1
|
Tromp J, Lam CSP, Alemayehu W, de Filippi CR, Melenovský V, Sliwa K, Lopatin Y, Arango JL, Bahit MC, Roessig L, O'Connor CM, Shah P, Westerhout CM, Voors AA, Pieske B, Armstrong PW. Biomarker profiles associated with reverse ventricular remodelling in patients with heart failure and a reduced ejection fraction: Insights from the echocardiographic substudy of the VICTORIA trial. Eur J Heart Fail 2024. [PMID: 39078607 DOI: 10.1002/ejhf.3397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 07/31/2024] Open
Abstract
AIMS Reverse ventricular remodelling, defined as a decrease in left ventricular end-systolic volume indexed to body surface area (LVESVI) or an increase in left ventricular ejection fraction (LVEF), is associated with improved clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, the underlying pathophysiological mechanisms remain unclear. METHODS AND RESULTS We evaluated paired core-lab assessed echocardiograms and measurements of 92 biomarkers at baseline and 8 months thereafter in 419 participants with HFrEF. Reverse ventricular remodelling was defined as a >5% LVEF increase or >15% LVESVI relative decrease between baseline and 8 months. We evaluated the association between baseline biomarkers and their changes with reverse ventricular remodelling in the prospectively randomized controlled VICTORIA (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) trial. Of 419 patients (median age 66 [interquartile range 57-74] years, 27.4% women), 206 (49.2%) had reverse ventricular remodelling (either a 5% LVEF increase or a 15% LVESVI decrease). There were no differences in baseline biomarker concentrations between patients with versus those without reverse ventricular remodelling on follow-up. However, in patients with reverse ventricular remodelling there were significant decreases in biomarkers relating to inflammation and cardiac metabolism; particularly the tumour necrosis factor superfamily member 13B (ratio 0.82, 95% confidence interval [CI] 0.77-0.88), growth differentiation factor-15 (ratio 0.74, 95% CI 0.66-0.84), and insulin-like growth factor binding protein 7 (ratio 0.80, 95% CI 0.73-0.88). CONCLUSIONS Reverse ventricular remodelling in patients with HFrEF is associated with a decrease of biomarkers related to inflammation and cardiac metabolism.
Collapse
Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health National University of Singapore and National University of Singapore and National University Health System, Singapore, Singapore
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
| | | | - Christopher R de Filippi
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, Department of Medicine and Cardiology, University of Cape Town, Cape Town, South Africa
| | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | - Juan Luis Arango
- Unidad de Cirugía Cardiovascular de Guatemala, Guatemala City, Guatemala
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Argentina
| | | | - Christopher M O'Connor
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Palak Shah
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
- University of Groningen, Groningen, The Netherlands
| | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany
| | - Paul W Armstrong
- University of Alberta, Canadian VIGOUR Centre, Edmonton, AB, Canada
| |
Collapse
|
2
|
Ferreira JP, Blatchford JP, Teerlink JR, Kosiborod MN, Angermann CE, Biegus J, Collins SP, Tromp J, Nassif ME, Psotka MA, Comin-Colet J, Mentz RJ, Brueckmann M, Nordaby M, Ponikowski P, Voors AA. Time from admission to randomization and the effect of empagliflozin in acute heart failure: A post-hoc analysis from EMPULSE. Eur J Heart Fail 2024. [PMID: 38980272 DOI: 10.1002/ejhf.3369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/31/2024] [Accepted: 06/14/2024] [Indexed: 07/10/2024] Open
Abstract
AIMS Patients hospitalized for acute heart failure (HF) could be enrolled in EMPULSE (NCT04157751) upon haemodynamic stabilization and between 24 h and 5 days after hospital admission. The timing of treatment initiation may influence the efficacy and safety of drugs such as empagliflozin. The aim of this study was to evaluate patient characteristics, clinical events, and treatment effects according to time from admission to randomization. METHODS AND RESULTS The EMPULSE population was dichotomized by median time from hospital admission to randomization (1-2 days vs. 3-5 days). The primary outcome was a hierarchical composite endpoint of time to all-cause death, number of HF events, time to first HF event, and a ≥5-point difference in Kansas City Cardiomyopathy Questionnaire total symptom score change from baseline after 90 days, analysed using the win ratio (WR) method. Patients randomized later (3-5 days, average time 3.9 days; n = 312) had a higher risk of experiencing clinical events than patients randomized earlier (1-2 days, average time 1.7 days; n = 215). The treatment effect favoured empagliflozin versus placebo in patients randomized later (3-5 days: WR 1.69, 95% confidence interval [CI] 1.26-2.25) but was attenuated in patients randomized earlier (1-2 days: WR 1.04, 95% CI 0.74-1.44) (interaction p = 0.029). A similar pattern was observed for the composite of HF hospitalization or cardiovascular death and all-cause hospitalizations (interaction p < 0.1 for both). The reduction of N-terminal pro-B-type natriuretic peptide levels was more pronounced with empagliflozin among patients randomized later than in patients randomized earlier (interaction p = 0.004). CONCLUSIONS Among patients hospitalized for acute HF enrolled in EMPULSE, those randomized later after hospital admission (3-5 days) experienced greater clinical benefit with empagliflozin than those randomized earlier (1-2 days). These findings should be confirmed in future studies before clinical application.
Collapse
Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Sky Tower, Borsigstr. 4, D-74321 Bietigheim-Bissingen, Germany on behalf of Boehringer Ingelheim, Pharma GmbH & Co. KG, Biberach, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore, Singapore
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | | | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL and CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
3
|
Bergmark BA, Park JG, Hamershock RA, Melloni GEM, De Caterina R, Antman EM, Ruff CT, Rutman H, Mercuri MF, Lanz HJ, Braunwald E, Giugliano RP. Application of the Win Ratio Method in the ENGAGE AF-TIMI 48 Trial Comparing Edoxaban With Warfarin in Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2024; 17:e010561. [PMID: 38828563 DOI: 10.1161/circoutcomes.123.010561] [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: 09/22/2023] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Cardiovascular trials often use a composite end point and a time-to-first event model. We sought to compare edoxaban versus warfarin using the win ratio, which offers data complementary to time-to-first event analysis, emphasizing the most severe clinical events. METHODS ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) was a double-blind, randomized trial in which patients with atrial fibrillation were assigned 1:1:1 to a higher dose edoxaban regimen (60/30 mg daily), a lower dose edoxaban regimen (30/15 mg daily), or warfarin. In an exploratory analysis, we analyzed the trial outcomes using an unmatched win ratio approach. The win ratio for each edoxaban regimen was the total number of edoxaban wins divided by the number of warfarin wins for the following ranked clinical outcomes: 1: death; 2: hemorrhagic stroke; 3: ischemic stroke/systemic embolic event/epidural or subdural bleeding; 4: noncerebral International Society on Thrombosis and Haemostasis major bleeding; and 5: cardiovascular hospitalization. RESULTS 21 105 patients were randomized to higher dose edoxaban regimen (N=7035), lower dose edoxaban regimen (N=7034), or warfarin (N=7046), yielding >49 million pairs for each treatment comparison. The median age was 72 years, 38% were women, and 59% had prior vitamin K antagonist use. The win ratio was 1.11 (95% CI, 1.05-1.18) for higher dose edoxaban regimen versus warfarin and 1.11 (95% CI, 1.05-1.18) for lower dose edoxaban regimen versus warfarin. The favorable impacts of edoxaban on death (34% of wins) and cardiovascular hospitalization (41% of wins) were the major contributors to the win ratio. Results consistently favored edoxaban in subgroups based on creatine clearance and dose reduction at baseline, with heightened benefit among those without prior vitamin K antagonist use. CONCLUSIONS In a win ratio analysis of the ENGAGE AF-TIMI 48 trial, both dose regimens of edoxaban were superior to warfarin for the net clinical outcome incorporating ischemic and bleeding events. As the win ratio emphasizes the most severe clinical events, this analysis supports the superiority of edoxaban over warfarin in patients with atrial fibrillation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00781391.
Collapse
Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | | | - Giorgio E M Melloni
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Raffaele De Caterina
- University of Pisa and Cardiology Division, Pisa University Hospital, Italy (R.D.C.)
| | - Elliott M Antman
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Christian T Ruff
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Howard Rutman
- Daiichi Sankyo Pharma Development, Edison, NJ (H.R., M.F.M., H.-J.L.)
| | - Michele F Mercuri
- Daiichi Sankyo Pharma Development, Edison, NJ (H.R., M.F.M., H.-J.L.)
| | - Hans-Joachim Lanz
- Daiichi Sankyo Pharma Development, Edison, NJ (H.R., M.F.M., H.-J.L.)
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.A.B., J.-G.P., G.E.M.M., E.M.A., C.T.R., E.B., R.P.G.)
| |
Collapse
|
4
|
Chien SC, Wang CA, Liu HY, Lin CF, Huang CY, Chien LN. Comparison of the prognosis among in-hospital survivors of cardiogenic shock based on etiology: AMI and Non-AMI. Ann Intensive Care 2024; 14:74. [PMID: 38735891 PMCID: PMC11089020 DOI: 10.1186/s13613-024-01305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Current data on post-discharge mortality and rehospitalization is still insufficient among in-hospital survivors of cardiogenic shock (CS), including acute myocardial infarction (AMI) and non-AMI survivors. METHODS Patients with CS who survived after hospital discharge were selected from the Taiwan National Health Insurance Research Database. Each patient was followed up at 3-year intervals. Mortality and rehospitalization were analyzed using Kaplan-Meier curves and Cox regression models. RESULTS There were 16,582 eligible patients. Of these, 42.4% and 57.6% were AMI-CS and non-AMI-CS survivors, respectively. The overall mortality and rehospitalization rates were considerably high, with reports of 7.0% and 22.1% at 30 days, 24.5% and 58.2% at 1 year, and 38.9% and 73.0% at 3 years, respectively, among in-hospital CS survivors. Cardiovascular (CV) problems caused approximately 40% mortality and 60% rehospitalization. Overall, the non-AMI-CS group had a higher mortality burden than the AMI-CS group owing to older age and a higher prevalence of comorbidities. In multivariable models, the non-AMI-CS group exhibited a lower risk of all-cause mortality (adjusted hazard ratio [aHR] 0.69, 95% confidence interval [CI] 0.60 to 0.78) and CV mortality (aHR 0.65, 95% CI 0.54 to 0.78) compared to the AMI-CS group. However, these risks diminished and even reversed after one year (aHR 1.13, 95% CI 1.03 to 1.25 for all-cause mortality; aHR 1.27, 95% CI 1.09 to 1.49 for CV mortality).This reversal was not observed in all-cause and CV rehospitalization. For rehospitalization, AMI-CS was associated with the risk of CV rehospitalization in the entire observation period (aHR:0.80, 95% CI:0.76-0.84). CONCLUSIONS In-hospital AMI-CS survivors had an increased risk of CV rehospitalization and 30-day mortality, whereas those with non-AMI-CS had a greater mortality risk after 1-year follow-up.
Collapse
Affiliation(s)
- Shih-Chieh Chien
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheng-An Wang
- Division of Cardiology, Department of Internal Medicine, Taipei Medical University Wan Fang Hospital, Taipei, Taiwan
| | - Hung-Yi Liu
- Health and Clinical Research Data Center, Office of Data Center, Taipei Medical University, Taipei, Taiwan
| | - Chao-Feng Lin
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chun-Yao Huang
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
5
|
Cuthbert JJ, Brown OI, Pellicori P, Dobbs K, Bulemfu J, Kazmi S, Sokoreli I, Pauws SC, Riistama JM, Cleland JGF, Clark AL. Medicines optimization prior to discharge in patients admitted to hospital with heart failure. ESC Heart Fail 2024; 11:950-961. [PMID: 38229241 DOI: 10.1002/ehf2.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/18/2024] Open
Abstract
AIMS Approximately half of patients with heart failure and a reduced ejection fraction (HeFREF) are discharged from hospital on triple therapy [angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), beta-blockers (BBs), and mineralocorticoid receptor antagonists (MRAs)]. We investigated what proportion of patients are on optimal doses prior to discharge and how many might be eligible for initiation of sacubitril-valsartan or sodium-glucose co-transporter-2 inhibitors (SGLT2Is). METHODS AND RESULTS Between 2012 and 2017, 1277 patients admitted with suspected heart failure were enrolled at a single hospital serving a local community around Kingston upon Hull, UK. Eligibility for sacubitril-valsartan or SGLT2I was based on entry criteria for the PIONEER-HF, DAPA-HF, and EMPEROR-Reduced trials. Four hundred fifty-five patients had HeFREF with complete data on renal function, heart rate, and systolic blood pressure (SBP) prior to discharge. Eighty-three per cent of patients were taking an ACE-I or ARB, 85% a BB, and 63% an MRA at discharge. More than 60% of patients were eligible for sacubitril-valsartan and >70% for SGLT2I. Among those not already receiving a prescription, 37%, 28%, and 49% were eligible to start ACE-I or ARB, BB, and MRA, respectively. Low SBP (≤105 mmHg) was the most frequent explanation for failure to initiate or up-titrate therapy. CONCLUSIONS Most patients admitted for heart failure are eligible for initiation of life-prolonging medications prior to discharge. A hospital admission may be a common missed opportunity to improve treatment for patients with HeFREF.
Collapse
Affiliation(s)
- Joseph J Cuthbert
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Kingston upon Hull, East Riding of Yorkshire, UK
- Department of Cardiology, Hull University Teaching Hospital Trust, Castle Hill Hospital, Kingston upon Hull, East Riding of Yorkshire, UK
| | - Oliver I Brown
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Kingston upon Hull, East Riding of Yorkshire, UK
- Department of Cardiology, Hull University Teaching Hospital Trust, Castle Hill Hospital, Kingston upon Hull, East Riding of Yorkshire, UK
| | - Pierpaolo Pellicori
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Glasgow, G12 8TA, Lanarkshire, UK
| | - Karen Dobbs
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Kingston upon Hull, East Riding of Yorkshire, UK
| | - Jeanne Bulemfu
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Kingston upon Hull, East Riding of Yorkshire, UK
| | - Syed Kazmi
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Kingston upon Hull, East Riding of Yorkshire, UK
| | - Ioanna Sokoreli
- Remote Patient Management and Chronic Care, Philips Research Eindhoven, Eindhoven, The Netherlands
| | - Steffan C Pauws
- Remote Patient Management and Chronic Care, Philips Research Eindhoven, Eindhoven, The Netherlands
- Department of Communication and Cognition, Tilburg University, Tilburg, The Netherlands
| | | | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Glasgow, G12 8TA, Lanarkshire, UK
| | - Andrew L Clark
- Department of Cardiology, Hull University Teaching Hospital Trust, Castle Hill Hospital, Kingston upon Hull, East Riding of Yorkshire, UK
| |
Collapse
|
6
|
Tromp J, Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Blatchford JP, Steubl D, Voors AA. Treatment effects of empagliflozin in hospitalized heart failure patients across the range of left ventricular ejection fraction - Results from the EMPULSE trial. Eur J Heart Fail 2024; 26:963-970. [PMID: 38572654 DOI: 10.1002/ejhf.3218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/23/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024] Open
Abstract
AIM The EMPULSE (EMPagliflozin in patients hospitalised with acUte heart faiLure who have been StabilizEd) trial showed that, compared to placebo, the sodium-glucose cotransporter 2 inhibitor empagliflozin (10 mg/day) improved clinical outcomes of patients hospitalized for acute heart failure (HF). We investigated whether efficacy and safety of empagliflozin were consistent across the spectrum of left ventricular ejection fraction (LVEF). METHODS AND RESULTS A total of 530 patients hospitalized for acute de novo or decompensated HF were included irrespective of LVEF. For the present analysis, patients were classified as HF with reduced (HFrEF, LVEF ≤40%), mildly reduced (HFmrEF, LVEF 41-49%) or preserved (HFpEF, LVEF ≥50%) ejection fraction at baseline. The primary endpoint was a hierarchical outcome of death, worsening HF events (HFE) and quality of life over 90 days, assessed by the win ratio. Secondary endpoints included individual components of the primary endpoint and safety. Out of 523 patients with baseline data, 354 (67.7%) had HFrEF, 54 (10.3%) had HFmrEF and 115 (22.0%) had HFpEF. The clinical benefit (hierarchical composite of all-cause death, HFE and Kansas City Cardiomyopathy Questionnaire total symptom score) of empagliflozin at 90 days compared to placebo was consistent across LVEF categories (≤40%: win ratio 1.35 [95% confidence interval 1.04, 1.75]; 41-49%: win ratio 1.25 [0.66, 2.37)] and ≥50%: win ratio 1.40 [0.87, 2.23], pinteraction = 0.96) with a favourable safety profile. Results were consistent across individual components of the hierarchical primary endpoint. CONCLUSION The clinical benefit of empagliflozin proved consistent across LVEF categories in the EMPULSE trial. These results support early in-hospital initiation of empagliflozin regardless of LVEF.
Collapse
Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore & the National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre and Department of Medicine I (Cardiology), University and University Hospital of Würzburg, Würzburg, Germany
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Dominik Steubl
- Boehringer Ingelheim International, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Faculty of Medicine, Technical University, Munich, Germany
| | - Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
7
|
Greene SJ, Butler J, Kosiborod MN. Chapter 3: Clinical Trials of Sodium-Glucose Co-Transporter-2 Inhibitors for Treatment of Heart Failure. Am J Med 2024; 137:S25-S34. [PMID: 38184323 DOI: 10.1016/j.amjmed.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/18/2023] [Indexed: 01/08/2024]
Abstract
Cardiovascular outcomes trials of sodium-glucose co-transporter-2 (SGLT2) inhibitors have demonstrated consistent signals of benefit in terms of both prevention and treatment of heart failure (HF), in patients with and without type 2 diabetes (T2D). In response to growing evidence of the benefits of SGLT2 inhibitors, including increased survival, reduced hospitalizations and improved patient-reported symptoms, functional status, and quality of life, the treatment landscape for HF has evolved. Importantly, these agents have also demonstrated safety and tolerability in individuals with HF across the spectrum of left ventricular ejection fraction, with improvements in clinical and patient-reported outcomes occurring as early as days to weeks after treatment initiation. For patients with heart failure with reduced ejection fraction (HFrEF), SGLT2 inhibitors are now increasingly recognized as foundational disease-modifying therapy. An updated joint guideline from the American College of Cardiology and American Heart Association now recommends including SGLT2 inhibitors for patients with HF across the spectrum of ejection fraction, irrespective of the presence of diabetes, and regardless of background therapy (Class 1 recommendation for HFrEF, Class 2a recommendation for HF with mildly reduced ejection fraction [HFmrEF] and HF with preserved ejection fraction [HFpEF]). The European Society of Cardiology also include a Class I recommendation to use SGLT2 inhibitors for patients with HFrEF to reduce the risk of hospitalization for HF and CV death, irrespective of T2D status. This chapter reviews published clinical trial data about the efficacy and safety of SGLT2 inhibitors among patients with HFrEF, HFpEF, and patients hospitalized for HF.
Collapse
Affiliation(s)
- Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, MS.
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Mo; University of Missouri-Kansas City, Kansas City, Mo
| |
Collapse
|
8
|
Rоsul ММ, М Bletskan М, Ivano NV, Rudakova SO. Expanding the possibilities of using sodium-glucose cotransporter 2 inhibitors in patients with heart failure. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:585-590. [PMID: 38691804 DOI: 10.36740/wlek202403130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Aim: To study the potential mechanisms of the beneficial cardiovascular effects of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, the possibilities of improving the treatment and prognosis of patients with acute heart failure (HF) during their use. PATIENTS AND METHODS Materials and Methods: The data analysis of literary sources has been conducted regarding the results of existing studies evaluating the clinical benefit and safety of SGLT-2 inhibitors in patients with acute heart failure. CONCLUSION Conclusions: The peculiarities of the pharmacological action of SGLT-2 inhibitors and the obtained research results expand the possibilities of using this group of drugs, demonstrating encouraging prospects in improving the prognosis of patients hospitalized with acute heart failure.
Collapse
|
9
|
Emara AN, Wadie M, Mansour NO, Shams MEE. The clinical outcomes of dapagliflozin in patients with acute heart failure: A randomized controlled trial (DAPA-RESPONSE-AHF). Eur J Pharmacol 2023; 961:176179. [PMID: 37923161 DOI: 10.1016/j.ejphar.2023.176179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
AIMS Dapagliflozin may confer additional decongestive and natriuretic benefits to patients with acute heart failure (AHF). Nonetheless, this hypothesis was not clinically examined. This study aimed primarily to investigate the effect of dapagliflozin on symptomatic relief in those patients. METHODS This was a randomized, double-blind study that included 87 patients with AHF presenting with dyspnea. Within 24 h of admission, patients were randomized to receive either dapagliflozin (10 mg/day, N = 45) or placebo (N = 42) for 30 days. The primary outcome was the difference between the two groups in the area under the curve (AUC) of visual analogue scale (VAS) dyspnea score over the first 4 days. Secondary endpoints included urinary sodium (Na) after 2 h of randomization, percent change in NT-proBNP, cumulative urine output (UOP), and differences in mortality and hospital readmission rates. RESULTS The results showed that dapagliflozin significantly reduced the AUC of VAS dyspnea score compared to placebo (3192.2 ± 1631.9 mm × h vs 4713.1 ± 1714.9 mm × h, P < 0.001). The relative change of NT-proBNP compared to its baseline was also larger with dapagliflozin (-34.89% vs -10.085%, P = 0.001). Additionally, higher cumulative UOP was found at day 4 (18600 ml in dapagliflozin vs 13700 in placebo, P = 0.031). Dapagliflozin decreased rehospitalization rates within 30 days after discharge, while it did not affect the spot urinary Na concentration, incidence of worsening of heart failure, or mortality rates. CONCLUSION Dapagliflozin may provide symptomatic relief and improve diuresis in patients with AHF. Further studies are needed to confirm these findings. https://clinicaltrials.gov/study/NCT05406505.
Collapse
Affiliation(s)
- Abdelrahman N Emara
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt.
| | - Moheb Wadie
- Cardiology Department, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt.
| | - Noha O Mansour
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt; Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura National University, Egypt.
| | - Mohamed E E Shams
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt.
| |
Collapse
|
10
|
Ferreira JP, Blatchford JP, Teerlink JR, Kosiborod MN, Angermann CE, Biegus J, Collins SP, Tromp J, Nassif ME, Psotka MA, Comin-Colet J, Mentz RJ, Brueckmann M, Nordaby M, Ponikowski P, Voors AA. Mineralocorticoid receptor antagonist use and the effects of empagliflozin on clinical outcomes in patients admitted for acute heart failure: Findings from EMPULSE. Eur J Heart Fail 2023; 25:1797-1805. [PMID: 37540060 DOI: 10.1002/ejhf.2982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS In patients hospitalized for acute heart failure (AHF) empagliflozin produced greater clinical benefit than placebo. Many patients with AHF are treated with mineralocorticoid receptor antagonists (MRAs). The interplay between empagliflozin and MRAs in AHF is yet to be explored. This study aimed to evaluate the efficacy and safety of empagliflozin versus placebo according to MRA use at baseline in the EMPULSE trial (NCT04157751). METHODS AND RESULTS In this analysis all comparisons were performed between empagliflozin and placebo, stratified by baseline MRA use. The primary outcome included all-cause death, heart failure events, and a ≥5 point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score at 90 days, assessed using the win ratio (WR). First heart failure hospitalization or cardiovascular death was a secondary outcome. From the 530 patients randomized, 276 (52%) were receiving MRAs at baseline. MRA users were younger, had lower ejection fraction, better renal function, and higher KCCQ scores. The primary outcome showed benefit of empagliflozin irrespective of baseline MRA use (WR 1.46, 95% confidence interval [CI] 1.08-1.97 and WR 1.27, 95% CI 0.93-1.73 in MRA users and non-users, respectively; interaction p = 0.52). The effect of empagliflozin on first heart failure hospitalization or cardiovascular death was not modified by MRA use (hazard ratio [HR] 0.58, 95% CI 0.30-1.11 and HR 0.85, 95% CI 0.47-1.52 in MRA users and non-users, respectively; interaction p = 0.39). Investigator-reported and severe hyperkalaemia events were infrequent (<6%) irrespective of MRA use. CONCLUSIONS In patients admitted for AHF, initiation of empagliflozin produced clinical benefit and was well tolerated irrespective of background MRA use. These findings support the early use of empagliflozin on top of MRA therapy in patients admitted for AHF.
Collapse
Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Bietigheim-Bissingen, Germany on behalf of Boehringer Ingelheim, Pharma GmbH & Co. KG, Biberach, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore, Singapore, Singapore
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas, MO, USA
| | | | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL and CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Matias Nordaby
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
11
|
Tomasoni D, Adamo M, Metra M. October 2023 at a glance: From prevention to diagnosis, prognosis and treatment of acute decompensation and comorbidities. Eur J Heart Fail 2023; 25:1719-1721. [PMID: 37903656 DOI: 10.1002/ejhf.3070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| |
Collapse
|
12
|
Tomasoni D, Adamo M, Metra M. September 2023 at a glance: focus on acute heart failure and health status. Eur J Heart Fail 2023; 25:1473-1476. [PMID: 37848348 DOI: 10.1002/ejhf.3047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| |
Collapse
|
13
|
Biegus J, Fudim M, Salah HM, Heerspink HJL, Voors AA, Ponikowski P. Sodium-glucose cotransporter-2 inhibitors in heart failure: Potential decongestive mechanisms and current clinical studies. Eur J Heart Fail 2023; 25:1526-1536. [PMID: 37477086 DOI: 10.1002/ejhf.2967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 07/22/2023] Open
Abstract
Congestion is a key pathophysiological feature of heart failure (HF) syndrome that drives most of the clinical manifestations of acute HF and is related with poor quality of life and outcomes. Therefore, safe and effective decongestion is an important therapeutic target in the management of acute HF and despite the use of guideline-recommended loop diuretics, adequate decongestion is not always achieved in patients with acute HF. Recently, sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to provide clinical benefits across a broad spectrum of patients with HF, including consistent reduction in the risk of acute HF episodes. While the exact mechanisms underlying these benefits remain a matter of debate, a growing body of evidence suggests that effective decongestion may be partly responsible, especially in the setting of acute HF. In this review, we discuss the potential decongestive mechanisms of SGLT-2 inhibitors, such as osmotic diuresis, natriuresis, preservation of glomerular filtration and facilitation of interstitial drainage, which can collectively translate into effective and safe decongestion. Furthermore, we provide a comprehensive review of up-to-date clinical data of SGLT-2 inhibitor use in the acute HF population.
Collapse
Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Husam M Salah
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
14
|
Tomasoni D, Adamo M, Metra M. July 2023 at a glance: heart failure with preserved ejection fraction and comorbidities. Eur J Heart Fail 2023; 25:925-928. [PMID: 37550181 DOI: 10.1002/ejhf.2976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| |
Collapse
|
15
|
Forzano I, Wilson S, Lombardi A, Jankauskas SS, Kansakar U, Mone P, Varzideh F, Santulli G. SGLT2 inhibitors: an evidence-based update on cardiovascular implications. Expert Opin Investig Drugs 2023; 32:839-847. [PMID: 37740906 PMCID: PMC10591907 DOI: 10.1080/13543784.2023.2263354] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/22/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Sodium Glucose co-Transporter 2 (SGLT2) inhibitors (also known as 'gliflozins') represent a cornerstone to treat diabetes mellitus. Moreover, recent randomized clinical trials have demonstrated important cardioprotective effects of gliflozins, independent of the presence of diabetes. Herein, we summarize the recent therapeutic progress in the cardiovascular field obtained with SGLT2 inhibitors. AREA COVERED We critically examine the rationale and results of recent clinical studies examining the effects of SGLT2 inhibitors on cardiovascular outcomes, along with a brief overview of the main ongoing trials that have been designed in order to answer the many pending questions in the field of gliflozins and cardiovascular disease. EXPERT OPINION The favorable results of several clinical trials have broadened the therapeutic scenario for SGLT2 inhibitors, opening, at the same time, new challenges. Additionally, recent preclinical findings have evidenced off-target effects of SGLT2 inhibitors.
Collapse
Affiliation(s)
| | - Scott Wilson
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Angela Lombardi
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | | | - Urna Kansakar
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Pasquale Mone
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Fahimeh Varzideh
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Gaetano Santulli
- University of Naples “Federico II”
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| |
Collapse
|
16
|
Patel J, Rassekh N, Fonarow GC, Deedwania P, Sheikh FH, Ahmed A, Lam PH. Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction. Drugs 2023; 83:747-759. [PMID: 37254024 DOI: 10.1007/s40265-023-01887-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/01/2023]
Abstract
Guideline-directed medical therapy (GDMT) is the cornerstone of pharmacological therapy for patients with heart failure with reduced ejection fraction (HFrEF) and consists of the four main drug classes: renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors and sodium glucose cotransporter 2 inhibitors. The recommendation for use of GDMT is based on the results of multiple major randomized controlled trials demonstrating improved clinical outcomes in patients with HFrEF who are maintained on this therapy. The effect is most beneficial when medications from the four main drug classes are used in conjunction. Despite this, there is an underutilization of GDMT, partially due to lack of awareness of how to safely and effectively initiate and titrate these medications. In this review article, we describe the different drug classes included in GDMT and offer an approach to initiation and effective titration in both the inpatient as well as outpatient setting.
Collapse
Affiliation(s)
- Jay Patel
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, 20010, USA
- Georgetown University, Washington, DC, USA
| | - Negin Rassekh
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, 20010, USA
| | | | | | - Farooq H Sheikh
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, 20010, USA
- Georgetown University, Washington, DC, USA
| | - Ali Ahmed
- Georgetown University, Washington, DC, USA
- George Washington University, Washington, DC, USA
- Veterans Affairs Medical Center, Washington, DC, USA
| | - Phillip H Lam
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, 20010, USA.
- Georgetown University, Washington, DC, USA.
- Veterans Affairs Medical Center, Washington, DC, USA.
| |
Collapse
|
17
|
Monzo L, Ferrari I, Cicogna F, Tota C, Cice G, Girerd N, Calò L. Sodium-glucose co-transporter 2 inhibitors in heart failure: an updated evidence-based practical guidance for clinicians. Eur Heart J Suppl 2023; 25:C309-C315. [PMID: 37125324 PMCID: PMC10132577 DOI: 10.1093/eurheartjsupp/suad055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to reduce risks of clinical events in patients with heart failure (HF), with early and sustained benefits regardless of ejection fraction, diabetic status, and care setting. As part and parcel of the modern foundational HF therapy, clinicians should be familiar with these drugs, in order to implement their use and limit the potential adverse effects. We present an up-to-date review of current evidence and a practical guide for the prescription of SGLT2 inhibitors in patients with HF, highlighting important elements for patient selection, treatment initiation, dosing, and problem solving.
Collapse
Affiliation(s)
- Luca Monzo
- Corresponding author. Tel: +33 383157306, Fax: +33 383157324,
| | - Ilaria Ferrari
- Department of Cardiology, Policlinico Casilino, Rome 00169, Italy
| | | | - Claudia Tota
- Department of Cardiology, Policlinico Casilino, Rome 00169, Italy
| | - Gennaro Cice
- Department of Cardiology, Policlinico Casilino, Rome 00169, Italy
| | - Nicolas Girerd
- Centre d'Investigation Clinique 1433 module Plurithématique, CHRU Nancy – Hôpitaux de Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, Université de Lorraine INSERM, 4 rue du Morvan, 54500 Vandoeuvre les Nancy, France
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Rome 00169, Italy
| |
Collapse
|
18
|
Pocock SJ, Ferreira JP, Collier TJ, Angermann CE, Biegus J, Collins SP, Kosiborod M, Nassif ME, Ponikowski P, Psotka MA, Teerlink JR, Tromp J, Gregson J, Blatchford JP, Zeller C, Voors AA. The win ratio method in heart failure trials: lessons learnt from EMPULSE. Eur J Heart Fail 2023; 25:632-641. [PMID: 37038330 PMCID: PMC10330107 DOI: 10.1002/ejhf.2853] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/28/2023] [Accepted: 04/08/2023] [Indexed: 04/12/2023] Open
Abstract
AIMS The EMPULSE trial evaluated the clinical benefit of empagliflozin versus placebo using the stratified win ratio approach in 530 patients with acute heart failure (HF) after initial stabilization. We aim to elucidate how this method works and what it means, thereby giving guidance for use of the win ratio in future trials. METHODS AND RESULTS The primary trial outcome is a hierarchical composite of death, number of HF events, time to first HF event, or a ≥5-point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score change at 90 days. In an overall (unstratified) analysis we show how comparison of all 265 x 265 patients pairs contribute to 'wins' for empagliflozin and placebo at all four levels of the hierarchy, leading to an unstratified win ratio of 1.38 (95% confidence interval [CI] 1.11-1.71; p = 0.0036). How such a win ratio should (and should not) be interpreted is then described. The more complex primary analysis using a stratified win ratio is then presented in detail leading to a very similar overall result. Win ratios for de novo acute HF and decompensated chronic HF patients were 1.29 and 1.39, respectively, their weighted combination yielding an overall stratified win ratio of 1.36 (95% CI 1.09-1.68) (p = 0.0054). Alternative ways of including HF events and KCCQ scores in the clinical hierarchy are presented, leading to recommendations for their use in future trials. Specifically, inclusion of both number of HF events and time-to-first HF event appears an unnecessary complication. Also, the use of a 5-point margin for KCCQ score paired comparisons is not statistically necessary. CONCLUSIONS The EMPULSE trial findings illustrate how deaths, clinical events and patient-reported outcomes can be integrated into a win ratio analysis strategy that yields clinically meaningful findings of patient benefit. This has implications for future trial designs that recognize the clinical priorities of patient evaluation and the need for efficient progress towards approval of new treatments.
Collapse
Affiliation(s)
- Stuart J Pocock
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - João Pedro Ferreira
- Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Université de Lorraine, and Inserm U1116, CHRU, Nancy, France
| | - Timothy J Collier
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, and Department of Medicine I, University Hospital of Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | - John Gregson
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
19
|
Tomasoni D, Adamo M, Metra M. May 2023 at a glance: focus on pathophysiology, comorbidities and devices. Eur J Heart Fail 2023; 25:599-601. [PMID: 37326134 DOI: 10.1002/ejhf.2921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/17/2023] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| |
Collapse
|
20
|
Heart Failure Pharmacological Management: Gaps and Current Perspectives. J Clin Med 2023; 12:jcm12031020. [PMID: 36769667 PMCID: PMC9917449 DOI: 10.3390/jcm12031020] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/07/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Proper therapeutic management of patients with heart failure (HF) is a major challenge for cardiologists. Current guidelines indicate to start therapy with angiotensin converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors (ACEi/ARNI), beta blockers (BB), mineralocorticoid receptor antagonists (MRAs) and sodium glucose cotransporter 2 inhibitors (SGLT2i) to reduce the risk of death and hospitalization due to HF. However, certain aspects still need to be defined. Current guidelines propose therapeutic algorithms based on left ventricular ejection fraction values and clinical presentations. However, these last do not always reflect the precise hemodynamic status of patients and pathophysiological mechanisms involved, particularly in the acute setting. Even in the field of chronic management there are still some critical points to discuss. The guidelines do not specify which of the four pillar drugs to start first, nor at what dosage. Some authors suggest starting with SGLT2i and BB, others with ACEi or ARNI, while one of the most recent approach proposes to start with all four drugs together at low doses. The aim of this review is to revise current gaps and perspectives regarding pharmacological therapy management in HF patients, in both the acute and chronic phase.
Collapse
|
21
|
Biegus J, Voors AA, Collins SP, Kosiborod MN, Teerlink JR, Angermann CE, Tromp J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Salsali A, Blatchford JP, Ponikowski P. Impact of empagliflozin on decongestion in acute heart failure: the EMPULSE trial. Eur Heart J 2023; 44:41-50. [PMID: 36254693 PMCID: PMC9805406 DOI: 10.1093/eurheartj/ehac530] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS Effective and safe decongestion remains a major goal for optimal management of patients with acute heart failure (AHF). The effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on decongestion-related endpoints in the EMPULSE trial (NCT0415775) were evaluated. METHODS AND RESULTS A total of 530 patients hospitalized for AHF were randomized 1:1 to either empagliflozin 10 mg once daily or placebo for 90 days. The outcomes investigated were: weight loss (WL), WL adjusted for mean daily loop diuretic dose (WL-adjusted), area under the curve of change from baseline in N-terminal pro-B-type natriuretic peptide levels, hemoconcentration, and clinical congestion score after 15, 30, and 90 days of treatment. Compared with placebo, patients treated with empagliflozin demonstrated significantly greater reductions in all studied markers of decongestion at all time-points, adjusted mean differences (95% confidence interval) at Days 15, 30, and 90 were: for WL -1.97 (-2.86, -1.08), -1.74 (-2.73, -0.74); -1.53 (-2.75, -0.31) kg; for WL-adjusted: -2.31 (-3.77, -0.85), -2.79 (-5.03, -0.54), -3.18 (-6.08, -0.28) kg/40 mg furosemide i.v. or equivalent; respectively (all P < 0.05). Greater WL at Day 15 (i.e. above the median WL in the entire population) was associated with significantly higher probability for clinical benefit at Day 90 (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in Kansas City Cardiomyopathy Questionnaire total symptom score change from baseline to 90 days) with the win ratio of 1.75 (95% confidence interval 1.37, 2.23; P < 0.0001). CONCLUSION Initiation of empagliflozin in patients hospitalized for AHF resulted in an early, effective and sustained decongestion which was associated with clinical benefit at Day 90.
Collapse
Affiliation(s)
- Jan Biegus
- Corresponding author. Tel: +48 71 733 11 12,
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O Box 30001, 9700 RB Groningen, HPC AB 31, The Netherlands
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
- The George Institute for Global Health and the University of New South Wales, Sydney, New South Wales, Australia
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, 4150 Clement Street San Francisco, CA 94121, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Am Schwarzenberg 15, Haus A15 97078 Würzburg, Germany
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore; 12 Science Drive 2, #10-01, Singapore 117549
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- UnIC@RISE, Department of Surgery and Physiology, Cardiovascular Research and Development Center, University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, 3300 Gallows Road Falls Church, Virginia 22042, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Binger Straße 173, 55216 Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Afshin Salsali
- Novo Nordisk pharmaceutical company, Vandtårnsvej 110, 2860 Søborg, Copenhagen, Denmark
- Faculty of Medicine, Rutgers University, New Brunswick, NJ, 125 Paterson street, New Brunswick, NJ 08901, USA
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Sky Tower, Borsigstr. 4, D-74321 Bietigheim-Bissingen, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wroclaw 50-556, Poland
| |
Collapse
|
22
|
Chandra A, Polanczyk CA, Claggett BL, Vaduganathan M, Packer M, Lefkowitz MP, Rouleau JL, Liu J, Shi VC, Schwende H, Zile MR, Desai AS, Pfeffer MA, McMurray JJV, Solomon SD, Lewis EF. Health-related quality of life outcomes in PARAGON-HF. Eur J Heart Fail 2022; 24:2264-2274. [PMID: 36394533 DOI: 10.1002/ejhf.2738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/03/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
AIMS Heart failure (HF) is associated with poor health-related quality of life (HRQL). Patients with HF with preserved ejection fraction (HFpEF) have similar HRQL impairment as those with reduced ejection fraction. This study describes the impact of sacubitril/valsartan on HRQL in patients with HFpEF enrolled in the PARAGON-HF trial. METHODS AND RESULTS Patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQol (EQ-5D) at randomization, 4, 8 months, and annually thereafter. Changes in HRQL scores were evaluated using repeated measures models adjusted for treatment, baseline values and region. The pre-specified principal efficacy assessment was at 8 months at which time patients randomized to sacubitril/valsartan had borderline higher KCCQ clinical summary score (CSS) with least squares mean (LSM) adjusted difference of 1.0 (95% confidence interval [CI] 0.0, 2.1; p = 0.051). Including all visits up to 36 months, the LSM difference in KCCQ-CSS favoured sacubitril/valsartan with average adjusted difference of 1.1 (95% CI 0.1, 2.0; p = 0.034). Patients treated with sacubitril/valsartan had greater odds of clinically meaningful improvement (≥5-point increase) in KCCQ-CSS (odds ratio 1.31; 95% CI 1.06, 1.61) at 8 months. At 8 months, there was no significant difference in the EQ visual analogue scale between the treatment arms, but sacubitril/valsartan was associated with higher EQ-5D utility score (US-based) with LSM adjusted difference of 0.01 (95% CI 0.00, 0.02; p = 0.019). CONCLUSION Compared with valsartan, sacubitril/valsartan had a borderline benefit on KCCQ-CSS at 8 months in patients with HFpEF. This benefit became more significant when data from all visits up to 36 months were included. This modest overall benefit was also supported by greater odds of patients reporting a clinically meaningful improvement in HRQL with sacubitril/valsartan.
Collapse
Affiliation(s)
- Alvin Chandra
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montreal, Université de Montreal Canada, Montreal, Canada
| | | | | | | | - Michael R Zile
- RHJ Department of Veterans Administration Medical Center, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Eldrin F Lewis
- Cardiovascular Division, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
23
|
Ul Amin N, Sabir F, Amin T, Sarfraz Z, Sarfraz A, Robles-Velasco K, Cherrez-Ojeda I. SGLT2 Inhibitors in Acute Heart Failure: A Meta-Analysis of Randomized Controlled Trials. Healthcare (Basel) 2022; 10:healthcare10122356. [PMID: 36553880 PMCID: PMC9778112 DOI: 10.3390/healthcare10122356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Acute heart failure (AHF) is a major public health concern, affecting 26 million worldwide. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of glucose-lowering drugs, comprising canagliflozin, dapagliflozin, and empagliflozin that are being explored for AHF. We aim to meta-analyze the effectiveness of SGLT2 inhibitors compared to placebo for primary outcomes including all-cause and cardiovascular mortality, heart failure events, symptomatic improvement, and readmissions. Our secondary outcome is the risk of serious adverse events. This meta-analysis has been designed in accordance with the PRISMA Statement 2020. A systematic search across PubMed, Scopus, and Cochrane Library was conducted through August 13, 2022. The following keywords were utilized: sglt2, sodium-glucose transporter 2 inhibitors, sglt2 inhibitors, decompensated heart failure, de-novo heart failure, and/or acute heart failure. Only randomized controlled trials (RCTs) with adult patients (>18 years), hospitalized with de-novo AHF, acutely decompensated chronic heart failure with reduced, borderline, or preserved ejection, and receiving SGLT2 inhibitors were included. A quantitative analytical methodology was applied where the standardized mean difference (SMD) applying 95% confidence intervals (CI) for continuous outcomes and risk ratio (RR) with 95% CI was yielded. All tests were carried out on Review Manager 5.4 (Cochrane). In total, three RCTs were included pooling in a total of 1831 patients where 49.9% received SGLT2 inhibitors. The mean age was 72.9 years in the interventional group compared to 70.6 years in the placebo. Only 33.7% of the sample was female. The follow-up spanned 2−9 months. Heart failure events were reduced by 62% in the interventional group (RR = 0.66, p < 0.0001). readmissions had a reduced risk of 24% with SGLT2 inhibitors (RR = 0.76, p = 0.03). We assessed the efficacy and safety of SGLT2 inhibitors in preventing complications post-AHF. The odds of all-cause mortality, cardiovascular mortality, heart failure events, and re-admissions rates were substantially reduced within the first 1−9 months of hospitalization.
Collapse
Affiliation(s)
- Noor Ul Amin
- Department of Acute Medicine, King’s Mill Hospital, Sutton-in-Ashfield NG17 4JL, UK
| | - Faiza Sabir
- Department of Research, King Edward Medical University, Lahore 54000, Pakistan
| | - Talal Amin
- Department of Research, Nishtar Medical College, Multan 60000, Pakistan
| | - Zouina Sarfraz
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore 54000, Pakistan
| | - Azza Sarfraz
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74800, Pakistan
- Correspondence: (A.S.); (I.C.-O.)
| | - Karla Robles-Velasco
- Department of Allergy, Immunology & Pulmonary Medicine, Universidad Espíritu Santo, Samborondón 092301, Ecuador
| | - Ivan Cherrez-Ojeda
- Department of Allergy, Immunology & Pulmonary Medicine, Universidad Espíritu Santo, Samborondón 092301, Ecuador
- Correspondence: (A.S.); (I.C.-O.)
| |
Collapse
|
24
|
Zhirov IV, Nasonova SN, Tereshchenko SN. Acute decompensation of heart failure: state of the problem. TERAPEVT ARKH 2022; 94:1047-1051. [DOI: 10.26442/00403660.2022.09.201839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
Are presented the key aspects of the management of patients with acute decompensation of heart failure leading to improved clinical outcomes. Are described the existing problems and possible solutions.
Collapse
|
25
|
Abdin A, Bauersachs J, Soltani S, Eden M, Frey N, Böhm M. A practical approach to the guideline-directed pharmacological treatment of heart failure with reduced ejection fraction. ESC Heart Fail 2022; 10:24-31. [PMID: 36229988 PMCID: PMC9871719 DOI: 10.1002/ehf2.14197] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/30/2022] [Accepted: 10/02/2022] [Indexed: 01/29/2023] Open
Abstract
Over the last 15-20 years, remarkable developments of heart failure (HF) pharmacotherapies have been achieved. However, HF remains a global healthcare challenge with more than 64 million patients worldwide. Optimization of guideline-directed chronic HF medical therapy is highly recommended with every patient visit to improve outcomes in patients with HF with reduced ejection fraction. However, the majority of patients in real-world settings are treated with doses that are lower than those with proven efficacy in clinical trials, which might be due to concerns of adverse effects and inertia of physicians. Likewise, a significant proportion of patients still do not receive all drug classes that could improve their prognosis. The recent European Society of Cardiology guidelines do not provide detailed recommendations on how these drug classes should be implemented in the treatment of inpatients to allow for both safety and a high likelihood of efficacy. We therefore propose a practical approach algorithm to support physicians to treat HF patients in their daily practice.
Collapse
Affiliation(s)
- Amr Abdin
- Department of Internal Medicine III—Cardiology, Angiology and Intensive Care MedicineSaarland University Medical Center, Saarland UniversitySaarbrückenGermany
| | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical SchoolHanoverGermany
| | - Samira Soltani
- Department of Cardiology and AngiologyHannover Medical SchoolHanoverGermany
| | - Matthias Eden
- Department of Internal Medicine IIIUniversity of HeidelbergHeidelbergGermany
| | - Norbert Frey
- Department of Internal Medicine IIIUniversity of HeidelbergHeidelbergGermany
| | - Michael Böhm
- Department of Internal Medicine III—Cardiology, Angiology and Intensive Care MedicineSaarland University Medical Center, Saarland UniversitySaarbrückenGermany
| |
Collapse
|
26
|
Voors AA, Damman K, Teerlink JR, Angermann CE, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. Renal effects of empagliflozin in patients hospitalized for acute heart failure: from the EMPULSE trial. Eur J Heart Fail 2022; 24:1844-1852. [PMID: 36066557 PMCID: PMC9828037 DOI: 10.1002/ejhf.2681] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 01/12/2023] Open
Abstract
AIM The sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin improved clinical outcomes in patients hospitalized for acute heart failure. In patients with chronic heart failure, SGLT2 inhibitors cause an early decline in estimated glomerular filtration rate (eGFR) followed by a slower eGFR decline over time than placebo. However, the effects of SGLT2 inhibitors on renal function during a hospital admission for acute heart failure remain largely unknown. METHODS AND RESULTS Between 1 and 5 days after a hospitalization for acute heart failure, 530 patients with an eGFR >20 ml/min/1.73 m2 were randomized to 10 mg of empagliflozin or placebo and treated for 90 days. Renal function and electrolytes were measured at baseline, and after 15, 30 and 90 days. We evaluated the effect of empagliflozin on eGFR over time and the impact of baseline eGFR on the primary hierarchical outcome of death, worsening heart failure events and quality of life. Mean baseline eGFR was 52.4 ml/min/1.73 m2 in the empagliflozin group and 55.7 ml/min/1.73 m2 in the placebo group. Empagliflozin caused an initial decline in eGFR (-2 ml/min/1.73 m2 at day 15 compared to placebo). At day 90, eGFR was similar between empagliflozin and placebo. Investigator-reported acute renal failure occurred in 7.7% of empagliflozin versus 12.1% of placebo patients. The overall clinical benefit (hierarchical composite of all-cause death, heart failure events and quality of life) of empagliflozin was unaffected by baseline eGFR. CONCLUSION In patients hospitalized for acute heart failure, empagliflozin caused an early modest decline in renal function which was no longer evident after 90 days. Acute renal events were similar in both groups. The clinical benefit of empagliflozin was consistent regardless of baseline renal function.
Collapse
Affiliation(s)
- Adriaan A. Voors
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Christiane E. Angermann
- Comprehensive Heart Failure CentreUniversity & University Hospital of WürzburgWürzburgGermany
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical CareTennessee Valley Healthcare Facility VA Medical CenterNashvilleTNUSA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMSUSA,The George Institute for Global Health and The University of New South WalesSydneyNSWAustralia
| | - Jan Biegus
- Institute of Heart DiseasesMedical UniversityWroclawPoland
| | - João Pedro Ferreira
- Inserm INI‐CRCT, CHRUUniversité de LorraineNancyFrance,Cardiovascular Research and Development Center, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
| | - Michael E. Nassif
- Saint Luke's Mid America Heart Institute and the University of MissouriKansas CityMSUSA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public HealthNational University of Singapore, and the National University Health SystemSingapore
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbHIngelheimGermany,First Department of Medicine faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc.RidgefieldCTUSA,Faculty of MedicineRutgers UniversityNew BrunswickNJUSA
| | | | | |
Collapse
|
27
|
Razuk V, Chiarito M, Cao D, Nicolas J, Pivato CA, Camaj A, Power D, Beerkens F, Jones D, Alter A, Mathew A, Spirito A, Contreras JP, Dangas GD, Mehran R. SGLT-2 inhibitors and cardiovascular outcomes in patients with and without a history of heart failure: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:557-567. [PMID: 35021205 DOI: 10.1093/ehjcvp/pvac001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 12/18/2022]
Abstract
AIMS Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have cardiovascular (CV) benefits in patients with heart failure with reduced ejection fraction (HFrEF). Whether these medications improve CV outcomes irrespective of heart failure history or left ventricular ejection fraction (LVEF) in HFrEF remains unknown. METHODS AND RESULTS All randomized, placebo-controlled trials of SGLT-2 inhibitors reporting similar CV outcomes were searched in PubMed from 1 January 2010 to 1 October 2021. The primary outcome was the composite of hospitalization for heart failure or CV death. Secondary outcomes included all-cause mortality. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were used as effect estimates and calculated with a random-effects model. Data from 11 trials and a total of 66 957 patients (n = 36 758 SGLT-2 group, n = 30 199 placebo group) were included. SGLT-2 inhibitors reduced the risk of hospitalization for heart failure or CV death in patients with (HR 0.76, 95% CI 0.71-0.80) and without (HR 0.76, 95% CI 0.68-0.86; Pinteraction = 0.69) heart failure. Patients with (HR 0.87, 95% CI 0.80-0.95) and without (HR 0.84, 95% CI 0.73-0.95; Pinteraction = 0.67) heart failure treated with SGLT-2 inhibitors had a reduction in all-cause mortality. Reduction in the primary outcome was consistently observed in HFrEF patients with (HR 0.68, 95% CI 0.59-0.78) and without (HR 0.84, 95% CI 0.71-0.99; Pinteraction = 0.13) severely reduced LVEF, and in heart failure with preserved ejection fraction patients (HR 0.80, 95% CI 0.70-0.92; Pinteraction = 0.65). CONCLUSION SGLT-2 inhibitors improved CV outcomes irrespective of heart failure history or type, and severity of LVEF reduction.
Collapse
Affiliation(s)
- Victor Razuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Carlo A Pivato
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David Power
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Frans Beerkens
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Davis Jones
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Aviv Alter
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Alvin Mathew
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Johanna P Contreras
- Advanced Heart Failure Department, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| |
Collapse
|
28
|
Liang B, Li R, Zhang P, Gu N. Empagliflozin for Patients with Heart Failure and Type 2 Diabetes Mellitus: Clinical Evidence in Comparison with Other Sodium-Glucose Co-transporter-2 Inhibitors and Potential Mechanism. J Cardiovasc Transl Res 2022; 16:327-340. [PMID: 35969357 DOI: 10.1007/s12265-022-10302-4] [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: 04/02/2022] [Accepted: 08/05/2022] [Indexed: 11/25/2022]
Abstract
Heart failure remains a leading cause of morbidity and mortality globally and has been recognized as a common complication of diabetes, especially type 2 diabetes mellitus. Heart failure occurs in diabetic patients even in the absence of hypertension, coronary heart disease, or valvular heart disease, and is, therefore, a major cardiovascular complication in this vulnerable population. Given the continued rise in the prevalence of type 2 diabetes mellitus worldwide, the burden of heart failure on the healthcare system will continue to increase. Recent evidence demonstrates that empagliflozin, a sodium-glucose co-transporter-2 inhibitor, brings clinical benefit to patients with established heart failure and type 2 diabetes mellitus. Herein, we critically reviewed the clinical evidence of empagliflozin for patients with heart failure and type 2 diabetes mellitus with the comparison with other sodium-glucose co-transporter-2 inhibitors and potential mechanism to provide the optimal and evidence-based management for patients with established heart failure and type 2 diabetes mellitus with the goal to be conducive to the mechanism exploration of empagliflozin to advance a more comprehensive understanding of empagliflozin.
Collapse
Affiliation(s)
- Bo Liang
- Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Rui Li
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Peng Zhang
- Neijiang Health Vocational College, Neijiang, China
| | - Ning Gu
- Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China.
| |
Collapse
|
29
|
Voorrips SN, Saucedo-Orozco H, Sánchez-Aguilera PI, De Boer RA, Van der Meer P, Westenbrink BD. Could SGLT2 Inhibitors Improve Exercise Intolerance in Chronic Heart Failure? Int J Mol Sci 2022; 23:ijms23158631. [PMID: 35955784 PMCID: PMC9369142 DOI: 10.3390/ijms23158631] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/04/2022] Open
Abstract
Despite the constant improvement of therapeutical options, heart failure (HF) remains associated with high mortality and morbidity. While new developments in guideline-recommended therapies can prolong survival and postpone HF hospitalizations, impaired exercise capacity remains one of the most debilitating symptoms of HF. Exercise intolerance in HF is multifactorial in origin, as the underlying cardiovascular pathology and reactive changes in skeletal muscle composition and metabolism both contribute. Recently, sodium-related glucose transporter 2 (SGLT2) inhibitors were found to improve cardiovascular outcomes significantly. Whilst much effort has been devoted to untangling the mechanisms responsible for these cardiovascular benefits of SGLT2 inhibitors, little is known about the effect of SGLT2 inhibitors on exercise performance in HF. This review provides an overview of the pathophysiological mechanisms that are responsible for exercise intolerance in HF, elaborates on the potential SGLT2-inhibitor-mediated effects on these phenomena, and provides an up-to-date overview of existing studies on the effect of SGLT2 inhibitors on clinical outcome parameters that are relevant to the assessment of exercise capacity. Finally, current gaps in the evidence and potential future perspectives on the effects of SGLT2 inhibitors on exercise intolerance in chronic HF are discussed.
Collapse
Affiliation(s)
- Suzanne N. Voorrips
- Correspondence: (S.N.V.); (B.D.W.); Tel.: +31-50-361-2355 (S.N.V. & B.D.W.); Fax: +31-50-361-4391 (S.N.V. & B.D.W.)
| | | | | | | | | | - B. Daan Westenbrink
- Correspondence: (S.N.V.); (B.D.W.); Tel.: +31-50-361-2355 (S.N.V. & B.D.W.); Fax: +31-50-361-4391 (S.N.V. & B.D.W.)
| |
Collapse
|
30
|
Canepa M, Kapelios CJ, Benson L, Savarese G, Lund LH. Temporal Trends of Heart Failure Hospitalizations in Cardiology Versus Noncardiology Wards According to Ejection Fraction: 16-Year Data From the SwedeHF Registry. Circ Heart Fail 2022; 15:e009462. [PMID: 35938444 DOI: 10.1161/circheartfailure.121.009462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients hospitalized for acute heart failure (AHF) may receive different care depending on type of ward. We describe temporal changes in triage of HF patients with preserved, mildly reduced, and reduced ejection fraction (HFpEF, HFmrEF, and HFrEF) hospitalized for AHF to cardiology versus noncardiology wards in Sweden. METHODS We analyzed temporal changes in ward type for AHF for HFrEF versus HFmrEF versus HFpEF between 2000 and 2016. RESULTS Among 37 918 patients with AHF, 19 777 (52%) had HFrEF, 7712 (20%) had HFmrEF, and 10 429 (28%) had HFpEF. Overall, 19 646 (52%) were hospitalized in cardiology and 18 272 (48%) in noncardiology. The proportions hospitalized in noncardiology in 2000 to 2004 versus in 2013 to 2016 were for HFrEF: 45 versus 47%, for HFmrEF: 52 versus 56%, and for HFpEF: 46 versus 64%, respectively. The overall proportion of HFrEF in 2000 to 2004 versus in 2013 to 2016 decreased (60% versus 49%) especially in noncardiology (58% versus 41%), whereas the overall proportion of HFpEF increased (20% versus 30%) especially in noncardiology (21% versus 37%). The average age and prevalence of comorbidities also increased over time, with older patients with multiple comorbidities being more frequently admitted to noncardiology wards. CONCLUSIONS Over time, AHF hospitalization for HFpEF occurred increasingly in noncardiology, whereas for HFrEF and HFmrEF the proportions of patients treated in cardiology versus noncardiology were substantially unchanged over time. This may have implications for implementation of emerging HFpEF therapy.
Collapse
Affiliation(s)
- Marco Canepa
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Italy (M.C.)
- Ospedale Policlinico San Martino IRCCS, Genoa, Italy (M.C.)
| | - Chris J Kapelios
- Cardiology Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (C.J.K.)
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden (L.B.)
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.)
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.)
| |
Collapse
|
31
|
Schulze PC, Bogoviku J, Westphal J, Aftanski P, Haertel F, Grund S, von Haehling S, Schumacher U, Möbius-Winkler S, Busch M. Effects of Early Empagliflozin Initiation on Diuresis and Kidney Function in Patients With Acute Decompensated Heart Failure (EMPAG-HF). Circulation 2022; 146:289-298. [PMID: 35766022 DOI: 10.1161/circulationaha.122.059038] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Effective diuretic regimens using loop diuretics in patients with acute decompensated heart failure are often limited by the development of worsening kidney function. Sodium-glucose cotransporter-2 inhibitors induce glucosuria and sodium excretion with nephroprotective effects in patients with stable heart failure but their role in acute decompensated heart failure is unclear. METHODS In this single-center, prospective, double-blind, placebo-controlled, randomized study, we randomly assigned patients with acute decompensated heart failure to empagliflozin 25 mg daily or placebo in addition to standard decongestive treatments that included loop diuretics. The primary end point was cumulative urine output over 5 days. Secondary end points included diuretic efficiency, dynamics in markers of kidney function and injury, and NT-proBNP (N-terminal pro-B-type natriuretic peptide). RESULTS Sixty patients were randomized within 12 hours of hospitalization for acute decompensated heart failure. Addition of empagliflozin daily to standard medical treatment of acute decompensated heart failure resulted in a 25% increase in cumulative urine output over 5 days (median 10.8 versus 8.7 L mL in placebo, group difference estimation 2.2 L [95% CI, 8.4 to 3.6]; P=0.003). Empagliflozin increased diuretic efficiency compared with placebo (14.1 mL urine per milligram furosemide equivalent [95% CI, 0.6-27.7]; P=0.041) without affecting markers of renal function (estimated glomerular filtration rate, 51±19 versus 54±17 mL/min per 1.73 m²; P=0.599) or injury (total urinary protein, 492±845 versus 503±847 mg/g creatinine; P=0.975; and urinary α1-microglobulin, 55.4±38.6 versus 31.3±33.6 mg/g creatinine; P=0.066) with more pronounced decrease in NT-proBNP in the empagliflozin group compared with placebo (-1861 versus -727.2 pg/mL after 5 days; quotient in slope, 0.89 [95% CI, 0.83-0.95]; P<0.001). There were no differences in the incidence of safety events between groups. CONCLUSIONS Early addition of empagliflozin to standard diuretic therapy increases urine output without affecting renal function in patients with acute decompensated heart failure. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04049045.
Collapse
Affiliation(s)
- P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Jürgen Bogoviku
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Julian Westphal
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Pawel Aftanski
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Franz Haertel
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Sissy Grund
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre Göttingen, Germany (S.v.H.)
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Germany (S.v.H.)
| | - Ulrike Schumacher
- Center for Clinical Studies (U.S.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care (P.C.S., J.B., J.W., P.A., F.H., S.G., S.M.-W.), Friedrich-Schiller-University, University Hospital Jena, Germany
| | - Martin Busch
- Department of Internal Medicine III, Division of Nephrology (M.B.), Friedrich-Schiller-University, University Hospital Jena, Germany
| |
Collapse
|
32
|
Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Comin-Colet J, Ferreira JP, Mentz RJ, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Voors AA. Effects of Empagliflozin on Symptoms, Physical Limitations, and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial. Circulation 2022; 146:279-288. [PMID: 35377706 PMCID: PMC9311476 DOI: 10.1161/circulationaha.122.059725] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalized for acute heart failure experience poor health status, including a high burden of symptoms and physical limitations, and poor quality of life. SGLT2 (sodium-glucose cotransporter 2) inhibitors improve health status in chronic heart failure, but their effect on these outcomes in acute heart failure is not well characterized. We investigated the effects of the SGLT2 inhibitor empagliflozin on symptoms, physical limitations, and quality of life, using the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the EMPULSE trial (Empagliflozin in Patients Hospitalized With Acute Heart Failure Who Have Been Stabilized). METHODS Patients hospitalized for acute heart failure were randomized to empagliflozin 10 mg daily or placebo for 90 days. The KCCQ was assessed at randomization and 15, 30, and 90 days. The effects of empagliflozin on the primary end point of clinical benefit (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in KCCQ Total Symptom Score [TSS] change from baseline to 90 days) were examined post hoc across the tertiles of baseline KCCQ-TSS. In prespecified analyses, changes (randomization to day 90) in KCCQ domains, including TSS, physical limitations, quality of life, clinical summary, and overall summary scores were evaluated using a repeated measures model. RESULTS In total, 530 patients were randomized (265 each arm). Baseline KCCQ-TSS was low overall (mean [SD], 40.8 [24.0] points). Empagliflozin-treated patients experienced greater clinical benefit across the range of KCCQ-TSS, with no treatment effect heterogeneity (win ratio [95% CIs] from lowest to highest tertile: 1.49 [1.01-2.20], 1.37 [0.94-1.99], and 1.48 [1.00-2.20], respectively; P for interaction=0.94). Beneficial effects of empagliflozin on health status were observed as early as 15 days and persisted through 90 days, at which point empagliflozin-treated patients experienced a greater improvement in KCCQ TSS, physical limitations, quality of life, clinical summary, and overall summary (placebo-adjusted mean differences [95% CI]: 4.45 [95% CI, 0.32-8.59], P=0.03; 4.80 [95% CI, 0.00-9.61], P=0.05; 4.66 [95% CI, 0.32-9.01], P=0.04; 4.85 [95% CI, 0.77-8.92], P=0.02; and 4.40 points [95% CI, 0.33-8.48], P=0.03, respectively). CONCLUSIONS Initiation of empagliflozin in patients hospitalized for acute heart failure produced clinical benefit regardless of the degree of symptomatic impairment at baseline, and improved symptoms, physical limitations, and quality of life, with benefits seen as early as 15 days and maintained through 90 days. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT0415775.
Collapse
Affiliation(s)
- Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Christiane E. Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Germany (C.E.A.)
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN (S.P.C.).,Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville (S.P.C.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, The Institute of Biomedical Research of Bellvitge (IDIBELL), Barcelona, Spain (J.C.-C.)
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (J.P.F.).,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (R.J.M.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.)
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore (J.T.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Germany (M.B.).,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany (M.B.)
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany (J.P.B.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.).,Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Adriaan A. Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (A.A.V.)
| |
Collapse
|
33
|
Delgado E, Jódar E, Mezquita-Raya P, Moreno-Pérez Ó. Benefits of SGLT2i for the Treatment of Heart Failure Irrespective of Diabetes Diagnosis: A State-of-the-Art Review. Diabetes Ther 2022; 13:19-34. [PMID: 35704165 PMCID: PMC9198410 DOI: 10.1007/s13300-022-01278-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/13/2022] [Indexed: 11/03/2022] Open
Abstract
Morbidity and mortality associated with heart failure (HF) has remained high despite advances in therapy. Furthermore, HF-associated risk in patients with type 2 diabetes mellitus (T2D) is even higher than in patients without T2D owing to the strong reciprocal relationship between conditions. However, until recently, no therapy to treat patients with diabetes also reduced cardiovascular risks related to HF. Recent clinical studies (DAPA-HF, EMPEROR-Reduced and EMPEROR-Preserved, SOLOIST-WHF trial) and meta-analysis have demonstrated that sodium-glucose cotransporter-2 inhibitors (SGLT2i) are among the first antidiabetic drugs capable of reducing cardiovascular risks related to HF and improving the prognosis of patients with and without diabetes. Their pleiotropic mechanisms of action place them at the intersection of hemodynamic, metabolic, and neurohumoral pathways, with clear advantages for treating these patients independent of its glucose-lowering effect. Moreover, the benefits of SGLT2i were consistent across the cardiorenal continuum in different populations and clinical settings, which has led to different guidelines introducing SGLT2i as a first-line treatment for HF.
Collapse
Affiliation(s)
- Elías Delgado
- Department of Medicine, University of Oviedo, Oviedo, Spain
- Endocrinology and Nutrition Service, Central University Hospital of Asturias (HUCA), Oviedo, Spain
- Spanish Biomedical Research Network in Rare Diseases (CIBERER), Madrid, Spain
- Health Research Institute of Asturias (ISPA), Oviedo, Spain
| | - Esteban Jódar
- Endocrinology and Clinical Nutrition Department, University Hospital Quiron Salud Madrid, Universidad Europea, Madrid, Spain
| | - Pedro Mezquita-Raya
- Endocrinology and Nutrition Service, Torrecárdenas University Hospital, Almería, Spain
- Biomedical Research Unit, Torrecárdenas University Hospital, Almería, Spain
| | - Óscar Moreno-Pérez
- Endocrinology and Nutrition Department, Alicante General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Alicante, Spain.
- Clinical Medicine Department, Miguel Hernández University, Elche, Spain.
| |
Collapse
|
34
|
McDowell K, Docherty KF. Sodium-glucose cotransporter 2 inhibitors: the first universal treatment for heart failure? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:371-373. [PMID: 34921601 PMCID: PMC9170565 DOI: 10.1093/ehjqcco/qcab088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Kirsty McDowell
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| |
Collapse
|
35
|
Ostrominski JW, Vaduganathan M. Evolving therapeutic strategies for patients hospitalized with new or worsening heart failure across the spectrum of left ventricular ejection fraction. Clin Cardiol 2022; 45 Suppl 1:S40-S51. [PMID: 35789014 PMCID: PMC9254675 DOI: 10.1002/clc.23849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
Heart failure (HF) is a chronic, progressive, and increasingly prevalent syndrome characterized by stepwise declines in health status and residual lifespan. Despite significant advancements in both pharmacologic and nonpharmacologic management approaches for chronic HF, the burden of HF hospitalization-whether attributable to new-onset (de novo) HF or worsening of established HF-remains high and contributes to excess HF-related morbidity, mortality, and healthcare expenditures. Owing to a paucity of evidence to guide tailored interventions in this heterogeneous group, management of acute HF events remains largely subject to clinician discretion, relying principally on alleviation of clinical congestion, as-needed correction of hemodynamic perturbations, and concomitant reversal of underlying trigger(s). Following acute stabilization, the subsequent phase of care primarily involves interventions known to improve long-term outcomes and rehospitalization risk, including initiation and optimization of disease-modifying pharmacotherapy, targeted use of adjunctive therapies, and attention to contributing comorbid conditions. However, even with current standards of care many patients experience recurrent HF hospitalization, or after admission incur worsening clinical trajectories. These patterns highlight a persistent unmet need for evidence-based approaches to inform in-hospital HF care and call for renewed focus on urgent implementation of interventions capable of ameliorating risk of worsening HF. In this review, we discuss key contemporary and emerging therapeutic strategies for patients hospitalized with de novo or worsening HF.
Collapse
Affiliation(s)
- John W. Ostrominski
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
| |
Collapse
|
36
|
Lapteva AE, Nasonova SN, Zhirov IV, Tereshchenko SN. SGLT2 inhibitors in acute decompensated heart failure, what do we know? TERAPEVT ARKH 2022; 94:565-571. [DOI: 10.26442/00403660.2022.04.201449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 01/10/2023]
Abstract
The current worldwide prevalence of heart failure is growing, while its combination with cardiovascular and other conditions determines a poor prognosis in these patients. Furthermore, acute decompensated heart failure is associated with a low survival rate mostly caused by target organ damage. The effects of early administration of SGLT2 inhibitors on renal function in patients with acute decompensated heart failure are being studied to determine the possibility of improving response to treatment, as well as partial or complete recovery of renal function. The goal of the review was to synthesize currently available evidence for the use of SGLT2 inhibitors in patients with acute decompensated heart failure. A systematic search for studies published from 2018 to 2021 and their analysis was carried out in the following databases: Web of Science, Scopus, PubMed/MEDLINE.
Collapse
|
37
|
Hernandez M, Sullivan RD, McCune ME, Reed GL, Gladysheva IP. Sodium-Glucose Cotransporter-2 Inhibitors Improve Heart Failure with Reduced Ejection Fraction Outcomes by Reducing Edema and Congestion. Diagnostics (Basel) 2022; 12:diagnostics12040989. [PMID: 35454037 PMCID: PMC9024630 DOI: 10.3390/diagnostics12040989] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 02/07/2023] Open
Abstract
Pathological sodium-water retention or edema/congestion is a primary cause of heart failure (HF) decompensation, clinical symptoms, hospitalization, reduced quality of life, and premature mortality. Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) based therapies reduce hospitalization due to HF, improve functional status, quality, and duration of life in patients with HF with reduced ejection fraction (HFrEF) independently of their glycemic status. The pathophysiologic mechanisms and molecular pathways responsible for the benefits of SGLT-2i in HFrEF remain inconclusive, but SGLT-2i may help HFrEF by normalizing salt-water homeostasis to prevent clinical edema/congestion. In HFrEF, edema and congestion are related to compromised cardiac function. Edema and congestion are further aggravated by renal and pulmonary abnormalities. Treatment of HFrEF patients with SGLT-2i enhances natriuresis/diuresis, improves cardiac function, and reduces natriuretic peptide plasma levels. In this review, we summarize current clinical research studies related to outcomes of SGLT-2i treatment in HFrEF with a specific focus on their contribution to relieving or preventing edema and congestion, slowing HF progression, and decreasing the rate of rehospitalization and cardiovascular mortality.
Collapse
Affiliation(s)
- Michelle Hernandez
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
- School of Medicine, Universidad Autónoma de Guadalajara, Zapopan 45129, Mexico
| | - Ryan D. Sullivan
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
| | - Mariana E. McCune
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
| | - Guy L. Reed
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
| | - Inna P. Gladysheva
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
- Correspondence: ; Tel.: +1-(602)-827-2919
| |
Collapse
|
38
|
Morillas H, Galcerá E, Alania E, Seller J, Larumbe A, Núñez J, Valle A. Sodium-glucose Co-transporter 2 Inhibitors in Acute Heart Failure: A Review of the Available Evidence and Practical Guidance on Clinical Use. Rev Cardiovasc Med 2022; 23:139. [PMID: 39076216 PMCID: PMC11273890 DOI: 10.31083/j.rcm2304139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/04/2022] [Accepted: 02/22/2022] [Indexed: 07/31/2024] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors were initially conceived as glucose-lowering agents. However, striking renal and cardiovascular benefits were observed in type 2 diabetes trials. This led to evaluate it in dedicated studies in chronic heart failure (HF) and chronic kidney disease, which also showed remarkable clinical results. Given this findings, and taking into account the multiple mechanisms of action, the use of SGLT2 inhibitors in acute heart failure seemed promising. Sotagliflozin was the first SGLT2 inhibitor to reduce heart failure hospitalizations within the acute setting in the SOLOIST-WHF trial. Only type 2 diabetes patients were included, with a preserved and reduced ejection fraction. In slightly less than half of the cohort, this medication was started when the diuretic therapy was transitioned from intravenous to oral, during the hospital admission. In the rest of the patients, sotagliflozin was started early after discharge. Empagliflozin proved to be safe, well-tolerated, increased diuresis, and reduced a combined clinical endpoint (worsening HF, rehospitalization for HF, or death at 60 days) when administered within the first 24 hours of an acute heart failure hospitalization in the EMPA-RESPONSE-AHF trial. More recently, empagliflozin showed a reduction in a composite primary endpoint of death, heart failure events, and quality of life compared to placebo in the EMPULSE trial. Empagliflozin was started after the initial stabilization phase, but while patients were still admitted and receiving intravenous loop diuretics. Less than half of the patients were diabetic and two-thirds had a left ventricular ejection fraction below 40%. Dapagliflozin is currently being tested in the DAPA ACT HF-TIMI 68 trial, which plans to enroll 2400 patients admitted with acute heart failure and reduced ejection fraction. We envision SGLT2 inhibitors as a useful tool in acute heart failure syndrome given the additive diuretic effect, and minimal impact on blood pressure, kidney function, and electrolytes. Its dosage schedule is simple and can help initiation and tolerance of other medical therapy. However, there is an increased risk of genital infections and euglycaemic ketoacidosis. Notwithstanding, once critically ill and fasting patients are excluded, early administration of SGLT2 inhibitors is safe. This review summarizes the development of SGLT2 inhibitors and the available evidence supporting their use during an acute heart failure admission. We also propose a practical guideline for in-hospital initiation and monitoring.
Collapse
Affiliation(s)
- Herminio Morillas
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Emilio Galcerá
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Edgardo Alania
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Julia Seller
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Ainhoa Larumbe
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Health Research Institute, 46010 Valencia, Spain
- CIBER Cardiovascular, Spanish Cardiovascular Research Network, Carlos III Health Research Institute, 28029 Madrid, Spain
| | - Alfonso Valle
- Cardiology Department, Hospital Marina-Salud de Denia, 03700 Alicante, Spain
| |
Collapse
|
39
|
Voors AA, Angermann CE, Teerlink JR, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Borleffs CJW, Ma C, Comin-Colet J, Fu M, Janssens SP, Kiss RG, Mentz RJ, Sakata Y, Schirmer H, Schou M, Schulze PC, Spinarova L, Volterrani M, Wranicz JK, Zeymer U, Zieroth S, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med 2022; 28:568-574. [PMID: 35228754 PMCID: PMC8938265 DOI: 10.1038/s41591-021-01659-1] [Citation(s) in RCA: 370] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/14/2021] [Indexed: 12/22/2022]
Abstract
The sodium–glucose cotransporter 2 inhibitor empagliflozin reduces the risk of cardiovascular death or heart failure hospitalization in patients with chronic heart failure, but whether empagliflozin also improves clinical outcomes when initiated in patients who are hospitalized for acute heart failure is unknown. In this double-blind trial (EMPULSE; NCT04157751), 530 patients with a primary diagnosis of acute de novo or decompensated chronic heart failure regardless of left ventricular ejection fraction were randomly assigned to receive empagliflozin 10 mg once daily or placebo. Patients were randomized in-hospital when clinically stable (median time from hospital admission to randomization, 3 days) and were treated for up to 90 days. The primary outcome of the trial was clinical benefit, defined as a hierarchical composite of death from any cause, number of heart failure events and time to first heart failure event, or a 5 point or greater difference in change from baseline in the Kansas City Cardiomyopathy Questionnaire Total Symptom Score at 90 days, as assessed using a win ratio. More patients treated with empagliflozin had clinical benefit compared with placebo (stratified win ratio, 1.36; 95% confidence interval, 1.09–1.68; P = 0.0054), meeting the primary endpoint. Clinical benefit was observed for both acute de novo and decompensated chronic heart failure and was observed regardless of ejection fraction or the presence or absence of diabetes. Empagliflozin was well tolerated; serious adverse events were reported in 32.3% and 43.6% of the empagliflozin- and placebo-treated patients, respectively. These findings indicate that initiation of empagliflozin in patients hospitalized for acute heart failure is well tolerated and results in significant clinical benefit in the 90 days after starting treatment. In a multinational trial, empagliflozin has clinical benefit when administered to hospitalized patients with acute heart failure, extending the reach of SGLT2 inhibitor therapy to this patient population.
Collapse
Affiliation(s)
- Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of 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, CA, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.,George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT (Cardiovascular and Renal Clinical Trialists), Centre Hospitalier Régional Universitaire, Nancy, France.,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | | | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Michael Fu
- Section of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Stefan P Janssens
- Department of Cardiovascular Sciences, Clinical Cardiology, Belgium University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Henrik Schirmer
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital Copenhagen, Copenhagen, Denmark
| | | | - Lenka Spinarova
- First Department of Medicine, Masaryk University Hospital, Brno, Czech Republic
| | | | - Jerzy K Wranicz
- Department of Electrocardiology, Medical University of Lodz, Central Clinical Hospital, Lodz, Poland
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| |
Collapse
|
40
|
Tomasoni D, Fonarow GC, Adamo M, Anker SD, Butler J, Coats AJS, Filippatos G, Greene SJ, McDonagh TA, Ponikowski P, Rosano G, Seferovic P, Vaduganathan M, Voors AA, Metra M. Sodium-glucose co-transporter 2 inhibitors as an early, first-line therapy in patients with heart failure and reduced ejection fraction. Eur J Heart Fail 2022; 24:431-441. [PMID: 34894038 PMCID: PMC9303969 DOI: 10.1002/ejhf.2397] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently been recommended as a foundational therapy for patients with heart failure (HF) and reduced ejection fraction (HFrEF) because of their favourable effects on mortality, clinical events and quality of life. While clinical practice guidelines have recommended dapagliflozin or empagliflozin in all patients with HFrEF, or sotagliflozin in those with HFrEF and concomitant diabetes, the timing and practical integration of these drugs in clinical practice is less well defined. We propose that these drugs are candidates for early, upfront administration to patients with newly diagnosed HFrEF and for patients hospitalized with HF. Growing evidence has established early benefits, with clinically meaningful reductions in clinical events that reach statistical significance within days to weeks, following dapagliflozin, empagliflozin or, in diabetic patients, sotagliflozin initiation. Secondly, although major clinical trials have tested these drugs in patients already receiving background HF therapy, secondary analyses showed that their efficacy is independent of that. Third, SGLT2 inhibitors are generally safe and well tolerated, with clinical trial data reporting minimal effects on blood pressure, glycaemia-related adverse events, and no excess in acute kidney injury. Rather, they exert renal protective effects and reduce risk of hyperkalaemia, properties that favour initiation, tolerance and persistence of renin-angiotensin system inhibitors and mineralocorticoid receptor antagonists. This review supports the early initiation of dapagliflozin and empagliflozin (or sotagliflozin limited to patients with diabetes) to rapidly improve clinical outcome and quality of life of HFrEF patients.
Collapse
Affiliation(s)
- Daniela Tomasoni
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - 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, MS, USA
| | - Andrew J S Coats
- Department of Cardiology, IRCCS San Raffaele Pisana, Rome, Italy.,Faculty of Medicine, University of Warwick, Coventry, UK
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Theresa A McDonagh
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, London, UK.,Department of Cardiology, King's College Hospital London, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University & Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Giuseppe Rosano
- Department of Cardiology, IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Petar Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade & Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| |
Collapse
|
41
|
Vishram-Nielsen JKK, Tomasoni D, Gustafsson F, Metra M. Contemporary Drug Treatment of Advanced Heart Failure with Reduced Ejection Fraction. Drugs 2022; 82:375-405. [PMID: 35113350 PMCID: PMC8820365 DOI: 10.1007/s40265-021-01666-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
Collapse
Affiliation(s)
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| |
Collapse
|
42
|
Dębska-Kozłowska A, Książczyk M, Lelonek M. New therapeutic options for patients with heart failure with reduced ejection fraction and acute decompensated heart failure. Adv Med Sci 2022; 67:95-102. [PMID: 35101654 DOI: 10.1016/j.advms.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/27/2021] [Accepted: 01/16/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with acute decompensated heart failure (ADHF) are at severe risk of death and rehospitalization. Several clinical studies have been designed to evaluate the efficacy and safety of new molecules administered before discharge or shortly after ADHF. The aim of this article is to summarize current knowledge on recently published findings on treatment of patients with heart failure with reduced ejection fraction (HFrEF) and ADHF. METHODS We performed a thorough search for literature pertaining to our review via the PubMed database. RESULTS In this review, we summarize original papers concerning the efficacy and safety of new molecules in patients with HFrEF and ADHF. CONCLUSIONS Peri-discharge initiation of treatment with new molecules is possible and safe for patients with HFrEF and ADHF. New molecules, if administered before discharge or shortly after, reduce the risk of cardiovascular death or worsening heart failure within the vulnerable phase, and are also nephroprotective.
Collapse
Affiliation(s)
- Agnieszka Dębska-Kozłowska
- Military Medical Academy Memorial Teaching Hospital of the Medical University of Lodz - Central Veterans' Hospital, 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
| |
Collapse
|
43
|
Salah HM, Al'Aref SJ, Khan MS, Al-Hawwas M, Vallurupalli S, Mehta JL, Mounsey JP, Greene SJ, McGuire DK, Lopes RD, Fudim M. Efficacy and safety of sodium-glucose cotransporter 2 inhibitors initiation in patients with acute heart failure, with and without type 2 diabetes: a systematic review and meta-analysis. Cardiovasc Diabetol 2022; 21:20. [PMID: 35123480 PMCID: PMC8817537 DOI: 10.1186/s12933-022-01455-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND There is uncertainty and limited data regarding initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors among patients hospitalized with acute heart failure (AHF). This systematic review and meta-analysis aim to establish the efficacy and safety of SGLT2 inhibitors initiated in patients hospitalized for AHF. METHODS PubMed/Medline, Embase, and Cochrane library were searched using the following terms: ("sglt2" and "acute heart failure") and ("sglt2" and "worsening heart failure") from inception till November 15th, 2021 for randomized controlled trials (RCTs) comparing the efficacy and safety of initiating an SGLT2 inhibitor compared with placebo in patients with AHF. Major cardiovascular and diabetes scientific meetings in 2021 were also searched for relevant studies. Prespecified efficacy outcomes were all-cause mortality, rehospitalization for heart failure, and improvement in Kansas City Cardiomyopathy Questionnaire (KCCQ) scale score. Prespecified safety outcomes were acute kidney injury (AKI), hypotension, and hypoglycemia. Random effects odds ratio (OR) and mean difference with 95% confidence intervals (CIs) were calculated. RESULTS Three RCTs with a total of 1831 patients were included. Initiation of SGLT2 inhibitors in patients with AHF reduced the risk of rehospitalization for heart failure (OR 0.52; 95% CI [0.42, 0.65]) and improved Kansas City Cardiomyopathy Questionnaire scores (mean difference 4.12; 95% CI [0.1.89, 6.53]). There was no statistically significant effect for initiation of SGLT2 inhibitors in patients with AHF on all-cause mortality (OR 0.70; 95% CI [0.46, 1.08]). Initiation of SGLT2 inhibitors in patients with AHF did not increase the acute kidney injury (OR 0.76; 95% CI [0.50, 1.16]), hypotension (OR 1.17; 95% CI [0.80, 1.71]), or hypoglycemia (OR 1.51; 95% CI [0.86, 2.65]). CONCLUSION Initiation of SGLT2 inhibitors in patients hospitalized for AHF during hospitalization or early post-discharge (within 3 days) reduces the risk of rehospitalization for heart failure and improves patient-reported outcomes with no excess risk of adverse effects.
Collapse
Affiliation(s)
- Husam M Salah
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Subhi J Al'Aref
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC, USA
| | - Malek Al-Hawwas
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Srikanth Vallurupalli
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jawahar L Mehta
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J Paul Mounsey
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stephen J Greene
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University Texas Southwestern, and Parkland Health and Hospital System, Dallas, TX, USA
| | - Renato D Lopes
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
44
|
Hias J, Hellemans L, Walgraeve K, Tournoy J, Van der Linden L. SGLT2 Inhibitors in Older Adults with Heart Failure with Preserved Ejection Fraction. Drugs Aging 2022; 39:185-190. [PMID: 35118602 DOI: 10.1007/s40266-022-00920-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
Heart failure is an important medical condition that is prevalent in older adults. Multiple therapies have been identified that improve clinical outcome in heart failure with a reduced ejection fraction. Conversely, this has not been the case in heart failure with preserved ejection fraction (HFpEF). Until now, empagliflozin is the first therapy that has convincingly been shown to improve clinical outcome in HFpEF. Importantly, some key points should be considered to better understand the impact of empagliflozin on the patient trajectory, particularly in older adults with HFpEF. In this current opinion article, we have therefore provided more information on how to translate the findings of the EMPEROR-Preserved trial to the setting of older adults, with a focus on the impact of empagliflozin on hospitalizations, both heart failure-related and all-cause. To better understand the importance of EMPEROR-Preserved findings, we compared these findings with previous relevant HFpEF and heart failure with reduced ejection fraction (HFrEF) trials and provided information on ongoing trials in the HFpEF setting.
Collapse
Affiliation(s)
- Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Laura Hellemans
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Geriatrics and Gerontology, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| |
Collapse
|
45
|
Zhirov IV, Nasonova SN, Khalilova UA, Osmolovskaya YF, Zhirova IA, Gimadiev RR, Chaikovskaia OI, Reitblat OM, Prints IS, Kochetov AG, Tereshchenko SN. Acute decompensated heart failure. What has changed in the clinical guidelines in 2021? CONSILIUM MEDICUM 2022. [DOI: 10.26442/20751753.2022.1.201410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In September 2021, the European Society of Cardiology issued new guidelines on the management of patients with heart failure (HF). In the current version, experts have focused on the 4 most common variants: acute HF decompensation, acute pulmonary edema, cardiogenic shock, and isolated right ventricular failure. There has been a change in approaches to the initial management of patients with acute HF decompensation towards a decrease in the evidence-based use of peripheral vasodilators and a "return" to loop diuretics as the basis of treatment. This raises the question of monitoring the efficacy of diuretic therapy. The paper presents an algorithm proposed by the European Society of Cardiology.
Collapse
|
46
|
Bauersachs J, de Boer RA, Lindenfeld J, Bozkurt B. The year in cardiovascular medicine 2021: heart failure and cardiomyopathies. Eur Heart J 2022; 43:367-376. [PMID: 34974611 PMCID: PMC9383181 DOI: 10.1093/eurheartj/ehab887] [Citation(s) in RCA: 10] [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: 09/16/2021] [Revised: 10/27/2021] [Accepted: 11/16/2021] [Indexed: 12/22/2022] Open
Abstract
In the year 2021, the universal definition and classification of heart failure (HF) was published that defines HF as a clinical syndrome with symptoms and/or signs caused by a cardiac abnormality and corroborated by elevated natriuretic peptide levels or objective evidence of cardiogenic congestion. This definition and the classification of HF with reduced ejection fraction (HFrEF), mildly reduced, and HF with preserved ejection fraction (HFpEF) is consistent with the 2021 ESC Guidelines on HF. Among several other new recommendations, these guidelines give a Class I indication for the use of the sodium–glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin and empagliflozin in HFrEF patients. As the first evidence-based treatment for HFpEF, in the EMPEROR-Preserved trial, empagliflozin reduced the composite endpoint of cardiovascular death and HF hospitalizations. Several reports in 2021 have provided novel and detailed analyses of device and medical therapy in HF, especially regarding sacubitril/valsartan, SGLT2 inhibitors, mineralocorticoid receptor antagonists, ferric carboxymaltose, soluble guanylate cyclase activators, and cardiac myosin activators. In patients hospitalized with COVID-19, acute HF and myocardial injury is quite frequent, whereas myocarditis and long-term damage to the heart are rather uncommon.
Collapse
Affiliation(s)
- Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston TX, USA
| |
Collapse
|
47
|
Cox ZL, Nandkeolyar S, Johnson AJ, Lindenfeld J, Rali AS. In-hospital Initiation and Up-titration of Guideline-directed Medical Therapies for Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2022; 8:e21. [PMID: 35815257 PMCID: PMC9253962 DOI: 10.15420/cfr.2022.08] [Citation(s) in RCA: 6] [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: 01/25/2022] [Accepted: 04/16/2022] [Indexed: 11/04/2022] Open
Abstract
Implementation of guideline-directed medical therapy for patients with heart failure is suboptimal. The use of guideline-directed medical therapy improves minimally after heart failure hospitalisation, despite this event clearly indicating increased risk of further hospitalisation and death. In-hospital initiation and titration of guideline-directed medical therapies is one potential strategy to fill these gaps in care, both in the acute vulnerable period after hospital discharge and in the long term. The purpose of this article is to review the knowledge gaps in best practices of in-hospital initiation and up-titration of guideline-directed medical therapies, the benefits and risks of in-hospital initiation and post-discharge focused titration of guideline-directed medical therapies, the recent literature evaluating these practices, and propose strategies to apply these principles to the care of patients with heart failure with reduced ejection fraction.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of PharmacyNashville, TN, US
- Department of Pharmacy, Vanderbilt University Medical CenterNashville, TN, US
| | - Shuktika Nandkeolyar
- Division of Cardiovascular Medicine, Vanderbilt University Medical CenterNashville, TN, US
| | - Andrew J Johnson
- Department of Pharmacy, Vanderbilt University Medical CenterNashville, TN, US
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical CenterNashville, TN, US
| | - Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical CenterNashville, TN, US
| |
Collapse
|
48
|
Greenberg B. Medical Management of Patients With Heart Failure and Reduced Ejection Fraction. Korean Circ J 2022; 52:173-197. [PMID: 35257531 PMCID: PMC8907986 DOI: 10.4070/kcj.2021.0401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
The options for treating heart failure with reduced ejection fraction (HFrEF) have expanded considerably over the past decade. While neurohormonal modulation using angiotensin converting enzyme inhibitors and angiotensin receptor blockers, beta blockers and mineralocorticoid receptor antagonists remain the cornerstone of therapy, additional novel approaches including angiotensin receptor neprilysin inhibitors, sodium glucose cotransporter 2 inhibitors, ivrabradine, vericiguat and omecamtiv mecarbil have been shown to improve outcomes in patients with HFrEF. This reviews summarizes currently available approaches as well as promising additional strategies that may be used in the future. Treatment options for patients with heart failure (HF) with reduced ejection fraction (HFrEF) have expanded considerably over the past few decades. Whereas neurohormonal modulation remains central to the management of patients with HFrEF, other pathways have been targeted with drugs that have novel mechanisms of action. The angiotensin receptor-neprilysin inhibitors (ARNIs) which enhance levels of compensatory molecules such as the natriuretic peptides while simultaneously providing angiotensin receptor blockade have emerged as the preferred strategy for inhibiting the renin angiotensin system. Sodium glucose cotransporter 2 (SGLT2) inhibitors which were developed as hypoglycemic agents have been shown to improve outcomes in patients with HF regardless of their diabetic status. These agents along with beta blockers and mineralocorticoid receptor antagonists are the core medical therapies for patients with HFrEF. Additional approaches using ivabradine to slow heart rate in patients with sinus rhythm, the hydralazine/isosorbide dinitrate combination to unload the heart, digoxin to provide inotropic support and vericiguat to augment cyclic guanosine monophosphate production have been shown in well-designed trials to have beneficial effects in the HFrEF population and are used as adjuncts to the core therapies in selected patients. This review provides an overview of the medical management of patients with HFrEF with focus on the major developments that have taken place in the field. It offers prospective of how these drugs should be employed in clinical practice and also a glimpse into some strategies that may prove to be useful in the future.
Collapse
|
49
|
Brownell NK, Ziaeian B, Fonarow GC. The Gap to Fill: Rationale for Rapid Initiation and Optimal Titration of Comprehensive Disease-modifying Medical Therapy for Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2021; 7:e18. [PMID: 34950508 PMCID: PMC8674626 DOI: 10.15420/cfr.2021.18] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/06/2021] [Indexed: 12/11/2022] Open
Abstract
There are gaps in the use of therapies that save lives and improve quality of life for patients with heart failure with reduced ejection fraction, both in the US and abroad. The evidence is clear that initiation and titration of guideline-directed medical therapy (GDMT) and comprehensive disease-modifying medical therapy (CDMMT) to maximally tolerated doses improves patient-focused outcomes, yet observational data suggest this does not happen. The purpose of this review is to describe the gap in the use of optimal treatment worldwide and discuss the benefits of newer heart failure therapies including angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter 2 inhibitors. It will also cover the efficacy and safety of such treatments and provide potential pathways for the initiation and rapid titration of GDMT/CDMMT.
Collapse
Affiliation(s)
- Nicholas K Brownell
- Division of Cardiology, University of California Los Angeles (UCLA) Los Angeles, CA, US
| | - Boback Ziaeian
- Division of Cardiology, University of California Los Angeles (UCLA) Los Angeles, CA, US
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles (UCLA) Los Angeles, CA, US.,Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, US
| |
Collapse
|
50
|
Cherney DZ, Udell JA, Drucker DJ. Cardiorenal mechanisms of action of glucagon-like-peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors. MED 2021; 2:1203-1230. [DOI: 10.1016/j.medj.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/14/2021] [Accepted: 10/05/2021] [Indexed: 12/14/2022]
|