT2i), originally launched as glucose-lowering drugs, have been studied in large cardiovascular outcome trials to ascertain safety. Surprisingly, these compounds reduced the risk of cardiovascular events (cardiovascular death, non-fatal myocardial and non-fatal stroke) and total mortality. The mechanisms behind this benefit are only partly understood, but a major contributor is the reduction of heart failure hospitalisations, evident already within weeks after the initiation of the SGLT2i. SGLT2 inhibition increases urinary glucose excretion, thereby improving glycaemic control in an insulin-independent manner. Moreover, SGLT2i potentially impact the cardiovascular system both indirectly via weight loss and blood pressure lowering and directly through osmotic diuresis and increased sodium excretion and presumably by improving myocardial energetics. The aim of this review is to summarise evidence from all major outcome trials investigating SGLT2i in patients with diabetes, as well as recent evidence from trials in heart failure patients without glucose perturbations, which pave the way for novel treatment of large groups of patients. The results of these studies have been taken into account in recently issued guidelines for the management of diabetes and cardiovascular disease. An important task for diabetologists, cardiologists and general practitioners is to incorporate them into clinical practice to the benefit of many patients.
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Affiliation(s)
- Giulia Ferrannini
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden.
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190
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Zheng C, Lin M, Chen Y, Xu H, Yan L, Dai H. Effects of sodium-glucose cotransporter type 2 inhibitors on cardiovascular, renal, and safety outcomes in patients with cardiovascular disease: a meta-analysis of randomized controlled trials. Cardiovasc Diabetol 2021; 20:83. [PMID: 33888126 PMCID: PMC8063441 DOI: 10.1186/s12933-021-01272-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background Controlled studies and observational studies have shown that sodium-glucose cotransporter type 2 inhibitors (SGLT-2i) are beneficial for the survival of patients with heart failure (HF). However, it is unclear whether SGLT-2i can provide benefit in patients with other cardiovascular diseases. Here, we conducted a systematic review and meta-analysis to determine the outcomes of cardiovascular, renal, and safety outcomes of SGLT-2i administration in patients with cardiovascular diseases. Methods We searched PubMed, EMBASE, Cochrane Library, Web of Science databases, and ClinicalTrials.gov databases for randomised controlled trials written in English from inception until November 1, 2020. Two reviewers independently identified randomised controlled trials comparing the effects of SGLT-2i in patients with cardiovascular disease with or without diabetes. Primary outcomes were cardiovascular outcomes and renal outcomes. Secondary outcomes were safety outcomes, including adverse endocrine outcomes and adverse infection outcomes. The effects of SGLT-2i were evaluated using RevMan5.3 software. The Cochrane risk of bias tool was used to assess study quality. Results We identified 10 randomised controlled trials (25,108 patients in the SGLT-2i group and 18,574 patients in the placebo group). Meta-analysis revealed that SGLT-2i treatment significantly reduced all-cause mortality, cardiovascular mortality, and hospitalisation for heart failure (HHF) in patients with cardiovascular disease (all-cause mortality relative risk [RR]: 0.86; 95% confidence interval [CI] 0.81–0.91; P < 0.00001; I2 = 0%; cardiovascular mortality RR: 0.85; 95% CI 0.79–0.92; P < 0.0001; I2 = 26%; HHF RR: 0.69; 95% CI 0.64–0.81; P < 0.00001; I2 = 0%). In patients with HF, mortality and HHF after SGLT-2i treatment for HF with reduced ejection fraction were significantly reduced, whereas HF with preserved ejection fraction did not differ compared with placebo treatment. Moreover, SGLT-2i induced a lower incidence of renal damage and myocardial infarction than the placebo group; however, the risk of infection, amputation, volume depletion, and diabetic ketoacidosis was higher. Conclusions SGLT-2i had significant clinical effects on cardiovascular outcomes and significantly influenced acute kidney injury. The effects of SGLT-2i on cardiovascular disease were independent of diabetic status. Sotagliflozin could have advantages over other SGLT-2i in lowering HHF. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01272-z.
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Affiliation(s)
- Caiyun Zheng
- Affiliated Fuqing City Hospital of Fujian Medical University, No. 267 Qingrong Avenue, Fuqing, Fuzhou, 350300, Fujian, China.,Fujian Medical University, No. 1 Xueyuan Road, University Town, Fuzhou, 350122, Fujian, China
| | - Meimei Lin
- Affiliated Fuqing City Hospital of Fujian Medical University, No. 267 Qingrong Avenue, Fuqing, Fuzhou, 350300, Fujian, China
| | - Yan Chen
- Affiliated Fuqing City Hospital of Fujian Medical University, No. 267 Qingrong Avenue, Fuqing, Fuzhou, 350300, Fujian, China
| | - Haiting Xu
- Affiliated Fuqing City Hospital of Fujian Medical University, No. 267 Qingrong Avenue, Fuqing, Fuzhou, 350300, Fujian, China
| | - Lingqun Yan
- Affiliated Fuqing City Hospital of Fujian Medical University, No. 267 Qingrong Avenue, Fuqing, Fuzhou, 350300, Fujian, China
| | - Hengfen Dai
- Affiliated Fuzhou First Hospital of Fujian Medical University, No. 190, Dadao Road, Taijiang District, Fuzhou, 350009, Fujian, China.
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191
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Lee JF, Berzan E, Sridhar VS, Odutayo A, Cherney DZ. Cardiorenal Protection in Diabetic Kidney Disease. Endocrinol Metab (Seoul) 2021; 36:256-269. [PMID: 33873265 PMCID: PMC8090466 DOI: 10.3803/enm.2021.987] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/26/2021] [Indexed: 12/21/2022] Open
Abstract
Over the last 5 years there have been many new developments in the management of diabetic kidney disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 (SGLT2) inhibitors were initially used for glycemic control, but more recent studies have now shown that their benefits extend to cardiovascular and kidney outcomes. The recent addition of data on the novel mineralocorticoid receptor antagonist (MRA) gives us another approach to further decrease the residual risk of diabetic kidney disease progression. In this review we describe the mechanism of action, key studies, and possible adverse effects related to these three classes of medications. The management of type 2 diabetes now includes an increasing number of medications for the management of comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors, GLP-1 RA and MRAs in patients with type 2 diabetes for heart and kidney protection.
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Affiliation(s)
- Jason F. Lee
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Ecaterina Berzan
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Vikas S. Sridhar
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, ON, Canada
| | - Ayodele Odutayo
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, ON, Canada
| | - David Z.I. Cherney
- Toronto General Hospital Research Institute, University Health Network, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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192
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Andreadou I, Daiber A, Baxter GF, Brizzi MF, Di Lisa F, Kaludercic N, Lazou A, Varga ZV, Zuurbier CJ, Schulz R, Ferdinandy P. Influence of cardiometabolic comorbidities on myocardial function, infarction, and cardioprotection: Role of cardiac redox signaling. Free Radic Biol Med 2021; 166:33-52. [PMID: 33588049 DOI: 10.1016/j.freeradbiomed.2021.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023]
Abstract
The morbidity and mortality from cardiovascular diseases (CVD) remain high. Metabolic diseases such as obesity, hyperlipidemia, diabetes mellitus (DM), non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) as well as hypertension are the most common comorbidities in patients with CVD. These comorbidities result in increased myocardial oxidative stress, mainly from increased activity of nicotinamide adenine dinucleotide phosphate oxidases, uncoupled endothelial nitric oxide synthase, mitochondria as well as downregulation of antioxidant defense systems. Oxidative and nitrosative stress play an important role in ischemia/reperfusion injury and may account for increased susceptibility of the myocardium to infarction and myocardial dysfunction in the presence of the comorbidities. Thus, while early reperfusion represents the most favorable therapeutic strategy to prevent ischemia/reperfusion injury, redox therapeutic strategies may provide additive benefits, especially in patients with heart failure. While oxidative and nitrosative stress are harmful, controlled release of reactive oxygen species is however important for cardioprotective signaling. In this review we summarize the current data on the effect of hypertension and major cardiometabolic comorbidities such as obesity, hyperlipidemia, DM, NAFLD/NASH on cardiac redox homeostasis as well as on ischemia/reperfusion injury and cardioprotection. We also review and discuss the therapeutic interventions that may restore the redox imbalance in the diseased myocardium in the presence of these comorbidities.
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Affiliation(s)
- Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece.
| | - Andreas Daiber
- Department of Cardiology 1, Molecular Cardiology, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany; Partner Site Rhine-Main, German Center for Cardiovascular Research (DZHK), Langenbeckstr, Germany.
| | - Gary F Baxter
- Division of Pharmacology, School of Pharmacy and Pharmaceutical Sciences, Cardiff University, United Kingdom
| | | | - Fabio Di Lisa
- Department of Biomedical Sciences, University of Padova, Italy; Neuroscience Institute, National Research Council of Italy (CNR), Padova, Italy
| | - Nina Kaludercic
- Neuroscience Institute, National Research Council of Italy (CNR), Padova, Italy
| | - Antigone Lazou
- Laboratory of Animal Physiology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki, 54124, Greece
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary
| | - Coert J Zuurbier
- Laboratory of Experimental Intensive Care Anesthesiology, Department Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rainer Schulz
- Institute of Physiology, Justus Liebig University Giessen, Giessen, Germany.
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; Pharmahungary Group, Szeged, Hungary
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Schnell O, Cos X, Cosentino F, Forst T, Giorgino F, Heersprink HJL, Kosiborod M, Wanner C, Standl E. Report from the CVOT Summit 2020: new cardiovascular and renal outcomes. Cardiovasc Diabetol 2021; 20:75. [PMID: 33789663 PMCID: PMC8010779 DOI: 10.1186/s12933-021-01254-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/26/2021] [Indexed: 02/08/2023] Open
Abstract
The 6th Cardiovascular Outcome Trial (CVOT) Summit “Cardiovascular and Renal Outcomes 2020” was the first to be held virtually on October 29–30, 2020. As in previous years, this summit served as reference meeting for in-depth discussions on the topic of recently completed and presented major outcome trials. This year, focus was placed on the outcomes of VERTIS-CV, EMPEROR-Reduced, DAPA-CKD, and FIDELIO-DKD. Trial implications for diabetes management and the impact on new treatment algorithms were highlighted for diabetologists, cardiologists, endocrinologists, nephrologists, and general practitioners. Discussion evolved from major outcome trials using SGLT-2 inhibitors for treatment and prevention of heart failure and chronic kidney disease in people with and without diabetes, to additional therapy options for chronic kidney disease with a novel mineralocorticoid receptor antagonist. Furthermore, challenges in diabetes management like COVID-19 and obesity, as well as novel treatment strategies and guidelines, were discussed. The 7th Cardiovascular Outcome Trial Summit will be held virtually on November, 18–19, 2021 (http://www.cvot.org).
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Affiliation(s)
- Oliver Schnell
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, 85764, Neuherberg (Munich), Germany.
| | - Xavier Cos
- Sant Marti de Provençals Primary Care Centres, Barcelona, Spain
| | | | - Thomas Forst
- CRS Clinical Research Services Mannheim GmbH, Mannheim, Germany
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Hiddo J L Heersprink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Mikhail Kosiborod
- Cardiometabolic Center of Excellence, University of Missouri-Kansas City, Kansas, MO, USA
| | | | - Eberhard Standl
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, 85764, Neuherberg (Munich), Germany
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194
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Sodium/glucose cotransporter 2 inhibitors in chronic kidney disease and heart failure: ready for prime time in patients without diabetes. Curr Opin Nephrol Hypertens 2021; 30:361-368. [PMID: 33767064 DOI: 10.1097/mnh.0000000000000703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The benefits of sodium/glucose cotransporter 2 (SGLT2) inhibitors seem to extend beyond glycemic control. We review recent randomized trial evidence evaluating SGLT2 inhibition in nondiabetic settings, including in patients with chronic kidney disease (CKD) and heart failure (HF). RECENT FINDINGS DAPA-CKD, DAPA-HF and EMPEROR-Reduced compared SGLT2 inhibitors to placebo, enrolling 5868 patients without diabetes. In DAPA-CKD, patients with an estimated glomerular filtration rate (eGFR) of 25-75 ml/min/1.73 m2 and macroalbuminuria irrespective of kidney disease aetiology had improved cardiovascular and kidney outcomes if randomized to receive SGLT2 inhibitors (primary composite endpoint: hazard ratio [HR] 0.61, 95% CI 0.51-0.72; absolute risk reduction [ARR] 5.3%). In DAPA-HF and EMPEROR-Reduced, participants with reduced ejection fraction (HFrEF) had improved cardiovascular outcomes when an SGLT2 inhibitor was added to guideline-directed medical therapy, mainly through a reduction in HF hospitalizations (HR 0.70, 95% CI 0.59-0.83; ARR 3.7% and HR 0.69, 95% CI 0.59-0.81; ARR 5.1% with dapagliflozin and empagliflozin, respectively). In all 3 trials, the benefits were not modified by diabetes, baseline eGFR or proteinuria. SUMMARY SGLT2 inhibitors improve kidney and HF outcomes in patients with high-risk CKD and HFrEF, irrespective of diabetes. Clinicians should become more comfortable prescribing these medications as we await studies that may further broaden their indications.
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195
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Salah HM, Al'Aref SJ, Khan MS, Al-Hawwas M, Vallurupalli S, Mehta JL, Mounsey JP, Greene SJ, McGuire DK, Lopes RD, Fudim M. Effects of sodium-glucose cotransporter 1 and 2 inhibitors on cardiovascular and kidney outcomes in type 2 diabetes: A meta-analysis update. Am Heart J 2021; 233:86-91. [PMID: 33385359 DOI: 10.1016/j.ahj.2020.12.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 02/08/2023]
Abstract
In this report, we aim to provide an updated meta-analysis of the sodium-glucose cotransporter 2 (SGLT2) inhibitors trial data with the new trial data on sotagliflozin, a first-in-class dual SGLT1 and SGLT2 inhibitor. We searched Medline, Cochrane library, and Embase databases for randomized clinical trials comparing cardiovascular and kidney outcomes between SGLT2 and dual SGLT1/2 inhibitors and placebo. Nine randomized clinical trials with a total of 60,914 patients with type 2 diabetes were included. In patients with type 2 diabetes, the use of SGLT2 and dual SGLT1/2 inhibitors improves the cardiovascular and kidney outcome.
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196
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Nassif ME, Qintar M, Windsor SL, Jermyn R, Shavelle DM, Tang F, Lamba S, Bhatt K, Brush J, Civitello A, Gordon R, Jonsson O, Lampert B, Pelzel J, Kosiborod MN. Empagliflozin Effects on Pulmonary Artery Pressure in Patients With Heart Failure: Results From the EMBRACE-HF Trial. Circulation 2021; 143:1673-1686. [PMID: 33550815 DOI: 10.1161/circulationaha.120.052503] [Citation(s) in RCA: 137] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sodium glucose cotransporter 2 inhibitors (SGLT2 inhibitors) prevent heart failure (HF) hospitalizations in patients with type 2 diabetes and improve outcomes in those with HF and reduced ejection fraction, regardless of type 2 diabetes. Mechanisms of HF benefits remain unclear, and the effects of SGLT2 inhibitor on hemodynamics (filling pressures) are not known. The EMBRACE-HF trial (Empagliflozin Evaluation by Measuring Impact on Hemodynamics in Patients With Heart Failure) was designed to address this knowledge gap. METHODS EMBRACE-HF is an investigator-initiated, randomized, multicenter, double-blind, placebo-controlled trial. From July 2017 to November 2019, patients with HF (regardless of ejection fraction, with or without type 2 diabetes) and previously implanted pulmonary artery (PA) pressure sensor (CardioMEMS) were randomized across 10 US centers to empagliflozin 10 mg daily or placebo and treated for 12 weeks. The primary end point was change in PA diastolic pressure (PADP) from baseline to end of treatment (average PADP weeks 8-12). Secondary end points included health status (Kansas City Cardiomyopathy Questionnaire score), natriuretic peptides, and 6-min walking distance. RESULTS Overall, 93 patients were screened, and 65 were randomized (33 to empagliflozin, 32 to placebo). The mean age was 66 years; 63% were male; 52% had type 2 diabetes; 54% were in New York Heart Association class III/IV; mean ejection fraction was 44%; median NT-proBNP (N-terminal pro B-type natriuretic peptide) was 637 pg/mL; and mean PADP was 22 mm Hg. Empagliflozin significantly reduced PADP, with effects that began at week 1 and amplified over time; average PADP (weeks 8-12) was 1.5 mm Hg lower (95% CI, 0.2-2.8; P=0.02); and at week 12, PADP was 1.7 mm Hg lower (95% CI, 0.3-3.2; P=0.02) with empagliflozin versus placebo. Results were consistent for PA systolic and PA mean pressures. There was no difference in mean loop diuretic management (daily furosemide equivalents) between treatment groups. No significant differences between treatment groups were observed in Kansas City Cardiomyopathy Questionnaire scores, natriuretic peptide levels, and 6-min walking distance. CONCLUSIONS In patients with HF and CardioMEMS PA pressure sensor, empagliflozin produced rapid reductions in PA pressures that were amplified over time and appeared to be independent of loop diuretic management. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03030222.
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Affiliation(s)
- Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., M.Q., S.L.W., F.T., M.N.K.).,University of Missouri-Kansas City (M.E.N., M.Q., M.N.K.)
| | - Mohammed Qintar
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., M.Q., S.L.W., F.T., M.N.K.).,University of Missouri-Kansas City (M.E.N., M.Q., M.N.K.)
| | - Sheryl L Windsor
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., M.Q., S.L.W., F.T., M.N.K.)
| | | | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., M.Q., S.L.W., F.T., M.N.K.)
| | - Sumant Lamba
- First Coast Cardiovascular Institute, Jacksonville, FL (S.L.)
| | | | - John Brush
- Sentara Healthcare, Norfolk, VA (J.B.).,Eastern Virginia Medical School, Norfolk (J.B.)
| | | | - Robert Gordon
- NorthShore University HealthSystem, Evanston, IL (R.G.)
| | - Orvar Jonsson
- University of South Dakota Sanford Health, Sioux Falls (O.J.)
| | | | - Jamie Pelzel
- Saint Cloud Hospital CentraCare Heart and Vascular Center, MN (J.P.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO (M.E.N., M.Q., S.L.W., F.T., M.N.K.).,University of Missouri-Kansas City (M.E.N., M.Q., M.N.K.).,The George Institute for Global Health, Sydney, Australia (M.N.K.).,University of New South Wales, Sydney, Australia (M.N.K.)
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197
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Affiliation(s)
- Amy Kang
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, Australia.,Prince of Wales Hospital, Sydney, Australia
| | - Meg J Jardine
- Renal and Metabolic Division, The George Institute for Global Health, UNSW Sydney, Sydney, Australia. .,NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia. .,Concord Repatriation General Hospital, Sydney, Australia.
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198
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Affiliation(s)
- Xiaoxiao Lin
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Shuai Wang
- Hangzhou First People's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jinyu Huang
- Hangzhou First People's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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199
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Kosiborod M. Diamonds in the Rough: The Incredible-but-True Story of Sodium Glucose Cotransporter 2 Inhibitors in Treatment of Heart Failure. Circulation 2021; 143:350-353. [PMID: 33493031 DOI: 10.1161/circulationaha.120.052446] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO. University of Missouri-Kansas City. George Institute for Global Health and University of New South Wales, Sydney, Australia
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200
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Yu YW, Zhao XM, Wang YH, Zhou Q, Huang Y, Zhai M, Zhang J. Effect of sodium-glucose cotransporter 2 inhibitors on cardiac structure and function in type 2 diabetes mellitus patients with or without chronic heart failure: a meta-analysis. Cardiovasc Diabetol 2021; 20:25. [PMID: 33494751 PMCID: PMC7836497 DOI: 10.1186/s12933-020-01209-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/27/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on cardiovascular events have been reported in patients with type 2 diabetes mellitus (T2DM) with or without heart failure (HF), the impact of SGLT2i on cardiac remodelling remains to be established. METHODS We searched the PubMed, Embase, Cochrane Library and Web of Science databases up to November 16th, 2020, for randomized controlled trials reporting the effects of SGLT2i on parameters of cardiac structure, cardiac function, plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) level or the Kansas City Cardiomyopathy Questionnaire (KCCQ) score in T2DM patients with or without chronic HF. The effect size was expressed as the mean difference (MD) or standardized mean difference (SMD) and its 95% confidence interval (CI). Subgroup analyses were performed based on the stage A-B or stage C HF population and HF types. RESULTS Compared to placebo or other antidiabetic drugs, SGLT2i showed no significant effects on left ventricular mass index, left ventricular end diastolic volume index, left ventricular end systolic volume index, or left atrial volume index. SGLT2i improved left ventricular ejection fraction only in the subgroup of HF patients with reduced ejection fraction (MD 3.16%, 95% CI 0.11 to 6.22, p = 0.04; I2 = 0%), and did not affect the global longitudinal strain in the overall analysis including stage A-B HF patients. SGLT2i showed benefits in the E/e' ratio (MD - 0.45, 95% CI - 0.88 to - 0.03, p = 0.04; I2 = 0%), plasma NT-proBNP level (SMD - 0.09, 95% CI - 0.16 to - 0.03, p = 0.004; I2 = 0%), and the KCCQ score (SMD 3.12, 95% CI 0.76 to 5.47, p = 0.01; I2 = 0%) in the overall population. CONCLUSION The use of SGLT2i was associated with significant improvements in cardiac diastolic function, plasma NT-proBNP level, and the KCCQ score in T2DM patients with or without chronic HF, but did not significantly affect cardiac structural parameters indexed by body surface area. The LVEF level was improved only in HF patients with reduced ejection fraction.
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Affiliation(s)
- Yi-Wen Yu
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xue-Mei Zhao
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yun-Hong Wang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qiong Zhou
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Huang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Mei Zhai
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jian Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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