Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction

The sodium/glucose cotransporter 2 inhibitor Empagliflozin inhibits long QT 3 late sodium currents in a mutation specific manner

BACKGROUND

Sodium/glucose cotransporter 2 inhibitors (SGLT2is) like empagliflozin have demonstrated cardioprotective effects in patients with or without diabetes. SGLT2is have been shown to selectively inhibit the late component of cardiac sodium current (late INa). Induction of late INa is the primary mechanism in the pathophysiology of congenital long QT syndrome type 3 (LQT3) gain-of-function mutations in the SCN5A gene encoding Nav1.5. We investigated empagliflozin's effect on late INa in thirteen known LQT3 mutations located in distinct regions of the channel.

METHODS

The whole-cell patch-clamp technique was used to investigate the effect of empagliflozin on late INa in recombinantly expressed Nav1.5 channels containing different LQT3 mutations. Molecular modeling of human Nav1.5 and simulations in a mathematical model of human ventricular myocytes were used to extrapolate our experimental results to excitation-contraction coupling.

RESULTS

Empagliflozin selectively inhibited late INa in LQT3 mutations in the inactivation gate region of Nav1.5, without affecting peak current or channel kinetics. In contrast, empagliflozin inhibited both peak and late INa in mutations in the S4 voltage-sensing regions, altered channel gating, and slowed recovery from inactivation. Empagliflozin had no effect on late/peak INa or channel kinetics in channels with mutations in the putative empagliflozin binding region. Simulation results predict that empagliflozin may have a desirable therapeutic effect in LQT3 mutations in the inactivation gate region.

CONCLUSIONS

Empagliflozin selectively inhibits late INa, without affecting channel kinetics, in LQT3 mutations in the inactivation gate region. Empagliflozin may thus be a promising precision medicine approach for patients with specific LQT3 mutations.

Cardiovascular Therapy Benefits of Novel Antidiabetic Drugs in Patients With Type 2 Diabetes Mellitus Complicated With Cardiovascular Disease: A Network Meta-Analysis

OBJECTIVE

Provide an evidence-based basis for the selection of cardiovascular benefit drugs in Type 2 diabetes mellitus (T2DM) patients with cardiovascular disease (CVD).

METHODS

Conduct a comprehensive search of all relevant literature from PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials.gov from their establishment until December 13, 2023, and select randomized controlled trials (RCTs) that meet the pre-established inclusion and exclusion criteria. Use the Cochrane bias risk assessment tool to evaluate the quality of the included literature. Use R 4.3.2 software to conduct network meta-analysis for drug category comparison.

RESULTS

A total of 24 large-scale randomized controlled trials (RCTs) were included, including 19 intervention measures, and 172 803 patients participated in the study. The results of the network meta-analysis show that: GLP1RA (OR 0.89, 95% CI 0.81-0.97) and SGLT2i (OR 0.91, 95% CI 0.83-0.99) can reduce the occurrence of major adverse cardiovascular events (MACE), GLP1RA (OR 0.88, 95% CI 0.79-0.97) and SGLT2i (OR 0.89, 95% CI 0.81-0.99) reduced the risk of cardiovascular death. SGLT2i (OR 0.68, 95% CI 0.62-0.75) reduced the occurrence of hospitalization for heart failure, GLP1RA (OR 0.88, 95% CI 0.81-0.97) and SGLT2i (OR 0.89, 95% CI 0.80-0.97) reduced the occurrence of all-cause death.

CONCLUSION

In the comparison of new hypoglycemic drug classes, GLP1RA and SGLT2i reduced MACE, cardiovascular mortality and all-cause mortality in T2DM patients with CVD, with no significant difference in efficacy, and DPP4i was noninferior to placebo. Only GLP1RA reduced the risk of nonfatal stroke, and only SGLT2i reduced the risk of HHF.

Sodium-Glucose Cotransporter-2 Inhibitor and Glucagon-Like Peptide-1 Receptor Agonist Discontinuation in Patients with CKD

Key Points

Treatment discontinuation is common among patients with CKD prescribed sodium-glucose cotransporter-2 (SGLT2) inhibitors (discontinued in 37%) or glucagon-like peptide-1 receptor agonists (GLP-1 RA; discontinued in 47%). Discontinuation of SGLT2 inhibitors and GLP-1 RA was associated with recent hospitalizations, Black race, Hispanic ethnicity, and vascular disease. Discontinuation of both agents was associated with death and cardiovascular events.

Background

Little is known about the association of discontinuation of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RA) with outcomes in patients with CKD.

Methods

We identified adults with CKD stages 3–4 from 2005 to 2022 in the Veterans Affairs health care system. Individuals with an incident prescription for SGLT2 inhibitors or GLP-1 RAs were included, with the first fill date considered the index date. Factors associated with time to first treatment discontinuation, defined as an interruption in SGLT2 inhibitor or GLP-1 RA prescription for ≥90 days, were studied using Cox proportional hazards regression models. Associations of discontinuation 90–179 and ≥180 days with death, myocardial infarction, coronary revascularization, hospitalization for heart failure, and ischemic stroke were assessed using Cox proportional hazards regression.

Results

Of 96,345 individuals who received an SGLT2 inhibitor and 60,020 who received a GLP-1 RA, at least one discontinuation occurred in 35,953 (37%) of SGLT2 inhibitor users and 28,407 (47%) of GLP-1 RA users. SGLT2 inhibitor users were 24% Black, 71% White, 71% age ≥70, and 84% with CKD stage 3a. GLP-1 RA users were 20% Black, 75% White, 63% age ≥70, and 81% with CKD stage 3a. Black race, Hispanic ethnicity, cerebrovascular disease, peripheral vascular disease, and ischemic heart disease were associated with discontinuation of both drug classes. Female sex and more advanced CKD stage were also associated with SGLT2 inhibitor discontinuation. SGLT2 inhibitor discontinuation ≥180 days was associated with death (adjusted hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.58 to 1.77) and heart failure hospitalization (adjusted HR, 1.26; 95% CI, 1.13 to 1.40). GLP-1 RA discontinuation ≥180 days was associated with death (adjusted HR, 1.97; 95% CI, 1.87 to 2.07), myocardial infarction (adjusted HR, 1.23; 95% CI, 1.11 to 1.36), heart failure hospitalization (adjusted HR, 1.48; 95% CI, 1.33 to 1.64), and ischemic stroke (adjusted HR, 1.24; 95% CI, 1.14 to 1.35).

Conclusions

SGLT2 inhibitor and GLP-1 RA discontinuation was common and associated with harmful outcomes in adults with CKD.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Role of SGLT2 Inhibitors in Cardiovascular Management

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

Are Two Gliflozins Different: A Prospective Multicenter Randomized Study to Assess Effect of Remogliflozin Compared With Empagliflozin on Biomarkers of Heart Failure in Indian Patients With Type 2 Diabetes Mellitus with Chronic Heart Failure (REMIT-HF Study)

There is limited data comparing two gliflozins on their effect on biomarkers in diabetic patients with chronic heart failure. A prospective, multicenter, active controlled, double-arm, investigator-initiated, interventional study enrolled 250 adults with type 2 diabetes mellitus (T2DM) and comorbid congestive heart failure (CHF; left ventricular ejection fraction [LVEF] <40%; N-terminal pro-B-type natriuretic peptide [NT-proBNP] >600 pg/mL). A total of 125 patients were allocated each to a remogliflozin (R) and empagliflozin (E) group and followed up for 24 weeks. The primary endpoint was the mean percentage change from baseline in NT-proBNP level after 24 weeks. There was significant improvement from baseline in mean NT-proBNP level in both groups after 24 weeks. However, there was no significant difference between the two groups (P = .214). The mean NT-proBNP level improved from 2078.15 ± 1764.70 pg/mL at baseline to 1185.06 ± 1164.21 pg/mL at 6 months in the R-group (P ≤ .001) and from 2283.98 ± 1759.15 pg/mL at baseline to 1395.33 ± 1304.18 pg/mL at 6 months in the E-group (P < .001). LVEF and LV volumes improved in both groups. The glycemic parameters (HbA1c, FPG, and PPG) demonstrated a significant reduction from baseline to week 24 in both groups. Similar improvement was seen in heart rate, blood pressure, and weight reduction over 6 months in both groups. There was no drug-related serious adverse events in any group. Remogliflozin and empagliflozin significantly improve glycemic parameters and NT-proBNP levels as the index of the therapeutic effects in T2DM patients with CHF. The positive effects are comparable in both groups.

In-hospital initiation of sodium-glucose co-transporter-2 inhibitors in patients with acute heart failure

Sodium-glucose cotransporter-2 (SGLT2) inhibitors provide cardiovascular and kidney benefits to patients with heart failure (HF) and/or chronic kidney disease (CKD), regardless of diabetes status and left ventricular ejection fraction (LVEF). Despite robust data demonstrating the efficacy of SGLT-2 inhibitors in both ambulatory and hospital settings, real-world evidence suggests slow and varied adoption of SGLT2 inhibitors among patients hospitalized for HF. Barriers to implementation of SGLT2i may include clinicians' concerns regarding potential adverse events such as diabetic ketoacidosis (DKA), volume depletion, and symptomatic hypoglycemia; or concerns regarding physiologically expected reductions in eGFR. Guidelines lack specific, practical safety data and definitive recommendations regarding in-hospital initiation and continuation of SGLT2i in patients hospitalized with HF. In this review, we discuss the safety of in-hospital SGLT2 inhibitor initiation based on recent trials and highlight the clinical implications of their early use in patients hospitalized for HF.

Machine learning in the prevention of heart failure

Heart failure (HF) is a global pandemic with a growing prevalence and is a growing burden on the healthcare system. Machine learning (ML) has the potential to revolutionize medicine and can be applied in many different forms to aid in the prevention of symptomatic HF (stage C). HF prevention currently has several challenges, specifically in the detection of pre-HF (stage B). HF events are missed in contemporary models, limited therapeutic options are proven to prevent HF, and the prevention of HF with preserved ejection is particularly lacking. ML has the potential to overcome these challenges through existing and future models. ML has limitations, but the many benefits of ML outweigh these limitations and risks in most scenarios. ML can be applied in HF prevention through various strategies such as refinement of incident HF risk prediction models, capturing diagnostic signs from available tests such as electrocardiograms, chest x-rays, or echocardiograms to identify structural/functional cardiac abnormalities suggestive of pre-HF (stage B HF), and interpretation of biomarkers and epigenetic data. Altogether, ML is able to expand the screening of individuals at risk for HF (stage A HF), identify populations with pre-HF (stage B HF), predict the risk of incident stage C HF events, and offer the ability to intervene early to prevent progression to or decline in stage C HF. In this narrative review, we discuss the methods by which ML is utilized in HF prevention, the benefits and pitfalls of ML in HF risk prediction, and the future directions.

Frailty in clinical drug trials: Frailty assessments, subgroup analyses and outcomes

With population ageing, drug trials are increasingly turning their attention to including older, frailer people. This review aimed to provide an overview of how frailty was assessed in published studies related to clinical pharmacological trials, and on the interaction of frailty on the efficacy of the treatments. We searched MEDLINE, EMBASE and Cochrane for clinical drug trials in older people. A total of 4031 abstracts were screened and 17 relevant studies were included in this review. We summarized the findings of these 17 trials into five main clinical areas: cardiovascular (eight studies), cognition (one study), vaccination (two studies), cancer (four studies) and other (two studies). Frailty was assessed retrospectively in most of the studies. Frailty was treated as an ordinal variable (with different levels of frailty) or binary variable (frail/non-frail) using cut-offs in some studies, and as a continuous in some other studies. The effect of frailty on the treatment efficacy was not consistent among the studies. While several trials, such as the Action in Diabetes and Vascular Disease-Preterax and Diamicron Modified Release Controlled Evaluation trials, the Systolic Blood Pressure Intervention Trial and the Aspirin in Reducing Events in the Elderly trial, showed some reduced effects of the treatment in frail patients, most of the trials showed that the benefits of the treatment are not affected by frailty. Some trials even showed that the benefits of the treatment were more significant in frailer patients (the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure and the Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure trials). The results of this review suggest that routine measurement of frailty in participants in clinical drug trials would improve our knowledge of the effect of treatment in the frail and identify those who have more or least to gain from treatment.

Heart failure with reduced ejection fraction and chronic kidney disease: a focus on therapies and interventions

In heart failure with reduced ejection fraction (HFrEF), the presence of concomitant chronic kidney disease (CKD) predicts poorer cardiovascular outcomes, more aggravated heart failure (HF) status, and higher mortality. Physicians might be reluctant to initiate life-saving anti-HF medications out of fear of worsening renal function and a higher incidence of adverse events. Moreover, international guidelines do not give clear recommendations on managing this subgroup of patients as well as advanced CKD was always an exclusion criterion in most major HF trials. Nevertheless, in this review, we will highlight several recent clinical trials and post-hoc analyses of major trials that showed the safety and efficacy of the different therapies in HFrEF patients with CKD, besides several small-scale cohorts that tested guideline-directed medical therapies in End Stage Kidney Disease (ESKD). Regarding interventions in this subgroup of patients, we will provide up-to-date data on implantable cardioverter defibrillators, cardiac resynchronization therapy, and coronary revascularization, in addition to mitral valve transcatheter edge-to-edge repair and implantable pulmonary artery pressure sensors.

Diuretic Potentiation Strategies in Acute Heart Failure

Several trials have evaluated diuretic-based strategies to improve symptoms and outcomes in patients with acute heart failure (AHF). The authors sought to summarize the effect of different combination strategies on symptoms, physical signs, physiological variables, and outcomes in patients with AHF. Twelve trials were identified that assessed the addition of thiazide diuretics, sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists, vasopressin receptor antagonists, carbonic anhydrase inhibitors, or loop diuretic intensification to conventional therapy for AHF. The trials evaluated short-term markers of congestion and symptoms, and none were powered for clinical outcomes. Short-term responses (such as relief from dyspnea, physical signs of congestion, and weight change) varied greatly across studies; all diuretic strategies were accompanied by short-term increases in serum creatinine and did not demonstrate benefits on mortality or recurrent heart failure events. The available evidence suggests that intensification of loop diuretic agents produces relief of physical signs of decongestion, but the importance of different strategies for short-term decongestion strategy for health status and long-term outcomes has not been established.

Integrating the new pharmacological standard of care with traditional nutritional interventions in non-dialysis CKD

Chronic kidney disease (CKD) is widely recognized as a leading and growing contributor to global morbidity and mortality worldwide. Nutritional therapy is the basic treatment for metabolic control, and may contribute to nephroprotection; however, the absence of solid evidence on slowing CKD progression together with poor adherence to dietary prescription limit de facto its efficacy and prevent its more widespread use. Sodium-glucose transport protein 2 inhibitors (SGLT2is) are now considered the new standard of care in CKD; in addition, novel potassium binders, glucagon-like peptide-1 receptor antagonists (GLP1-RAs) and nonsteroidal mineralocorticoid receptor antagonists (nsMRAs) show either direct (SGLT2i, GLP1-RA, nsMRA) or indirect (potassium binders that enable the optimal use of renin-angiotensin-aldosterone system inhibitors) nephroprotective effects. These drugs could potentially lead to a more permissive diet, thereby allowing the patient to reap the benefits of this approach. In particular, SGLT2is, and to a lesser extent also GLP1-RAs and nsMRAs in patients with diabetic kidney disease, can counterbalance hyperfiltration as well as the higher protein intake often recorded in obese patients; on the other hand, potassium binders can facilitate following plant-based diets, which are considered healthy because of the high content of essential micronutrients such as antioxidant vitamins, minerals, alkalies, and fibers. In this review paper, we discuss the current pharmacological paradigm shift that places a new, broader standard of care in light of its interaction with nutritional therapy in order to optimize the global approach to patients with CKD not on dialysis.

Tofogliflozin reduces sleep apnea severity in patients with type 2 diabetes mellitus and heart failure: a prospective study

Sleep apnea (SA) is prevalent among patients with heart failure (HF) and contributes to a poor prognosis. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated efficacy in reducing the risk of serious clinical events in patients with HF. Additionally, SGLT2 inhibitors may reduce the risk of incident SA and mitigate its severity in patients with cardiovascular disease and T2DM. We aimed to investigate whether the SGLT2 inhibitor tofogliflozin reduced the severity of SA, as assessed using the apnea-hypopnea index (AHI), in patients with HF and T2DM and whether a decrease in AHI correlates with changes in body composition and cardiorenal function parameters. This is a single-arm, prospective pathophysiologic study involving patients with HF, T2DM, and SA, defined as having an AHI of 15 events/h and more. SA was assessed using polysomnography. Changes in AHI before and 6 months after starting oral administration of tofogliflozin (20 mg) were assessed. Additionally, body composition and cardiorenal functions were assessed before and 6 months after tofogliflozin administration. Ten patients with HF, T2DM, and SA were finally enrolled (60% men, 66.9 ± 13.4 years). Tofogliflozin reduced AHI from 43.2 [30.2] to 35.3 [13.1] events/h (p = 0.024) at 6 months. Hemoglobin A1c, body weight, and body water content decreased significantly. However, no significant changes were observed in the cardiorenal function parameters. A linear relationship was observed between the changes in body water content and AHI (r = 0.642, p = 0.045). Tofogliflozin reduced AHI, possibly associated with a reduction in body water content.

Comparative Efficacy and Safety of Cardio-Renoprotective Pharmacological Interventions in Chronic Kidney Disease: An Umbrella Review of Network Meta-Analyses and a Multicriteria Decision Analysis

Sodium-glucose co-transporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP1a), and non-steroidal mineralocorticoid receptor antagonists (ns-MRA) are promising treatments for chronic kidney disease. This umbrella review of network meta-analyses evaluated their effects on cardiovascular outcomes, kidney disease progression, and adverse events, using the TOPSIS method to identify the optimal intervention based on P-scores. A total of 19 network meta-analyses and 44 randomized controlled trials involving 86,150 chronic kidney disease patients were included. Compared to placebo, SGLT2i were associated with reduced risks of cardiovascular events [Hazard ratio (HR): 0.776, 95% confidence intervals (CI): 0.727-0.998], kidney disease progression (HR: 0.679, 95% CI: 0.629-0.733), acute kidney injury (HR: 0.873, 95% CI: 0.773-0.907), and serious adverse events (HR: 0.881, 95% CI: 0.847-0.916). GLP1a and ns-MRA were also associated with significant reductions in cardiovascular and kidney-specific composite outcomes. Indirect evidence showed that SGLT2i demonstrated a lower risk of kidney disease progression compared to GLP1a (HR: 0.826, 95% CI: 0.716-0.952) and ns-MRA (HR: 0.818, 95% CI: 0.673-0.995), representing the best intervention across all endpoints. In conclusion, while SGLT2i, GLP1a, and ns-MRA all reduce cardiovascular and kidney disease risks in chronic kidney disease, SGLT2i appears to provide the most favorable balance of efficacy and safety.

Effect of sodium glucose cotransporter-2 inhibitors (SGLT-2is) on the clinical outcomes of patients with diabetic atrial fibrillation

BACKGROUND

Diabetes mellitus (DM) and atrial Fibrillation (AF) are among the most common health issues. They are responsible for the highest rates of morbidity and mortality. The importance of sodium glucose cotransporter-2 inhibitors (SGLT-2is) in treating DM has increased significantly in recent years. In our article, we aimed to evaluate the effect of SGLT-2i on the clinical outcomes of AF patients with DM.

METHODS

Our study is a retrospective, observational study. The patients with AF and DM were divided into two groups: those using SGLT-2i or not using SGLT-2i, and 3-year follow-up results were examined. The endpoints of the study were defined as all-cause death, the development of myocardial infarction (MI), major bleeding requiring hospitalization, and an ischemic cerebrovascular event (CVE). Differences between groups according to SGLT-2i use were analyzed.

RESULTS

The study included 485 patients, 205 (42.3%) of whom were male and had an average age of 70.7 ± 9.7 years. A total of 138 of 485 patients (28.5%) received SGLT-2i. All-cause mortality was lower in the group receiving SGLT-2i (p < 0.001). Similarly, a significant reduction in major bleeding events was observed among those who received SGLT-2i treatment (p = 0.009). The incidence of CVEs was lower among SGLT-2i recipients, but the difference was not statistically significant (p = 0.066). SGLT2i usage did not mitigate the risk of MI development (p = 0.317).

CONCLUSIONS

In our study, SGLT-2i treatment was associated with a significant reduction in all-cause mortality and major bleeding in diabetic AF patients. Our study provides evidence of the clinical benefit of SGLT-2i in AF patients.

Heart Failure in Elderly Patients: Medical Management, Therapies and Biomarkers

Heart failure (HF) is a common condition and one of the main morbidity and mortality factors in elderly patients. The incidence of HF progressively increases with age, reaching >10% in those aged 70 years or over. In the elderly population, both the diagnosis and the management of HF prove challenging, often requiring specialized care and a multidisciplinary approach. In seniors, atypical presentation of HF is much more common than in younger patients; thus, a holistic assessment with biomarkers related to HF allows for early diagnosis and accurate risk stratification in this group of patients. This article reviews the clinical and diagnostic differences in elderly patients with HF, highlighting the presence of comorbidities, frailty, cognitive impairment, and polypharmacy, as well as discussing potential biomarkers that may have clinical application in this population.

Therapeutic Consequences and Prognostic Impact of Multimorbidity in Heart Failure: Time to Act

Background/Objectives: In heart failure (HF) with reduced ejection fraction (HFrEF), the early diagnosis and proper treatment of comorbidities (CMs) are of fundamental relevance. Our aim was to assess the prevalence of CMs among real-world patients requiring hospitalisation for HFrEF and to investigate the effect of CMs on the implementation of guideline-directed medical therapy (GDMT) and on all-cause mortality (ACM). Methods: The data of a consecutive HFrEF patient cohort hospitalised for HF between 2021 and 2024 were analysed retrospectively. Sixteen CMs (6 CV and 10 non-CV) were considered. Patients were divided into three categories: 0-3 vs. 4-6 vs. ≥7 CMs. GDMT at discharge and ACM were compared among CM categories. The predictors of 1-year ACM were also evaluated. Results: From the 388 patients (male: 76%, age: 61 [50-70] years; NT-proBNP: 5286 [2570-9923] pg/mL; ≥2 cardiovascular-kidney-metabolic disease overlap: 46%), a large proportion received GDMT (RASi: 91%; βB: 85%; MRA: 95%; SGLT2i: 59%; triple therapy [TT: RASi+βB+MRA]: 82%; quadruple therapy [QT: TT + SGLT2i]: 54%) at discharge. Multimorbidity was accompanied with a (p < 0.05) lower application ratio of RASi (96% vs. 92% vs. 85%; 0-3 vs. 4-6 vs. ≥7 CMs) and βB therapy (94% vs. 85% vs. 78%), while MRA (99% vs. 94% vs. 94%) and SGTL2i use (61% vs. 59% vs. 57%) did not differ (p > 0.05). Patients with multimorbidity were less likely to be treated with TT (93% vs. 82% vs. 73%, p = 0.001), while no difference was detected in the implementation of QT (56% vs. 54% vs. 50%, p = 0.685). The 1-year ACM of patients with an increased burden of CMs was higher (9% vs. 13% vs. 25%, p = 0.003). The risk of 1-year ACM was favourably affected by the use of TT/QT and less severe left ventricular systolic dysfunction, while having ≥5 CMs had an unfavourable impact on prognosis. Conclusions: According to our real-world analysis, HFrEF patients with an increased burden of CMs can expect a less favourable outcome. However, modern GDMT can even be applied in this patient population, resulting in a significantly improved prognosis. Thus, clinicians should insist on the early, conscious implementation of a prognosis-modifying drug regime in multimorbid HF patients as well.

Discontinuation rates, clinical effects and provocation factors of SGLT-2 inhibitor in the real world

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are the only medications that improve clinical outcomes regardless of baseline left ventricular ejection fraction. Despite the recognized effectiveness of SGLT-2 inhibitors, there remains a paucity of research on the discontinuation of these medications. The objective of this study is to analyze the rate of discontinuation of SGLT-2 inhibitors, to evaluate the impact of discontinuation on the clinical outcome, and to identify the factors associated with discontinuation. From 2015 to 2021, 775 heart failure patients prescribed an SGLT-2 inhibitor were retrospectively collated at Samsung Medical Center, Seoul, Republic of Korea. The SGLT-2 inhibitor discontinuation rate and the effect of SGLT-2 inhibitor discontinuation on clinical outcome were analyzed using the Kaplan-Meier survival curve. Factors related to discontinuation were analyzed through Cox regression and competing risk survival analysis. The discontinuation rate of SGLT-2 inhibitors was 7.5% at 1 year and 20% at 5 years. General weakness, over-diuresis and volume depletion, renal dysfunction progression, and urinary tract infections are the major reasons for discontinuing SGLT-2 inhibitors in general medical practice. The group that stopped using SGLT-2 inhibitors had a higher rate of heart failure hospitalization than the control group (adjusted HR 2.600, 95% CI [1.233-5.481], P = 0.012). In multivariable Cox regression analysis, the factors associated with total SGLT-2 inhibitor discontinuation were women (HR 2.478, 95% CI [1.553-3.953], P < 0.001) and lower estimated glomerular filtration rate (eGFR) (HR 0.884 per 10 ml/min/1.73 m2, 95% CI [0.789-0.991], P = 0.034). Patients who discontinued SGLT-2 inhibitors experienced an increased risk of heart failure hospitalization, and the rate of discontinuation was higher in women and those with lower eGFR.

Dapagliflozin in acute heart failure management: a systematic review and meta-analysis of safety and effectiveness

BACKGROUND

Acute Heart Failure (AHF) presents as a serious pathophysiological disease with significant morbidity and mortality rates, requiring immediate medical intervention. Traditional treatment involves diuretics and vasodilators, but a subset of patients develop resistance due to acute cardiorenal syndrome. Dapagliflozin, categorized as a sodium-glucose cotransporter-2 inhibitor (SGLT2i), has emerged as a promising therapy for AHF, demonstrating substantial benefits in reducing both mortality and morbidity among patients. The purpose of this meta-analysis and systematic review is to determine dapagliflozin's safety and efficacy in AHF patients.

METHODS

In accordance with PRISMA guidelines, we conducted a systematic search across several databases (PubMed, Science Direct, and Cochrane Library) up to June 2024 to identify randomized controlled trials (RCTs) that compared dapagliflozin with control treatments in patients with AHF. Key outcomes of interest included In-Hospital Cardiovascular mortality rates, duration of hospitalization, and instances of in-hospital worsening. Data extraction and quality assessment adhered to established protocols and the results were evaluated using Review Manager (RevMan Version 5.4.1) The assessment of bias risk follows the principles established in the Cochrane Handbook for Systematic Reviews and Meta-Analysis.

RESULTS

Five RCTs comprising 912 patients met the inclusion criteria. Dapagliflozin significantly reduced In-Hospital Cardiovascular mortality (RR 0.56, 95% CI 0.36-0.88, p = 0.01, I²=26%) and 30-day hospital readmissions (RR 0.73, CI 0.54-0.99, p = 0.05, I²=7%). However, dapagliflozin did not significantly affect the length of hospital stay (MD -0.11, CI -0.73-0.51, p = 0.72, I²=60%) or the incidence of hypotension (RR 0.82, CI 0.36-1.84, p = 0.63, I²=0%). A significant weight change was observed (MD 0.93, CI 0.03-1.83, p = 0.04, I²=95%), which was resolved upon sensitivity analysis (MD 1.34, CI 1.02-1.66, p < 0.0001, I²=0%). No significant effects were found for worsening renal failure or changes in GFR in this study.

CONCLUSION

Dapagliflozin appears to be beneficial in reducing In-Hospital Cardiovascular mortality and 30-day hospital readmissions in AHF patients. Although it demonstrates potential, additional research is needed to establish its significance in AHF management. Further investigation with larger sample sizes, different doses, and comprehensive safety and cost-effectiveness is imperative to thoroughly evaluate the safety and clinical efficacy of Dapagliflozin, underscoring the necessity for additional data to substantiate its role in managing patients with AHF.

CLINICAL TRIAL NUMBER

Not applicable.

Dapagliflozin Mediates the Protective Effect against atrial fibrillation/atrial flutter and the Reduction in All-Cause Mortality Risk

OBJECTIVE

This study aimed to investigate the association between dapagliflozin and the incidence of atrial fibrillation (AF) and atrial flutter (AFL), along with its impact on all-cause mortality in patients with diabetes mellitus (DM).

MATERIAL AND METHODS

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this meta-analysis conducted a comprehensive search across PubMed, Embase, and ClinicalTrials.gov databases up to June 2021. We focused on randomized controlled trials (RCTs) that compared dapagliflozin with a placebo. Trial sequential analysis (TSA) was utilized to assess the reliability of the findings. All statistical analyses were performed using Review Manager software.

RESULTS

The final analysis included nine studies, encompassing a total of 30,235 patients. The findings indicated a statistically significant reduction in the incidence of AF / AFL in the dapagliflozin group compared to the placebo group (relative risk (RR) = 0.73, 95 % confidence interval (CI) = 0.59 to 0.89, p=0.002), although this result was not corroborated by TSA. The occurrences of AF and all-cause mortality were also lower in the dapagliflozin group than in the placebo group (RR = 0.71, 95 % CI = 0.57 to 0.89, p=0.003 and RR = 0.90, 95 % CI = 0.82 to 0.98, p=0.02, respectively). However, TSA did not confirm these outcomes.

CONCLUSION

Dapagliflozin appears to offer a significant protective effect against AF / AFL and may reduce the risk of all-cause mortality in patients with DM. However, further research is needed to confirm these findings due to the lack of confirmation by TSA.

Optimizing outcomes from cardiac resynchronization therapy: what do recent data and insights say?

INTRODUCTION

Cardiac Resynchronization Therapy (CRT) is an effective treatment for heart failure (HF) in approximately two-thirds of recipients, with a third remaining CRT 'non-responders.' There is an increasing body of evidence exploring the reasons behind non-response, as well as ways to preempt or counteract it.

AREAS COVERED

This review will examine the most recent evidence regarding optimizing outcomes from CRT, as well as explore whether traditional CRT indeed remains the best first-line therapy for electrical resynchronization in HF. We will start by discussing methods of preempting non-response, such as refining patient selection and procedural technique, before reviewing how responses can be optimized post-implantation. For the purpose of this review, evidence was gathered from electronic literature searches (via PubMed and GoogleScholar), with a particular focus on primary evidence published in the last 5 years.

EXPERT OPINION

Ever-expanding research in the field of device therapy has armed physicians with more tools than ever to treat dyssynchronous HF. Newer developments, such as artificial intelligence (AI) guided device programming and conduction system pacing (CSP) are particularly exciting, and we will discuss how they could eventually lead to truly personalized care by maximizing outcomes from CRT.

Baseline kidney function and the effects of dapagliflozin on health status in heart failure in DEFINE-HF and PRESERVED-HF

AIMS

Sodium-glucose co-transporter-2 (SGLT2) inhibitors improve health status and outcomes in the setting of heart failure (HF) across the range of ejection fraction (EF). Baseline kidney disease is common in HF, complicates HF management and is strongly linked to worse health status. This study aimed to assess whether the treatment effects of dapagliflozin on health status vary based on estimated glomerular filtration rate (eGFR).

METHODS AND RESULTS

We conducted a pooled participant-level analysis of two double-blind, randomized trials, DEFINE-HF (n = 236) and PRESERVED-HF (n = 324), which evaluated dapagliflozin versus placebo. Both multicentre studies enrolled adults with HF, New York Heart Association Class II or higher, elevated natriuretic peptides, and an EF < 40% in DEFINE-HF or >45% in PRESERVED-HF. The primary exposure was eGFR. The main outcome was the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS) at 12 weeks. Across both trials, there were 583 (99.3%) participants with a baseline eGFR. The median (25th, 75th) eGFR was 59 (46, 77) mL/min/1.73 m2. Dapagliflozin improved KCCQ-CSS at 12 weeks [placebo-adjusted difference, +5.0 points, 95% confidence interval (CI) 2.6-7.5; P < 0.001], and this was consistent in participants with an eGFR ≥ 60 (+6.0 points, 95% CI 2.4-9.7; P = 0.001) and eGFR < 60 (+4.1 points, 95% CI 0.5-7.7; P = 0.025) (P interaction = 0.46). The benefits of dapagliflozin on KCCQ-CSS remained robust across eGFR when modelled as a continuous variable (P interaction = 0.48).

CONCLUSIONS

Dapagliflozin led to early and clinically meaningful improvements in health status in HF patients, regardless of EF or baseline eGFR.

Ventricular arrhythmias and haemodynamic collapse during acute coronary syndrome: increased risk for sudden cardiac death?

AIMS

In the acute phase of acute coronary syndrome (ACS), ventricular tachycardia (VT) and/or ventricular fibrillation (VF) leading to resuscitation are not considered to be associated with increased long-term sudden cardiac death (SCD) because the cause-acute ischaemia-is believed to be reversible. The aim of this study is to investigate whether ventricular arrhythmias (VAs) leading to sudden cardiac arrest during ACS are associated with the risk of incident SCD in patients with a normal or mildly impaired left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

This study is based on a retrospective analysis of all 8062 consecutive ACS patients undergoing coronary angiography with the baseline LVEF ≥40% between 2007 and 2018 (follow-up until 31 December 2021). The primary outcome was SCD-equivalent life-threatening VAs (LTVAs) composed of true SCDs and SCDs aborted by successful resuscitation or appropriate implantable cardiac device (ICD) therapy. The risk of sudden LTVA was estimated with a multivariate subdistribution hazard model using other deaths as competing events. Two-hundred thirteen (n = 211, 2.6%) patients suffered acute phase VF/VT leading to resuscitation and survived to discharge, and most occurred before angiography (80.6%, n = 170) and were VF (92.9%, n = 196). During a median follow-up of 7.6 years, 3.9% (n = 316) of all the patients had LTVA (10.0% in the VF/VT group vs. 3.8% in other patients). Ventricular fibrillation/VTs during ACS are associated with an increased risk for future SCD (hazard ratio 3.07; 95% confidence interval 1.94-4.85, P < 0.001). Most LTVAs occurred in patients without ICDs.

CONCLUSION

Ventricular fibrillation/VT in ACS is associated with a remarkably high long-term risk for SCD in patients with an LVEF ≥40%.

Acute kidney injury in acute heart failure-when to worry and when not to worry?

Acute kidney injury is common in patients with acute decompensated heart failure. It is more common in patients with acute heart failure who suffer from chronic kidney disease. Worsening renal function is often defined as a rise in serum creatinine of more than 0.3 mg/dL (26.5 µmol/L) which, by definition, is acute kidney injury (AKI) stage 1. Perhaps the term AKI is more appropriate than worsening renal function as it is used universally by nephrologists, internists and other medical practitioners. In health, the heart and the kidney support each other to maintain the body's homeostasis. In disease, the heart and the kidney can adversely affect each other's function, causing further clinical deterioration. In patients presenting with acute heart failure and fluid overload, therapy with diuretics for decongestion often causes a rise in serum creatinine and AKI. However, in the longer term the decongestion improves survival and prevents hospital admissions despite rising serum creatinine and AKI. It is important to realize that renal venous congestion due to increased right-sided heart pressures in acute heart failure is a major cause of kidney dysfunction and hence decongestion therapy improves kidney function in the longer term. This review provides a perspective on the acceptable AKI with decongestion therapy, which is associated with improved survival, as opposed to AKI due to tubular injury related to sepsis or nephrotoxic drugs, which is associated with poor survival.

Efficacy and Safety of Sodium Zirconium Cyclosilicate in the Management of Hyperkalemia in Patients with Heart Failure with Reduced and Mildly Reduced Ejection Fraction and Chronic Kidney Disease Treated with Spironolactone: Rationale for and Design of the REGISTA-K Trial

BACKGROUND

To evaluate whether sodium zirconium cyclosilicate (SZC) enables the up-titration of spironolactone without increasing the risk of hyper- and hypokalemia in patients with heart failure with reduced and mildly reduced ejection fraction (HFrEF and HFmrEF) and moderate/severe chronic kidney disease (CKD) who developed hyperkalemia during treatment with suboptimal spironolactone dose.

METHODS

The REGISTA-K is a randomized, double-blind, placebo-controlled, multicenter trial that examined the efficacy and safety of SZC in up-titrating spironolactone without the occurrence of hyperkalemia or hypokalemia. A total of 266 patients with HFrEF and HFmrEF and hyperkalemia will be randomized in a 1:1 ratio to receive either SZC or placebo after treating hyperkalemia with SZC at 25 sites in Japan. The study enrolls patients with left ventricular EF <50%, moderate/severe CKD (estimated glomerular filtration rate 15-45 mL/min/1.73 m2), serum potassium level >5.0 mEq/L, and undergoing 12.5-37.5 mg spironolactone treatment. The primary endpoint is successful administration of 50 mg/day spironolactone at 16 weeks follow-up without the need for rescue therapy for either hypokalemia or hyperkalemia.

CONCLUSIONS

REGISTA-K will evaluate the efficacy and safety of SZC as adjunctive therapy in up-titrating spironolactone in patients with HFrEF and HFmrEF with moderate to severe renal dysfunction and hyperkalemia.

Impact of SGLT2 inhibitors on cardiovascular outcomes and metabolic events in Chinese han patients with chronic heart failure

OBJECTIVE

This study aimed to evaluate the real-world impact of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on the efficacy, safety, and metabolic profiles of patients with chronic heart failure (CHF), both with and without type 2 diabetes mellitus (T2DM).

METHODS

A cohort of 1,130 patients with reduced ejection fraction chronic heart failure (HFrEF) was recruited from Zhongnan Hospital of Wuhan University, spanning January 2021 to August 2023. Among these, 154 patients received SGLT2i therapy, while 131 patients were assigned to a non-SGLT2i group, following specified inclusion and exclusion criteria. The association between SGLT2i therapy and the risk of primary and secondary endpoints was analyzed, alongside the effect of guideline-recommended heart failure medications at varying dosages on Major Adverse Cardiovascular Events (MACE).

RESULTS

SGLT2i treatment led to reductions in blood pressure, uric acid, NT-proBNP, and pulmonary artery pressure, while increasing body mass index (BMI) and left ventricular ejection fraction (LVEF) in CHF patients. Multivariate Cox regression analysis revealed that SGLT2i therapy reduced the primary endpoint risk by 40.3% (HR 0.597, 95% CI 0.356-0.973, p = 0.047). Univariate Cox regression indicated that SGLT2i might also reduce the incidence of new diagnoses of atrial fibrillation, non-fatal acute myocardial infarction, and MACE in CHF patients. Moreover, the use of a four-drug combination for heart failure management was associated with a lower risk of MACE compared to monotherapy.

CONCLUSION

SGLT2i therapy not only enhances LVEF but also significantly reduces ambulatory blood pressure, uric acid, fasting blood glucose, pulmonary artery pressure, and NT-proBNP levels in CHF patients. Additionally, SGLT2i improves prognosis by lowering the risk of both primary and secondary endpoints. Compared to monotherapy, a four-drug regimen for CHF substantially reduces the risk of MACE, supporting the effectiveness of comprehensive treatment strategies.

Prognostic Value of Epicardial Adipose Tissue in Heart Failure With Mid-Range and Preserved Ejection Fraction: A Multicenter Study

BACKGROUND

Epicardial adipose tissue (EAT) accumulation is thought to play a role in the pathophysiology of heart failure (HF) with mid-range ejection fraction and HF with preserved ejection fraction, but its effect on outcome is unknown.

METHODS AND RESULTS

A total of 692 patients with HF with mid-range ejection fraction or HF with preserved ejection fraction who underwent cardiovascular magnetic resonance at 2 medical centers in China between October 2016 and October 2022 were included in this study. EAT volume and extracellular volume were calculated using cardiovascular magnetic resonance. The main outcome was the composite of all-cause mortality and first HF hospitalization. Of 692 participants, 41.3% were women. The mean age, body mass index, left ventricular ejection fraction, and EAT volume were 57.0 years, 27.2 kg/m2, 50.0%, and 67.1 mL/m2, respectively. During a median follow-up of 34 months, 169 patients (24.4%) died or were hospitalized for HF. EAT volume exhibited a strong unadjusted association with the composite outcome (hazard ratio per 1 mL/m2 [HR], 1.57 [95% CI, 1.40-1.76], P<0.001). After fully adjusting, EAT remained associated with the outcome (HR, 1.62 [95% CI, 1.42-1.86], P<0.001). We constructed a baseline multivariable model including comorbidities, New York Heart Association functional class, extracellular volume, age, body mass index, left ventricular ejection fraction, and N-terminal pro-brain natriuretic peptide. Addition of EAT volume to the baseline multivariable model significantly improved model performance (C statistic improvement: 0.711-0.760; P<0.001).

CONCLUSIONS

EAT accumulation is associated with an adverse prognosis in patients with HF with mid-range ejection fraction and those with HF with preserved ejection fraction. In addition, EAT provides incremental prognostic value beyond left ventricular ejection fraction and New York Heart Association class.

Beyond ketosis: the search for the mechanism underlying SGLT2-inhibitor benefit continues

Despite the impressive clinical benefits and widespread adoption of sodium glucose cotransporter 2 inhibitors (SGLT2i) to treat all classes of heart failure, their cardiovascular mechanisms of action are poorly understood. Proposed mechanisms range broadly and include enhanced ketogenesis, where the mild ketosis associated with SGLT2i use is presumed to be beneficial. However, in this issue of the JCI, carefully conducted metabolic flux studies by Goedeke et al. comparing the effects of SGLT2i and exogenous ketones suggest differential effects. Thus, the mechanisms of action for SGLT2i are likely pleiotropic, and further work is needed to fully understand their beneficial effects.

Advances in myocardial energy metabolism: metabolic remodelling in heart failure and beyond

The very high energy demand of the heart is primarily met by adenosine triphosphate (ATP) production from mitochondrial oxidative phosphorylation, with glycolysis providing a smaller amount of ATP production. This ATP production is markedly altered in heart failure, primarily due to a decrease in mitochondrial oxidative metabolism. Although an increase in glycolytic ATP production partly compensates for the decrease in mitochondrial ATP production, the failing heart faces an energy deficit that contributes to the severity of contractile dysfunction. The relative contribution of the different fuels for mitochondrial ATP production dramatically changes in the failing heart, which depends to a large extent on the type of heart failure. A common metabolic defect in all forms of heart failure [including heart failure with reduced ejection fraction (HFrEF), heart failure with preserved EF (HFpEF), and diabetic cardiomyopathies] is a decrease in mitochondrial oxidation of pyruvate originating from glucose (i.e. glucose oxidation). This decrease in glucose oxidation occurs regardless of whether glycolysis is increased, resulting in an uncoupling of glycolysis from glucose oxidation that can decrease cardiac efficiency. The mitochondrial oxidation of fatty acids by the heart increases or decreases, depending on the type of heart failure. For instance, in HFpEF and diabetic cardiomyopathies myocardial fatty acid oxidation increases, while in HFrEF myocardial fatty acid oxidation either decreases or remains unchanged. The oxidation of ketones (which provides the failing heart with an important energy source) also differs depending on the type of heart failure, being increased in HFrEF, and decreased in HFpEF and diabetic cardiomyopathies. The alterations in mitochondrial oxidative metabolism and glycolysis in the failing heart are due to transcriptional changes in key enzymes involved in the metabolic pathways, as well as alterations in redox state, metabolic signalling and post-translational epigenetic changes in energy metabolic enzymes. Of importance, targeting the mitochondrial energy metabolic pathways has emerged as a novel therapeutic approach to improving cardiac function and cardiac efficiency in the failing heart.

Can SGLT-2 inhibitors improve cardiovascular outcomes and ensure safety for patients with type 2 diabetes and heart failure in Thailand? A real-world multicentre retrospective cohort study

OBJECTIVES

To assess the real-world effectiveness and safety of sodium-glucose co-transporter-2 inhibitors (SGLT2i) on cardiovascular outcomes in patients with type 2 diabetes mellitus (T2D) and heart failure (HF) and to evaluate the associated risks of adverse events.

DESIGN

A retrospective cohort study using propensity score analysis to control confounding variables.

SETTING

Data were collected from the electronic health records of two large tertiary care hospitals in Thailand over a 12-year period (2010-2022).

PARTICIPANTS

Adults aged 18 years and older with a diagnosis of T2D and HF were included in the study. Patients who received SGLT2i for a minimum of 3 months were compared with those in a non-SGLT2i group. Participants with a diagnosis of HF that preceded their diagnosis of T2D were excluded from the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was heart failure hospitalisation (HFH). Secondary outcomes included non-fatal stroke, non-fatal myocardial infarction (MI), all-cause mortality and adverse events (urinary tract infections, hypoglycaemia and acute kidney injury).

RESULTS

A total of 11 758 patients were included in the study, with a median follow-up of 2.44 (IQR: 0.72-5.02) years. After applying inverse probability of treatment weighting, covariates were balanced, ensuring the validity of the treatment effect model's assumptions. SGLT2i use was associated with a 59% reduction in HFH (HR 0.41, 95% CI 0.28 to 0.61), a 54% reduction in stroke (HR 0.46, 95% CI 0.33 to 0.63), a 51% reduction in MI (HR 0.49, 95% CI 0.36 to 0.67) and a 76% reduction in in-hospital all-cause mortality (HR 0.24, 95% CI 0.14 to 0.42). Additionally, SGLT2i use was associated with fewer adverse events, including lower rates of urinary tract infections and hypoglycaemia, compared with the non-SGLT2i group.

CONCLUSIONS

SGLT2i significantly improved cardiovascular outcomes in patients with T2D and HF in a real-world clinical setting. These findings support the incorporation of SGLT2i in the management of high-risk patients with T2D and HF. Further research is warranted to explore long-term outcomes and barriers to SGLT2i prescription in routine practice.

Investigation of left ventricular ejection fraction in a Swiss heart failure population: Insights into mortality and sex differences

AIMS

Understanding heart failure (HF) characteristics is essential to improve patient outcomes. Categorizing HF beyond left ventricular ejection fraction (LVEF) is challenging due to heterogeneous clinical presentation and aetiologies. Despite global studies on HF, the role of LVEF on mortality remains controversial. We explored the association of LVEF with mortality, considering sex differences and comorbidities in a cohort from the largest tertiary cardiovascular centre in Switzerland.

METHODS

HF patients admitted to the University Hospital of Bern from January 2015 to December 2019 were evaluated. LVEF was used to classify patients into HF with preserved ejection fraction (HFpEF), HF with mid-range ejection fraction (HFmrEF) and HF with reduced preserved ejection fraction (HFrEF) categories. Cox proportional hazard models and time-stratified analyses adjusted for potential confounders were employed.

RESULTS

A total of 5824 HF patients were included, and 2912 died over a median follow-up time of 3.39 years. Mortality rates across LVEF categories showed no significant differences, while overall, women showed significantly higher mortality; 30 day mortality was lower in the HFpEF category [hazard ratio (HR) 0.67, 95% confidence interval (CI): 0.52-0.88, P = 0.003], with persistent effects upon stratification in males (HR 0.59, 95% CI: 0.42-0.81, P < 0.001) and non-diabetics (HR 0.62, 95% CI: 0.44-0.87, P = 0.005). An isolated reduction in HFpEF mortality was observed in females after 1 year (HR 0.72, 95% CI: 0.53-0.98, P = 0.035).

CONCLUSIONS

The prognostic role of LVEF on all-cause mortality remains unclear, while differences in mortality rate distribution between women and men mirror established HF pathophysiological sex differences. Future HF studies should focus on HF aetiology and include measures beyond LVEF for comprehensive characterization.

Hemodynamic Effects of SGLT2 Inhibitors in Patients with and Without Diabetes Mellitus-A Narrative Review

Background: The current review aims to present the beneficial effects of SGLT2 inhibitors (dapagliflozin and empagliflozin) on several hemodynamic parameters such as blood pressure, filtration pressure at the level of the glomerular capillaries, and the improvement of the preload and afterload of heart muscle. In order to stop chronic kidney disease (CKD) from progressing, SGLT2 inhibitors have become an important disease-modifying treatment. Materials and methods: Recent clinical studies have shown the success of these drugs in treating heart failure, reducing the risk of cardiovascular events, hospitalization, and mortality. Results: The hemodynamic effects of SGLT2 inhibitors include a diuretic effect, due to reduced sodium reabsorption. Also, at this level, numerous studies have confirmed the beneficial effect of dapagliflozin in patients with chronic kidney disease, associated with a 44% reduced risk of progression in this pathology. SGLT2 inhibitors are associated with a reduction in blood pressure and weight loss, because of their diuretic effect, especially empagliflozin, which can explain the beneficial effects in patients with heart failure. In addition, mainly empagliflozin reduces stiffness and arterial resistance. Conclusions: Although the exact mechanism of action is unknown, SGLT2 inhibitors reduce the interstitial volume by blocking the tubular reabsorption of glucose. This leads to reduced blood pressure and enhanced endothelial function. Consequently, there have been improvements in hospitalization and fatality rates. Because of their beneficial effects, these medications have been guidelines for managing heart failure and chronic kidney disease.

A Systematic Review and Meta-Analysis of the Efficacy and Safety of Sodium-Glucose Cotransporter-2 Inhibitor in Patients Using Left Ventricular Assist Devices

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2-i) have been shown to reduce risks of clinical events in patients with heart failure (HF). However, data on the use of SGLT2-i in patients with left ventricular assist devices (LVADs) are scarce. We thought to assess the efficacy and safety of SGLT2-i in patients with LVADs. Methods: A systematic search was conducted in PubMed, Scopus, Web of Science, Embase, and Cochrane from inception to November 2024. We used all relevant words for "SGLT2-i" and "LVAD" to search in databases, and we included studies and published abstracts in peer-reviewed journals of studies that assessed SGLT2-i in patients with LVAD. Results: Four studies and seven abstracts totaling 228 patients using SGLT2-i were included. Empagliflozin, Dapagliflozin, and Canagliflozin were the used SGLT2-i across the included studies. Pooled analysis showed that SGLT2-i significantly improved ejection fraction (EF) (Mean= 4.2, 95% CI [1.22, 7.19]) and hemoglobin A1c (HbA1c) (Mean = -0.44, 95% CI [-0.79, -0.09]) from baseline. However, no significant changes in B-type natriuretic peptide (BNP), or glomerular filtration rate (GFR) were noticed. Other outcomes of interest not included in the meta-analysis did not show significant changes, such as cardiac index (CI), left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVEDD), mean arterial pressure (MAP), or mean pulmonary artery pressure (MPAP). The pooled percentage of people with driveline infection was 9%, 95% CI (3, 19). Conclusions: SGLT2-i effectively improves EF and HbA1c in patients using LVAD. Further adequately powered randomized studies are warranted to ascertain its clinical efficacy and safety in that unique population.

Jin-Xin-Kang alleviates heart failure by mitigating mitochondrial dysfunction through the Calcineurin/Dynamin-Related Protein 1 signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Chronic heart failure (CHF) is a severe consequence of cardiovascular disease, marked by cardiac dysfunction. Jin-Xin-Kang (JXK) is a traditional Chinese herbal formula used for the treatment of CHF. This formula consists of seven medicinal herbs, including Ginseng (Ginseng quinquefolium (L.) Alph.Wood), Astragali Radix (Astragalus membranaceus (Fisch.) Bunge), Salvia miltiorrhiza (Salvia miltiorrhiza Bunge), Descurainiae Semen Lepidii Semen (Descurainia sophia (L.) Webb ex Prantl), Leonuri Herba (Leonurus japonicus Houtt.), Cinnamomi Ramulus (Cinnamomum cassia (L.) J.Presl), and Ilex pubescens (Ilex pubescens Hook. & Arn.). Its clinical efficacy has been validated through prospective randomized controlled studies. However, the specific mechanisms of action for this formula have yet to be elucidated.

AIM OF THE STUDY

This study aimed to investigate the effect of JXK on mitochondrial function and its mechanism in the treatment of CHF.

METHODS

JXK components were qualitatively analyzed using UPLC-Q-Orbitrap-MS. HF was induced in mice via transverse aortic constriction (TAC). After successful model establishment, lyophilized JXK-L (4.38 g/kg) and JXK-H (13.14 g/kg) were administered for 8 weeks. In vitro, hypertrophic myocardium was induced using angiotensin II (Ang II) for 48 h, followed by JXK-L and JXK-H treatment. Network pharmacology and molecular docking techniques were used to predict the relevant targets of JXK. Cardiac function, serum markers, and histopathological changes were evaluated to assess cardiac function. Immunofluorescence of Tomm20, mitochondrial membrane potential, and ROS were measured to assess mitochondrial dysfunction. Protein expression of calcineurin (CaN) and Drp1 in the myocardium was assessed by Western blot analysis.

RESULTS

We detected that the active components of JXK include terpenes, glycosides, flavonoids, amino acids, and alkaloids, among others. In mice with CHF, JXK improved cardiac function and reversed ventricular remodeling. Network pharmacology indicated that JXK can inhibit the calcium signaling pathway. The molecular docking results demonstrated that the active components of JXK effectively bind with CaN. Both in vitro and in vivo experiments confirmed that JXK regulated the CaN/Drp1 pathway and alleviated mitochondrial dysfunction.

CONCLUSION

JXK can inhibit the CaN/Drp1 pathway to improve mitochondrial function, and consequently treat CHF.

Effect of sodium glucose cotransporter 2 inhibitors on all cause death and rehospitalization for heart failure in patients with acute myocardial infarction

The impact of sodium-glucose co-transporter 2 inhibitors (SGLT2-i) on reducing the risk of all-cause mortality and rehospitalization for heart failure (HF) in patients with acute myocardial infarction (AMI) remains unclear. This study aims to evaluate the effect of SGLT2-i on all-cause mortality and rehospitalization for HF in patients diagnosed with AMI. A comprehensive search was conducted in PubMed, Web of Science, the Cochrane Library, and Embase for relevant studies published up to May 2024, following the PICOS principle. Eligible studies included randomized clinical trials and cohort studies comparing SGLT2-i with placebo regarding all-cause mortality, rehospitalization for HF, cardiovascular mortality, and the incidence of nonfatal MI in AMI patients. Patient-level data from each trial were synthesized into a pooled dataset and analyzed using a mixed-effects or random-effects model based on the I2 statistic. Ten clinical trials enrolling 15,748 participants (6913 in the SGLT2-i group and 8835 in the placebo group) were included. The follow-up duration ranged from 12 weeks to 2.1 years. SGLT2-i significantly reduced rehospitalization for HF (RR: 0.69, 95% CI 0.60-0.81, P < 0.00001, I2 = 39%) compared to placebo. However, SGLT2-i did not significantly reduce the risk of all-cause death (RR: 0.85, 95% CI 0.72-1.00, P = 0.05, I2 = 46%), cardiovascular death (RR: 0.96, 95% CI 0.78-1.18, P = 0.67, I2 = 24%) or nonfatal MI (RR: 0.71, 95% CI 0.44-1.14, P = 0.16, I2 = 64%) during follow-up. Compared to placebo, SGLT2-i significantly reduced rehospitalization for HF in patients with AMI, but did not reduce the risk of all-cause death, cardiovascular death and nonfatal MI.

Effect of optimisation to contemporary HFrEF medical therapy with sacubitril/valsartan (Entresto) and dapaglifloziN on left Ventricular reverse remodelling as demonstrated by cardiac magnetic resonance (CMR) Imaging: the ENVI study

INTRODUCTION

Heart failure with reduced ejection fraction (HFrEF) guidelines recommend 'four pillars' of medical therapy and device therapy if left ventricular ejection fraction (LVEF) remains ≤35% after 3 months optimum medical therapy.We conducted the first study to examine the effects of optimisation to contemporary medical therapy on cardiac reverse remodelling, as demonstrated by cardiac magnetic resonance imaging (CMR).We hypothesised a proportion of patients would undergo beneficial remodelling and LVEF improvement above the threshold for complex device prescription after 6 months.

METHODS

HFrEF patients with symptomatic LVEF≤35% despite ACE inhibitor/beta blocker/mineralocorticoid receptor antagonist therapy, and qualified for sacubitril/valsartan switchover were recruited to this single centre prospective study.CMR was performed at baseline and at follow-up. Clinical, volumetric and outcome data were collected and compared.

RESULTS

Between June 2021 and August 2022, 49 patients were recruited. The majority (80%) were male, mean age 63±14 years. 35 (71%) had non-ischaemic cardiomyopathy. 2 (4%) patients died and 47 were followed up for a median of 7.4 months. There were no heart failure hospitalisations.Significant reductions were seen in median indexed left atrial volume: 54 mL/m2 (41-72) to 39 mL/m2 (30-60) (p<0.001); indexed left ventricular end-diastolic volume: 109 mL/m2 (74-125) to 76 mL/m2 (58-102) (p<0.001); indexed left ventricular end-systolic volume: 74mL/m2 (50-92) to 43 mL/m2 (27-58) (p<0.001) and mean indexed left ventricular mass: 72±13 g/m2 to 62±13 g/m2 (p<0.001).Median LVEF increased by 12 points from 31% to 43% (p<0.001). 29 (59%) patients improved to LVEF>35%. 13 (27%) patients improved to LVEF≥50%.Median N-terminal pro B type natriuretic peptide (NTproBNP) reduced from 883 ng/L (293-2043) to 429 ng/L (171-1421) (p<0.001).

CONCLUSIONS

Optimisation to contemporary HFrEF medical therapy results in beneficial cardiac reverse remodelling and significant improvements in LVEF and NTproBNP at 6 months as demonstrated by CMR. 59% of our cohort no longer met complex device indications. Guidelines suggest re-assessment of LVEF at 3 months, but our data suggests a longer period is required.

TRIAL REGISTRATION NUMBER

NCT05348226.

Pharmacological Nephroprotection in Chronic Kidney Disease Patients with Type 2 Diabetes Mellitus-Clinical Practice Position Statement of the Polish Society of Nephrology

Both chronic kidney disease (CKD) and type 2 diabetes (T2D) are modern epidemics worldwide and have become a severe public health problem. Chronic kidney disease progression in T2D patients is linked to the need for dialysis or kidney transplantation and represents the risk factor predisposing to serious cardiovascular complications. In recent years, important progress has occurred in nephroprotective pharmacotherapy in CKD patients with T2D. In the current position paper, we described a nephroprotective approach in CKD patients with T2D based on the five following pillars: effective antihyperglycemic treatment, SGLT2 inhibitor or semaglutide, antihypertensive therapy, use of RASi (ARB or ACEi), and in selected patients, finerenone, as well as sodium bicarbonate in patients with metabolic acidosis. We thought that the current statement is comprehensive and up-to-date and addresses multiple pathways of nephroprotection in patients with CKD and T2D.

Evaluation of Sodium-Glucose Transport Protein 2 (SGLT2) Inhibitor Prescribing Patterns in Heart Failure Patients at Hospital Discharge

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) dapagliflozin and empagliflozin are indicated for heart failure with reduced ejection fraction (HFrEF) for cardiovascular death and heart failure hospitalization risk reduction. Due to the recent nature of these data, prescribing of SGLT2is may be suboptimal. Objective: This study sought to assess the prevalence of SGLT2i prescriptions at hospital discharge for HFrEF. Methods: A retrospective chart review was conducted on HFrEF patients discharged from April 1st to December 31st, 2021 from one academic medical center in the United States. The primary objective was to determine the percentage of eligible patients prescribed SGLT2i at discharge and the secondary objective was to characterize covariates impacting prescription. Results: Overall, 115 patients were included. The mean age was 72 ± 14.25 years. The majority were male (73.9%) and Caucasian (74.8%). At discharge, 15.7% of patients were prescribed an SGLT2i, although 94.8% were eligible. Baseline characteristics and concomitant medications did not differ significantly, although the mean number of discharge medications differed significantly between those prescribed an SGLT2i (15.78 ± 6.77) and those not (12.05 ± 5.28) (P = 0.023). Conclusions: SGLT2is are under-prescribed at discharge for HFrEF patients, despite many being eligible. Further studies should be done to elucidate factors that influence the under-prescription of SGLT2is.

GLP-1 receptor agonists in patients with chronic kidney disease and either overweight or obesity

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as game-changers across the cardiovascular-kidney-metabolic (CKM) spectrum: overweight/obesity, type 2 diabetes mellitus (T2DM) and associated chronic kidney disease (CKD) and cardiovascular disease (CVD). Liraglutide, semaglutide and tirzepatide are European Medicines Agency approved to improve metabolic control in T2DM and to decrease weight in persons with obesity [body mass index (BMI) ≥30 kg/m2] or with overweight (BMI ≥27 kg/m2) associated with weight-related comorbidities such as hypertension, dyslipidaemia, CVD and others. Additionally, liraglutide and semaglutide are approved to reduce CVD risk in patients with CVD and T2DM. Semaglutide is also approved to reduce CVD risk in patients with CVD and either obesity or overweight and in phase 3 clinical trials showed kidney and cardiovascular protection in patients with T2DM and albuminuric CKD (FLOW trial) as well as in persons without diabetes that had CVD and overweight/obesity (SELECT trial). Thus, nephrologists should consider prescribing GLP-1 RAs to improve metabolic control, reduce CVD risk or improve kidney outcomes in three scenarios: patients with overweight and a related comorbid condition such as hypertension, dyslipidaemia or CVD, patients with obesity and patients with T2DM. This review addresses the promising landscape of GLP-1 RAs to treat persons with overweight or obesity, with or without T2DM, within the context of CKD, assessing their safety and impact on weight, metabolic control, blood pressure and kidney and cardiovascular outcomes, as part of a holistic patient-centred approach to preserve CKM health.

Cardiovascular and kidney benefits of SGLT-2is and GLP-1RAs according to baseline blood pressure in type 2 diabetes: a systematic meta-analysis of cardiovascular outcome trials

Using a systematic meta-analysis, we investigated if patients with type 2 diabetes (T2D) and with varying baseline blood pressure (BP) differ in the cardiorenal benefits received from sodium-glucose co-transporter 2 inhibitors (SGLT-2is) and glucagon-like peptide 1 receptor agonists (GLP-1RAs). Design: Randomized, placebo-controlled, cardiovascular outcome trials (CVOTs) of SGLT-2is and GLP-1RAs were identified from MEDLINE, Embase, and the Cochrane Library up to April 2024. Hazard ratios (HRs) with 95% CIs were pooled. The differential treatment effect by baseline BP category within each trial was estimated as the ratio of the HR (RHR) and pooled. Results: Seventeen publications based on 9 unique CVOTs (4 SGLT-2is and 5 GLP-1RAs) were eligible. In participants with normal baseline BP, comparing SGLT-2is with placebo, the HRs (95% CIs) were 0.88 (0.79-0.97) for major adverse cardiovascular events (MACE), 0.73 (0.59-0.91) for heart failure (HF) hospitalization, 0.78 (0.65-0.94) for composite CVD death/HF hospitalization, and 0.55 (0.41-0.73) for composite renal outcome. The corresponding estimates for participants with higher baseline BP were 0.88 (0.81-0.96), 0.67 (0.57-0.79), 0.73 (0.65-0.82), and 0.61 (0.48-0.77), respectively. In participants with normal baseline BP, GLP-RAs had no strong effect on MACE, stroke and nephropathy, but reduced stroke and nephropathy risk in those with higher baseline BP. Estimated RHRs showed no statistical evidence that baseline BP modified the cardiorenal benefits of SGLT-2is and GLP-1RAs. Conclusions: In patients with T2D, the cardiorenal benefits of treatment with SGLT2-Is and GLP1-RAs were similar in patients with normal baseline BP compared to those with a higher baseline BP.

Management of Hyperglycemia in Hospitalized Patients

People with diabetes account for 25% of hospitalizations, or 8 million admissions annually. Poor glycemic control in the hospital is associated with increased morbidity, mortality, length of stay, and readmissions. Key considerations of inpatient diabetes management include initiation of appropriate insulin or medication regimens and frequent dose adjustments based on patient-specific factors. Inpatient diabetes management teams and new technologies are increasingly prevalent and can assist in achieving glycemic targets in the hospital. At discharge, standardized checklists should be used to ensure successful transitions of care.

A Systematic Review and Meta-Analysis of Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors and Their Impact on the Management of Heart Failure

Heart failure (HF) is a life-threatening condition with severe incapacitating consequences. Many body organs and systems may be affected, which may also hinder the quality of life and finances at the individual and societal levels. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have also emerged as potentially useful drugs in the HF domain and other medical fields, in addition to their glucose-lowering effect. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the authors searched Google Scholar, PubMed, and Scopus websites for SGLT2i and SGLT2i-related terms and their impact on HF events, major adverse cardiovascular events (MACEs), renal composite outcomes, and improvement in the Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, involving human adult populations. Two reviewers conducted the literature search, and disagreements were resolved through mutual consensus and input from a third reviewer. A literature search was conducted from 1st February to 20th February 2024. We included studies published after 2018 to focus only on the latest advancements. Randomized controlled trials, observational studies, or systematic reviews of these studies were included in our study. Of the 44 initial articles identified, only 14 met the inclusion and exclusion criteria. The outcomes revealed the superiority of SGLT2i therapeutics over placebo in all four domains mentioned above. A total of 234,509 patients from 11 papers with moderate heterogeneity (P = 0.07; I2 = 42%) evaluating the effect of SGLT2i in comparison to placebo on HF events were considered; of these, 128,477 patients received the intervention drug, and 106,032 individuals were assigned to the control group. The absolute numbers of HF events were 6845 and 8877, respectively. The study showed an overall benefit of SGLT2i in patients with heart failure due to their ability to major adverse cardiovascular events (MACE) in comparison to placebo (OR: 0.92; 95% CI: 0.89-0.96; P < 0.00001). This systematic review confirmed previous findings related to the use of SGLT2i as adjunctive therapy for HF and amelioration of KCCQ scores and as a protective agent against MACE and renal impairment progression.

Epicardial fat in heart failure-Friend, foe, or bystander

Epicardial adipose tissue (EAT) is a fat depot covering the heart. No physical barrier separates EAT from the myocardium, so EAT can easily affect the underlying cardiac muscle. EAT can participate in the development and progression of heart failure with preserved (HFpEF) and reduced ejection fraction (HFrEF). In healthy humans, excess EAT is associated with impaired cardiac function and worse outcomes. In HFpEF, this trend continues: EAT amount is usually increased, and excess EAT correlates with worse function/outcomes. However, in HFrEF, the opposite is true: reduced EAT amount correlates with worse cardiac function/outcomes. Surprisingly, although EAT has beneficial effects on cardiac function, it aggravates ventricular arrhythmias. Here, we dissect these phenomena, trying to explain these paradoxical findings to find a target for novel heart failure therapies aimed at EAT rather than the myocardium itself. However, the success of this approach depends on a thorough understanding of interactions between EAT and the myocardium.

Comorbidities and determinants of health on heart failure guideline-directed medical therapy adherence: All of us

Background

Heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) are challenging conditions to treat due to complex pathophysiology and associated comorbidities. However, recent trials have demonstrated improved outcomes with guideline-directed medical therapy (GDMT) for each subtype of heart failure.

Objective

We investigated the relationship of determinants of health and risk factors with GDMT use for HFrEF and HFpEF in a large, diverse US cohort.

Methods

Using the NIH-sponsored All of Us Program, we compared demographics, risk factors (e.g., hypertension, diabetes, smoking), and SDOH measures between HFrEF and HFpEF in US adults aged 18 years and older. We examined the proportions of HFrEF patients receiving fewer than four or all four GDMTs. HFpEF patients receiving two medications were compared with those receiving less than two recommended medications. Multiple logistic regression was used for data analysis.

Result

Of 6049 HFrEF patients, 5838 (97 %) received fewer than four GDMTs, and 210 (3 %) received quadruple therapy. Of 3774 HFpEF patients, 162 (4 %) were on 2/3 GDMT, and only 38 (1 %) were on all three recommended medications. Patients with ASCVD and diabetes had higher odds of being on more than half of the recommended GDMT for both HFrEF and HFpEF. Additionally, females had higher odds of being on 2/3 GDMT for HFpEF (1.46 [1.08, 2.00]). Race, income, education, and health insurance types did not predict GDMT optimization.

Conclusion

HFrEF and HFpEF GDMT remain underutilized. Future efforts to address comorbidities and system-wide healthcare interventions may improve heart failure GDMT.

New and future heart failure drugs

In the past decade, our understanding of heart failure pathophysiology has advanced significantly, resulting in the development of new medications such as angiotensin-neprilysin inhibitors, sodium-glucose cotransporter-2 inhibitors and oral soluble guanylate cyclase stimulators. Backed by positive findings from large randomized controlled trials, recommendations for their use were recently included in the 2022 AHA/ACC/HFSA guidelines and 2023 ESC guidelines for management of heart failure. Promising drugs for future heart failure treatment include agents that modulate the neurohormonal system, vasodilators, anti-inflammatory drugs, mitotropes, which improve deranged energy metabolism of the failing heart, and myotropes, which increase cardiac contractility by affecting cardiac sarcomere function. Here, we discuss these new and future heart failure drugs. We explain their mechanisms of action, critically evaluate their performance in clinical trials and summarize the clinical scenarios in which the latest guidelines recommend their use. This Review aims to offer clinicians and researchers a comprehensive overview of novel therapeutic classes in heart failure treatment.

Prognostic impact of beta-blocker use by N-terminal pro-brain natriuretic peptide level in acute heart failure patients

AIMS

Both patients with heart failure (HF) with reduced ejection fraction (HFrEF) and those with HF with preserved ejection fraction (HFpEF) present with elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) and have multiple comorbidities; consequently, the prognostic effect of NT-proBNP according to beta-blocker (BB) use is unknown.

METHODS

This retrospective study evaluated patients admitted for acute HF between January 2012 and December 2017 at Ulsan University Hospital. Clinical, echocardiographic, laboratory and drug prescription data, including BB data, were collected from the hospital database. Information on mortality was collected by reviewing medical records or using national death data.

RESULTS

Of the 472 patients evaluated, 216 (45.8%) and 256 (54.2%) patients were and were not prescribed BB at discharge, respectively. A total of 224 (47.5%) patients died within a median follow-up duration of 44 months. The Kaplan-Meier analysis showed reduced all-cause mortality with BB in HFrEF (ejection fraction ≤ 40%) but not in HFpEF (ejection fraction > 40%). In the multivariate Cox regression analysis, transmitral to tissue Doppler imaging, early diastolic velocity ratio (E/E'), NT-proBNP and BB use were independent predictors of all-cause mortality in HFrEF. Meanwhile, haemoglobin and NT-proBNP levels were independent predictors of HFpEF. The NT-proBNP cut-off value for determining all-cause mortality was set to 4800 pg/mL. Among HFrEF patients with NT-proBNP < 4800 pg/mL, the survival rate was higher for patients with BB use than those with no BB use (log-rank P < 0.001). However, in the HFpEF group, the survival rate associated with BB use did not differ according to the NT-proBNP levels. Both HFrEF and HFpEF patients with NT-proBNP levels of ≥4800 pg/mL presented with multiple comorbidities, including lower body mass index and haemoglobin levels and higher creatinine levels, NT-proBNP levels and E/E'.

CONCLUSION

In patients with acute HF, BB use is associated with reduced all-cause mortality in those with HFrEF but not in those with HFpEF. HFrEF patients with NT-proBNP levels of <4800 pg/mL treated with BB have a higher survival rate than those not treated with BB. However, this benefit is not seen in HFrEF patients with NT-proBNP levels of ≥4800 pg/mL or in all HFpEF patients, regardless of the NT-proBNP level. NT-proBNP levels are elevated in multiple comorbid conditions, and these comorbidities may contribute to the attenuated effects of BB on all-cause mortality.

SGLT2 inhibitors, cardiovascular outcomes, and mortality across the spectrum of kidney disease: A systematic review and meta-analysis

AIMS

To evaluate the effects of SGLT2 inhibitors on cardiovascular outcomes and mortality across KDIGO and urinary albumin-to-creatinine ratio [UACR] groups.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL up to August 8th, 2023. In pairs, researchers selected large randomized placebo-controlled trials of SGLT2 inhibitors, with minimum duration of one year. Researchers independently extracted study-level data and assessed within-study risk of bias with RoB 2.0 and certainty of evidence with GRADE. Meta-analyses employed a random-effects model.

RESULTS

We included 14 trials, encompassing 97,412 participants and a median follow-up of 2.5 years. Risk of bias was overall low. Overall, SGLT2 inhibitors reduced major adverse cardiovascular events (MACE) (HR 0.89, 95 %-CI 0.85-0.93), cardiovascular death or hospitalization for heart failure (HHF) (HR 0.78, 95 %-CI 0.75-0.82), all-cause death (HR 0.89, 95 %-CI 0.83-0.94), and HHF (HR 0.71, 95 %-CI 0.67-0.75). The effect of SGLT2 inhibitors on MACE was different across KDIGO (Pinteraction = 0.038) and UACR (Pinteraction = 0.008) groups, with greater benefits in KDIGO Very High (HR 0.72, 95 %-CI 0.61-0.86) and UACR > 300 mg/g (HR 0.76, 95 %-CI 0.68-0.86) groups.

CONCLUSIONS

SGLT2 inhibitors are associated with reductions in cardiovascular outcomes and mortality. Greater reductions in MACE are expected in subjects in high-risk groups for kidney disease.