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Nilsson CN, Ersbøll MK, Gustafsson F. Haemodynamic Effects of Sodium-Glucose Cotransporter 2 Inhibitor Treatment in Chronic Heart Failure Patients. Card Fail Rev 2024; 10:e09. [PMID: 39309522 PMCID: PMC11413986 DOI: 10.15420/cfr.2023.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/07/2024] [Indexed: 09/25/2024] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) are now recommended in the current European Society of Cardiology/American College of Cardiology guidelines for the treatment of heart failure (HF) across the spectrum of left ventricular ejection fraction (LVEF) and several large trials have documented the beneficial effects of this drug class on cardiovascular outcomes. Although the clinical efficacy of SGLT-2 inhibition in HF is now well recognised, research is still ongoing to better understand the underlying mechanistic effects of this drug class. In this paper we assess the haemodynamic effects following SGLT-2i treatment in HF patients by reviewing the current literature. We focus our review on preload of the LV in terms of filling pressure and pulmonary artery pressure, cardiac output and afterload. We discuss these variables stratified according to HF with reduced LVEF (HFrEF) and HF with preserved LVEF (HFpEF). Finally, we examine the evidence of LV remodelling in the setting of SGLT-2i-related changes in haemodynamics.
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Affiliation(s)
- C Noah Nilsson
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet Denmark
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2
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Abdin A, Aimo A, Hoevelmann J, Haring B. The month in heart failure! September 2024. Eur J Heart Fail 2024. [PMID: 39252382 DOI: 10.1002/ejhf.3465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 08/26/2024] [Indexed: 09/11/2024] Open
Affiliation(s)
- Amr Abdin
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Alberto Aimo
- Health Sciences Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Julian Hoevelmann
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Bernhard Haring
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
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3
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Pascual-Figal D, Bayes-Genis A. Looking for the ideal medication for heart failure with reduced ejection fraction: a narrative review. Front Cardiovasc Med 2024; 11:1439696. [PMID: 39314771 PMCID: PMC11417622 DOI: 10.3389/fcvm.2024.1439696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 08/20/2024] [Indexed: 09/25/2024] Open
Abstract
The main goals of the pharmacological treatment of Heart failure with reduced ejection fraction (HFrEF) are the reduction of mortality and the prevention of hospitalizations. However, other outcomes such as improvements in cardiac remodeling and clinical status, functional capacity and quality of life, should be taken into account. Also, given the significant inter-individual and intra-individual variability of HF, and the fact that patients usually present with comorbidities, an appropriate treatment for HFrEF should exert a clinical benefit in most patient profiles irrespective of their characteristics or the presence of comorbidities, while providing organ protection beyond the cardiovascular system. The aim of this narrative review is to determine which are the proven effects of the guideline-directed treatments for HFrEF on five key clinical outcomes: cardiovascular mortality and hospitalization due to HF, sudden death, reverse cardiac remodeling, renal protection and evidence in hospitalized patients. Publications that fulfilled the pre-established selection criteria were selected and reviewed. Renin-angiotensin system (RAS) inhibitors, namely angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), sodium-glucose co-transporter 2 inhibitors (SGLT2i) show a benefit in terms of mortality and hospitalization rates. ARNI, BB, and MRA have demonstrated a significant positive effect on the incidence of sudden death. ARB, ARNI, BB and SGLT2i have been associated with clear benefits in reverse cardiac remodeling. Additionally, there is consistent evidence of renal protection from ARB, ARNI, and SGLT2i in renal protection and of benefits for hospitalized patients from ARNI and SGLT2i. In conclusion, the combination of drugs that gather most beneficial effects in HFrEF, beyond cardiovascular mortality and hospitalization, would be ideally pursued.
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Affiliation(s)
- Domingo Pascual-Figal
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
- University of Murcia, Murcia, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Antoni Bayes-Genis
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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4
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Pourafkari M, Connelly KA, Verma S, Mazer CD, Teoh H, Quan A, Goodman SG, Rai A, Ng MY, Deva DP, Triverio P, Jiminez-Juan L, Yan AT, Ge Y. Empagliflozin and left atrial function in patients with type 2 diabetes mellitus and coronary artery disease: insight from the EMPA-HEART CardioLink-6 randomized clinical trial. Cardiovasc Diabetol 2024; 23:319. [PMID: 39198860 PMCID: PMC11360285 DOI: 10.1186/s12933-024-02344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 06/27/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated reduction in heart failure outcomes in patients with type 2 diabetes mellitus, although the exact mechanism of benefit remains unclear. Alteration in left atrial (LA) function due to chronic pressure or volume overload is a hallmark of heart failure. OBJECTIVE To evaluate the effect of the SGLT2 inhibitor empagliflozin on LA volume and function. METHODS 90 patients with coronary artery disease and type 2 diabetes (T2DM) were randomized to empagliflozin (n = 44) or placebo (n = 46), and underwent cardiac magnetic resonance (CMR) imaging at baseline and after 6 months. The main outcome was change in LA volume; LA function, including active and passive components, was also measured by a blinded reader. RESULTS At baseline, there was no significant difference in LA volumes between the empagliflozin (indexed maximum LA volume 26.4 ± 8.4mL/m2, minimum LA volume 11.1 ± 5.7mL/m2) and placebo (indexed maximum LA volume 28.7 ± 8.2mL/m2, minimum LA volume 12.6 ± 5.0mL/m2) groups. After 6 months, changes in LA volumes did not differ with adjusted difference (empagliflozin minus placebo): 0.99 mL/m2 (95% CI: -1.7 to 3.7 mL/m2; p = 0.47) for indexed maximum LA volume, and 0.87 mL/m2 (95% CI: -0.9 to 2.6 mL/m2; p = 0.32) for indexed minimum LA volume. Changes in total LA emptying fraction were also similar, with between-group adjusted mean difference - 0.01 (95% CI: -0.05 to 0.03, p = 0.59). CONCLUSION SGLT2 inhibition with empagliflozin for 6 months did not have a significant impact on LA volume and function in patients with T2DM and coronary artery disease. (Effects of Empagliflozin on Cardiac Structure in Patients with Type 2 Diabetes [EMPA-HEART]; NCT02998970).
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Affiliation(s)
- Marina Pourafkari
- Department of Medical Imaging, St. Michael's Hospital, Toronto, Canada
| | - Kim A Connelly
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- University of Toronto, Toronto, Canada.
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.
| | - Subodh Verma
- University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Division of Cardiac Surgery, St Michael's Hospital, Toronto, Canada
| | - C David Mazer
- University of Toronto, Toronto, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, St Michael's Hospital, Toronto, Canada
- Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, St Michael's Hospital, Toronto, Canada
| | - Shaun G Goodman
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Archana Rai
- Department of Medical Imaging, St. Michael's Hospital, Toronto, Canada
| | - Ming Yen Ng
- Department of Diagnostic Radiology, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Djeven P Deva
- Department of Medical Imaging, St. Michael's Hospital, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Piero Triverio
- Department of Electrical & Computer Engineering, Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Laura Jiminez-Juan
- Department of Medical Imaging, St. Michael's Hospital, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Andrew T Yan
- Department of Medical Imaging, St. Michael's Hospital, Toronto, Canada.
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- University of Toronto, Toronto, Canada.
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.
| | - Yin Ge
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- University of Toronto, Toronto, Canada.
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Kauffman ZS, Demede M. Dilated Cardiomyopathy, De Novo Heart Failure, and Cardiogenic Shock With End-Organ Failure in a Patient With No Cardiac History Following a Trial of Amitriptyline. Cureus 2024; 16:e67374. [PMID: 39310625 PMCID: PMC11413831 DOI: 10.7759/cureus.67374] [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] [Accepted: 08/17/2024] [Indexed: 09/25/2024] Open
Abstract
A 69-year-old female with no cardiac history presented with dilated cardiomyopathy and de novo congestive heart failure, with an ejection fraction of less than 20%. This patient had struggled over the prior six weeks with exacerbation of chronic obstructive pulmonary disease complicated by pneumonia and as such had taken several trials of antibiotics. Four days prior to her presentation, she was prescribed amitriptyline by her primary care physician to help with sleep. Two days after the presentation, she developed cardiogenic shock secondary to acutely decompensated heart failure. End-organ dysfunction presented as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of greater than 1000 U/L and a glomerular filtration rate (GFR) as low as 23 mL/min. Cardiac catheterization showed non-obstructive coronary artery disease, and cardiac MRI showed an ejection fraction of 14%. She was discharged 14 days after her initial presentation with a diagnosis of NYHA Class 3 Stage C acute systolic heart failure with dilated cardiomyopathy.
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Affiliation(s)
- Zachary S Kauffman
- Research, DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Beckley, USA
| | - Melaku Demede
- Cardiology, Beckley Appalachian Regional Hospital, Beckley, USA
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6
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Raposeiras Roubín S, López Canoa N. Heart failure and atrial fibrillation. Med Clin (Barc) 2024:S0025-7753(24)00401-9. [PMID: 39034182 DOI: 10.1016/j.medcli.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/18/2024] [Accepted: 05/22/2024] [Indexed: 07/23/2024]
Affiliation(s)
- Sergio Raposeiras Roubín
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Biomédica Galicia Sur, Vigo, Pontevedra, España; Departamento de Ciencias de la Salud, Universidad de Vigo, Vigo, Pontevedra, España; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Fuencarral-El Pardo, Madrid, España.
| | - Nicolás López Canoa
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, España; Instituto de Investigación Biomédica Galicia Sur, Vigo, Pontevedra, España
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7
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Pastore MC, Stefanini A, Mandoli GE, Piu P, Diviggiano EE, Iuliano MA, Carli L, Marchese A, Martini L, Pecere A, Cavigli L, Giacomin E, Pagliaro A, Righini FM, Sorini Dini C, Soliman Aboumarie H, Focardi M, D'Ascenzi F, Valente S, Cameli M. Dapagliflozin Effects on Cardiac Deformation in Heart Failure and Secondary Clinical Outcome. JACC Cardiovasc Imaging 2024:S1936-878X(24)00226-2. [PMID: 39023499 DOI: 10.1016/j.jcmg.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors were shown to reduce morbidity and mortality in patients with heart failure. OBJECTIVES This study aims to assess potential effects of dapagliflozin in nondiabetic patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with mildly reduced ejection fraction (HFmrEF) on cardiac function assessed by speckle tracking echocardiography (STE). METHODS This randomized, prospective, single-center, open-label trial compared consecutive nondiabetic outpatients with HFrEF or HFmrEF receiving dapagliflozin with patients treated with optimal medical therapy (OMT) except sodium-glucose cotransporter type 2 inhibitors. Primary endpoint was the presence of a significant modification of left ventricular global longitudinal strain, diastolic function (as peak atrial longitudinal strain) and right ventricular function by STE from baseline to 6 months. Cardiovascular events and parameters of congestion were assessed as safety-exploratory endpoints. RESULTS Overall, 88 patients (38% HFmrEF) were enrolled and randomized to start dapagliflozin on top of OMT (n = 44) or to continue with OMT (n = 44). All STE values improved in the dapagliflozin group after 6 months, whereas there was a nonsignificant improvement in OMT group. Moreover, when comparing the modification of STE parameters at follow-up in patients with HFrEF and HFmrEF, only the main treatment effect resulted statistically significant in both groups (P < 0.0001), indicating a significant difference between dapagliflozin and OMT. CONCLUSIONS This study provided randomized data on the beneficial effect of dapagliflozin in nondiabetic patients with HFrEF and HFmrEF in terms of myocardial performance measured by the most sensitive echocardiographic technique, ie, STE. This suggests its usefulness for left ventricular reverse remodeling and better quality of life in patients with HFrEF and HFmrEF. (Effects of Dapagliflozin on cardiac deformation and clinical outcomes in heart failure with reduced and mildly reduced ejection fraction [DAPA ECHO trial]; EudraCT number: 2021-005394-66).
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Affiliation(s)
- Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | - Andrea Stefanini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Pietro Piu
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Enrico Emilio Diviggiano
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Alma Iuliano
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Leonardo Carli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Andrea Marchese
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Luca Martini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Alessio Pecere
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Elisa Giacomin
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Antonio Pagliaro
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Maria Righini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Carlotta Sorini Dini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Hatem Soliman Aboumarie
- Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Riccardi M, Cikes M, Adamo M, Pagnesi M, Lombardi CM, Solomon SD, Metra M, Inciardi RM. Functional Mitral Regurgitation and Heart Failure With Preserved Ejection Fraction: Clinical Implications and Management. J Card Fail 2024; 30:929-939. [PMID: 38522637 DOI: 10.1016/j.cardfail.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 03/26/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and associated with worse cardiovascular outcomes. The pathophysiology of HFpEF mostly relies on the development of elevated left ventricle filling pressure, diastolic dysfunction, and atrial dilatation and impairment. This dynamic process may eventually lead to the development of functional mitral regurgitation (MR), characterized by mitral annular dilatation and consequent leaflet remodeling, in the context of preserved left ventricular ejection fraction. These observations highlight the possible common pathophysiology of MR and HFpEF. However, less is known about the prevalence and the clinical value of MR in the context of HFpEF. This review aims to provide an overview of the association and interplay between functional MR and HFpEF, discuss the underlying mechanisms that are common to these diseases, and summarize potential targeted pharmacological treatments.
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Scott David Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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Chee YJ, Dalan R. Novel Therapeutics for Type 2 Diabetes Mellitus-A Look at the Past Decade and a Glimpse into the Future. Biomedicines 2024; 12:1386. [PMID: 39061960 PMCID: PMC11274090 DOI: 10.3390/biomedicines12071386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 07/28/2024] Open
Abstract
Cardiovascular disease (CVD) and kidney disease are the main causes of morbidity and mortality in type 2 diabetes mellitus (T2DM). Globally, the incidence of T2DM continues to rise. A substantial increase in the burden of CVD and renal disease, alongside the socioeconomic implications, would be anticipated. Adopting a purely glucose-centric approach focusing only on glycemic targets is no longer adequate to mitigate the cardiovascular risks in T2DM. In the past decade, significant advancement has been achieved in expanding the pharmaceutical options for T2DM, with novel agents such as the sodium-glucose cotransporter type 2 (SGLT2) inhibitors and glucagon-like peptide receptor agonists (GLP-1 RAs) demonstrating robust evidence in cardiorenal protection. Combinatorial approaches comprising multiple pharmacotherapies combined in a single agent are an emerging and promising way to not only enhance patient adherence and improve glycemic control but also to achieve the potential synergistic effects for greater cardiorenal protection. In this review, we provide an update on the novel antidiabetic agents in the past decade, with an appraisal of the mechanisms contributing to cardiorenal protection. Additionally, we offer a glimpse into the landscape of T2DM management in the near future by providing a comprehensive summary of upcoming agents in early-phase trials.
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Affiliation(s)
- Ying Jie Chee
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore 308433, Singapore;
| | - Rinkoo Dalan
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore 308433, Singapore;
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
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10
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Battistoni I, Pongetti G, Falchetti E, Giannini I, Olivieri R, Gioacchini F, Bonelli P, Contadini D, Scappini L, Flori M, Giovagnoli A, De Maria R, Marini M. Safety and Efficacy of Dapagliflozin in Patients with Heart Failure with Reduced Ejection Fraction: Multicentre Retrospective Study on Echocardiographic Parameters and Biomarkers of Heart Congestion. J Clin Med 2024; 13:3522. [PMID: 38930049 PMCID: PMC11204467 DOI: 10.3390/jcm13123522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: Dapagliflozin has shown efficacy in clinical trials in patients with heart failure and reduced ejection fraction (HFrEF). However, real-world data on its use and outcomes in routine clinical practice are limited. We aimed to evaluate the utilisation and safety profile of dapagliflozin in a real-world population of HFrEF patients within the Marche region. Methods: Nine cardiology departments within the Marche region retrospectively included HFrEF patients who were initiated on dapagliflozin therapy in an outpatient setting. Data on medical history, comorbidities, echocardiographic parameters, and laboratory tests were collected at baseline and after 6 months. Telephone follow-up interviews were conducted at 1 and 3 months to assess adverse events. We defined the composite endpoint score as meeting at least 50% of four objective measures of improvement among: weight loss, NYHA decrease, ≥50% Natriuretic peptides (NP) decrease, and guideline/directed medical therapy (GDMT) up titration. Results: We included 95 HFrEF patients aged 66 ± 12 years, 82% were men, 48% had ischemic heart disease, and 20% had diabetes. At six months, glomerular filtration rate declined (p = 0.03) and natriuretic peptides levels decreased, on average, by 23% (p < 0.001). Echocardiographic measurements revealed a decrease in pulmonary artery pressure (p < 0.001) and E/e' (p < 0.001). In terms of drug therapy, furosemide dosage decreased (p = 0.001), and the percentage of the target dose achieved for angiotensin receptor-neprilysin inhibitors increased (p = 0.003). By multivariable Cox regression, after adjustment for age, sex, the presence of diabetes/prediabetes, and HF duration, higher baseline Hb concentrations (HR 1.347, 95% CI 1.038-1.746, p = 0.025), and eGFR levels (HR 1.016, 95% CI 1.000-1.033, p = 0.46). Conclusions: In a real-life HFrEF population, dapagliflozin therapy is safe and well-tolerated, improves echocardiographic parameters and biomarkers of congestion, and can also facilitate the titration of drugs with a prognostic impact.
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Affiliation(s)
- Ilaria Battistoni
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, 60100 Ancona, Italy; (G.P.); (M.M.)
| | - Giulia Pongetti
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, 60100 Ancona, Italy; (G.P.); (M.M.)
| | - Elena Falchetti
- Cardiology Department, Senigallia Hospital, 60019 Senigallia, Italy;
| | - Irene Giannini
- Department of Cardiology, Camerino-Hospital, 62032 Camerino, Italy;
| | - Roberto Olivieri
- Cardiology Unit, Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy (L.S.)
| | | | - Paolo Bonelli
- Department of Cardiology, Cardiac Intensive Care Unit, Centre of Telemedicine, Italian National Research Centre on Aging (INRCA), 60127 Ancona, Italy;
| | - Daniele Contadini
- Cardiology Division, Ospedale Provinciale AREA VASTA 3, 62100 Piediripa, Italy;
| | - Lorena Scappini
- Cardiology Unit, Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy (L.S.)
| | - Marco Flori
- U.O.C. Cardiology-Utic Ospedale della Misericordia Urbino AST Pesaro-Urbino, 61029 Urbino, Italy;
| | | | | | - Marco Marini
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, 60100 Ancona, Italy; (G.P.); (M.M.)
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11
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Riccardi M, Borlaug BA, Inciardi RM. Mitral regurgitation and heart failure with preserved ejection fraction: Should we treat the muscle, the valve, or both? Eur J Heart Fail 2024; 26:1443-1445. [PMID: 38740731 DOI: 10.1002/ejhf.3288] [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: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Riccardo M Inciardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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12
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Beghini A, Sammartino AM, Papp Z, von Haehling S, Biegus J, Ponikowski P, Adamo M, Falco L, Lombardi CM, Pagnesi M, Savarese G, Metra M, Tomasoni D. 2024 update in heart failure. ESC Heart Fail 2024. [PMID: 38806171 DOI: 10.1002/ehf2.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.
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Affiliation(s)
- Alberto Beghini
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gianluigi Savarese
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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13
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Trimarchi G, Teresi L, Licordari R, Pingitore A, Pizzino F, Grimaldi P, Calabrò D, Liotta P, Micari A, de Gregorio C, Di Bella G. Transient Left Ventricular Dysfunction from Cardiomyopathies to Myocardial Viability: When and Why Cardiac Function Recovers. Biomedicines 2024; 12:1051. [PMID: 38791012 PMCID: PMC11117605 DOI: 10.3390/biomedicines12051051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/30/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Transient left ventricular dysfunction (TLVD), a temporary condition marked by reversible impairment of ventricular function, remains an underdiagnosed yet significant contributor to morbidity and mortality in clinical practice. Unlike the well-explored atherosclerotic disease of the epicardial coronary arteries, the diverse etiologies of TLVD require greater attention for proper diagnosis and management. The spectrum of disorders associated with TLVD includes stress-induced cardiomyopathy, central nervous system injuries, histaminergic syndromes, various inflammatory diseases, pregnancy-related conditions, and genetically determined syndromes. Furthermore, myocardial infarction with non-obstructive coronary arteries (MINOCA) origins such as coronary artery spasm, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD) may also manifest as TLVD, eventually showing recovery. This review highlights the range of ischemic and non-ischemic clinical situations that lead to TLVD, gathering conditions like Tako-Tsubo Syndrome (TTS), Kounis syndrome (KS), Myocarditis, Peripartum Cardiomyopathy (PPCM), and Tachycardia-induced cardiomyopathy (TIC). Differentiation amongst these causes is crucial, as they involve distinct clinical, instrumental, and genetic predictors that bode different outcomes and recovery potential for left ventricular function. The purpose of this review is to improve everyday clinical approaches to treating these diseases by providing an extensive survey of conditions linked with TLVD and the elements impacting prognosis and outcomes.
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Affiliation(s)
- Giancarlo Trimarchi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Lucio Teresi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Roberto Licordari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98100 Messina, Italy; (R.L.); (A.M.)
| | - Alessandro Pingitore
- Istituto di Fisiologia Clinica, Clinical Physiology Institute, CNR, 56124 Pisa, Italy;
| | - Fausto Pizzino
- Cardiology Unit, Heart Centre, Fondazione Gabriele Monasterio—Regione Toscana, 54100 Massa, Italy;
| | - Patrizia Grimaldi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Danila Calabrò
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Paolo Liotta
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98100 Messina, Italy; (R.L.); (A.M.)
| | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, 98100 Messina, Italy; (L.T.); (P.G.); (D.C.); (P.L.); (C.d.G.); (G.D.B.)
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14
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Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, Arrobas-Velilla T, Baeza-Trinidad R, Calmarza P, Cebollada J, Civera-Andrés M, Cuende Melero JI, Díaz-Díaz JL, Espíldora-Hernández J, Fernández Pardo J, Guijarro C, Jericó C, Laclaustra M, Lahoz C, López-Miranda J, Martínez-Hervás S, Muñiz-Grijalvo O, Páramo JA, Pascual V, Pedro-Botet J, Pérez-Martínez P, Puzo J. SEA 2024 Standards for Global Control of Vascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:133-194. [PMID: 38490888 DOI: 10.1016/j.arteri.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 03/17/2024]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.
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Affiliation(s)
- José María Mostaza
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España.
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Bellvitge, Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición (CIBERobn), Fundación para la Investigación y Prevención de las Enfermedades Cardiovasculares (FIPEC), Universidad de Barcelona, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España
| | - Pedro Armario
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Luis Masana
- Unidad de Medicina Vascular y Metabolismo (UVASMET), Institut d'Investigació Sanitària Pere Virgili (IISPV), Hospital Universitari Sant Joan de Reus, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Universitat Rovira i Virgili, Tarragona, España
| | - José T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Pedro Valdivielso
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España
| | - Teresa Arrobas-Velilla
- Laboratorio de Nutrición y RCV, UGC de Bioquímica clínica, Hospital Virgen Macarena, Sevilla, España
| | | | - Pilar Calmarza
- Servicio de Bioquímica Clínica, Hospital Universitario Miguel Servet, Zaragoza, España; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Jesús Cebollada
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Miguel Civera-Andrés
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España
| | - José I Cuende Melero
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - José L Díaz-Díaz
- Sección de Medicina Interna, Unidad de Lípidos y Riesgo Cardiovascular, Hospital Abente y Lago Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - Javier Espíldora-Hernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España; Unidad de Lípidos y Unidad Asistencial de Hipertensión Arterial- Riesgo Vascular (HTA-RV), UGC Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - Jacinto Fernández Pardo
- Servicio de Medicina Interna, Hospital General Universitario Reina Sofía de Murcia, Universidad de Murcia, Murcia, España
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorón, España
| | - Carles Jericó
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Martín Laclaustra
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Carlos Lahoz
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España
| | - José López-Miranda
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Sergio Martínez-Hervás
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Ovidio Muñiz-Grijalvo
- Servicio de Medicina Interna, UCERV, UCAMI, Hospital Virgen del Rocío de Sevilla, Sevilla, España
| | - José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Navarra, España; Laboratorio Aterotrombosis, CIMA, Universidad de Navarra, Pamplona, España
| | - Vicente Pascual
- Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España
| | - Pablo Pérez-Martínez
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - José Puzo
- Servicio de Bioquímica Clínica, Unidad de Lípidos, Hospital General Universitario San Jorge de Huesca, Huesca, España; Departamento de Medicina, Universidad de Zaragoza, Zaragoza, España
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15
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Dhont S, van den Acker G, van Loon T, Verbrugge FH, Verwerft J, Deferm S, Churchill TW, Mullens W, Lumens J, Bertrand PB. Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium. Eur J Heart Fail 2024; 26:974-983. [PMID: 38629747 PMCID: PMC11184410 DOI: 10.1002/ejhf.3231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/22/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024] Open
Abstract
Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.
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Affiliation(s)
- Sebastiaan Dhont
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Gitte van den Acker
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Tim van Loon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frederik H. Verbrugge
- Center for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | | | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Philippe B. Bertrand
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
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16
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Zaher W, Della Rocca DG, Pannone L, Boveda S, de Asmundis C, Chierchia GB, Sorgente A. Anti-Arrhythmic Effects of Heart Failure Guideline-Directed Medical Therapy and Their Role in the Prevention of Sudden Cardiac Death: From Beta-Blockers to Sodium-Glucose Cotransporter 2 Inhibitors and Beyond. J Clin Med 2024; 13:1316. [PMID: 38592135 PMCID: PMC10931968 DOI: 10.3390/jcm13051316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/14/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Sudden cardiac death (SCD) accounts for a substantial proportion of mortality in heart failure with reduced ejection fraction (HFrEF), frequently triggered by ventricular arrhythmias (VA). This review aims to analyze the pathophysiological mechanisms underlying VA and SCD in HFrEF and evaluate the effectiveness of guideline-directed medical therapy (GDMT) in reducing SCD. Beta-blockers, angiotensin receptor-neprilysin inhibitors, and mineralocorticoid receptor antagonists have shown significant efficacy in reducing SCD risk. While angiotensin-converting enzyme inhibitors and angiotensin receptor blockers exert beneficial impacts on the renin-angiotensin-aldosterone system, their direct role in SCD prevention remains less clear. Emerging treatments like sodium-glucose cotransporter 2 inhibitors show promise but necessitate further research for conclusive evidence. The favorable outcomes of those molecules on VA are notably attributable to sympathetic nervous system modulation, structural remodeling attenuation, and ion channel stabilization. A multidimensional pharmacological approach targeting those pathophysiological mechanisms offers a complete and synergy approach to reducing SCD risk, thereby highlighting the importance of optimizing GDMT for HFrEF. The current landscape of HFrEF pharmacotherapy is evolving, with ongoing research needed to clarify the full extent of the anti-arrhythmic benefits offered by both existing and new treatments.
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Affiliation(s)
- Wael Zaher
- Department of Cardiology, Centre Hospitalier EpiCURA, Route de Mons 63, 7301 Hornu, Belgium;
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, 31076 Toulouse, France;
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Antonio Sorgente
- Department of Cardiology, Centre Hospitalier EpiCURA, Route de Mons 63, 7301 Hornu, Belgium;
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
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17
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Mapelli M, Salvioni E, Havakuk O, Agostoni P. Editorial: Cardiac reverse remodeling after novel heart failure therapies. Front Cardiovasc Med 2024; 11:1362760. [PMID: 38385131 PMCID: PMC10879630 DOI: 10.3389/fcvm.2024.1362760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/25/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Ofer Havakuk
- Cardiology Division, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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18
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Konduri A, West C, Lowery R, Hunter T, Jarosz A, Yu S, Lim HM, McCormick AD, Schumacher KR, Peng DM. Experience with SGLT2 Inhibitors in Patients with Single Ventricle Congenital Heart Disease and Fontan Circulatory Failure. Pediatr Cardiol 2023:10.1007/s00246-023-03332-5. [PMID: 37919530 DOI: 10.1007/s00246-023-03332-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
Heart failure is the leading cause of morbidity and mortality in patients with Fontan circulation. Sodium-glucose-cotransporter 2 inhibitors (SGLT2i) have become a mainstay of heart failure therapy in adult patients, however, there remains a paucity of literature to describe its use in pediatric heart failure patients, especially those with single ventricle physiology. We describe our early experience using SGLT2i in patients with single ventricle congenital heart disease surgically palliated to the Fontan circulation. We conducted a single-center retrospective chart review of all patients with Fontan circulation who were initiated on an SGLT2i from January 1, 2022 to March 1, 2023. Patient demographics, diagnoses, clinical status, and other therapies were collected from the electronic medical record. During the study period, 14 patients (median age 14.5 years, range 2.0-26.4 years) with Fontan circulation were started on a SGLT2i. Mean weight was 54 kg (range 11.6-80.4 kg). Median follow-up since SGLT2i initiation was 4.1 months (range 13 days-7.7 months). Four patients had a systemic left ventricle and 10 had a systemic right ventricle. Half the patients had Fontan Circulatory Failure with reduced Ejection Fraction (FCFrEF) of the systemic ventricle and the other half had Fontan Circulatory Failure with preserved Ejection Fraction (FCFpEF) of the systemic ventricle. In addition, 3 patients experienced Protein Losing Enteropathy (PLE) and 2 patients had plastic bronchitis, one of whom also was diagnosed with chylothorax. There were no genitourinary infections, hypoglycemia, ketoacidosis, hypotension or other significant adverse effects noted in our patient population. One patient experienced significant diuresis and transient acute kidney injury. Patients with FCFrEF showed a decrease in natriuretic peptide levels. Given the lack of proven therapies, demonstrated benefits of SGLT2i in other populations, and some suggestion of efficacy in Fontan circulation, further study of SGTLT2i in patients with Fontan circulation is warranted.
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Affiliation(s)
- Anusha Konduri
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA.
| | - Caroline West
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Tiffany Hunter
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Audrey Jarosz
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Heang M Lim
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | | | | | - David M Peng
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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19
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Marino PN. Sodium-dependent glucose transporter 2 inhibition and the atrial antiremodelling effects in HFrEF patients. J Cardiovasc Med (Hagerstown) 2023; 24:838-839. [PMID: 37773883 DOI: 10.2459/jcm.0000000000001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Affiliation(s)
- Paolo N Marino
- School of Medicine, Università del Piemonte Orientale, Novara, Istituto Iperbarico, Villafranca, Verona, Italy
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20
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Escobar C, Pascual-Figal D, Manzano L, Nuñez J, Camafort M. Current Role of SLGT2 Inhibitors in the Management of the Whole Spectrum of Heart Failure: Focus on Dapagliflozin. J Clin Med 2023; 12:6798. [PMID: 37959263 PMCID: PMC10649290 DOI: 10.3390/jcm12216798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Heart failure (HF) is associated with a high morbidity and mortality burden. In light of more recent evidence, SGLT2 inhibitors are currently recommended as first-line therapy in managing patients with HF, regardless of ejection fraction, to reduce HF burden. The DAPA-HF and DELIVER trials, and particularly, the pooled analysis of both studies, have shown that dapagliflozin significantly reduces the risk of cardiovascular death, all-cause death, total HF hospitalizations, and MACE in the whole spectrum of HF, with sustained benefits over time. Recent data have shown that the full implementation of dapagliflozin in clinical practice would translate into a robust reduction in hospitalizations for HF and death in real-life populations. Many pathophysiological mechanisms have been involved in these benefits, particularly the positive effects of dapagliflozin on reversing cardiac (atrial and ventricular) remodeling, reducing cardiac fibrosis and inflammation, and improving endothelial dysfunction. In this manuscript, we reviewed from a practical point of view the role of dapagliflozin in the management of the whole spectrum of patients with HF.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, University Hospital La Paz, 28046 Madrid, Spain
| | - Domingo Pascual-Figal
- Cardiology Department, Hospital Clinico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
- Spanish National Cardiovascular Research Centre (CNIC), 28029 Madrid, Spain
- Department of Medicine, Universidad de Murcia, 30100 Murcia, Spain
| | - Luis Manzano
- Internal Medicine Department, University Hospital Ramon y Cajal, Alcala de Henares University, 28034 Madrid, Spain;
| | - Julio Nuñez
- Cardiology Department, University Hospital Clínico of Valencia, Instituto de Investigación Sanitaria (INCLIVA), 46010 Valencia, Spain;
- CIBER Cardiovascular, 28029 Madrid, Spain
| | - Miguel Camafort
- Internal Medicine Department, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
- CIBER OBN, ISCIII (Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III), 28222 Madrid, Spain
- Working Group of Cardiovascular Risk, Nutrition, and Aging, IDIBAPS (Instituto de Investigaciones Biomédicas August Pi i Sunyer), 08036 Barcelona, Spain
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21
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Prosperi S, D’Amato A, Severino P, Myftari V, Monosilio S, Marchiori L, Zagordi LM, Filomena D, Di Pietro G, Birtolo LI, Badagliacca R, Mancone M, Maestrini V, Vizza CD. Sizing SGLT2 Inhibitors Up: From a Molecular to a Morpho-Functional Point of View. Int J Mol Sci 2023; 24:13848. [PMID: 37762152 PMCID: PMC10530908 DOI: 10.3390/ijms241813848] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/30/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i), or gliflozins, have recently been shown to reduce cardiovascular death and hospitalization in patients with heart failure, representing a revolutionary therapeutic tool. The purpose of this review is to explore their multifaceted mechanisms of actions, beyond their known glucose reduction power. The cardioprotective effects of gliflozins seem to be linked to the maintenance of cellular homeostasis and to an action on the main metabolic pathways. They improve the oxygen supply for cardiomyocytes with a considerable impact on both functional and morphological myocardial aspects. Moreover, multiple molecular actions of SGLT2i are being discovered, such as the reduction of both inflammation, oxidative stress and cellular apoptosis, all responsible for myocardial damage. Various studies showed controversial results concerning the role of SGLT2i in reverse cardiac remodeling and the lowering of natriuretic peptides, suggesting that their overall effect has yet to be fully understood. In addition to this, advanced imaging studies evaluating the effect on all four cardiac chambers are lacking. Further studies will be needed to better understand the real impact of their administration, their use in daily practice and how they can contribute to benefits in terms of reverse cardiac remodeling.
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Affiliation(s)
| | - Andrea D’Amato
- Correspondence: ; Tel.: +39-06-49979021; Fax: +39-06-49979060
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22
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Xanthopoulos A, Katsiadas N, Skoularigkis S, Magouliotis DE, Skopeliti N, Patsilinakos S, Briasoulis A, Triposkiadis F, Skoularigis J. Association between Dapagliflozin, Cardiac Biomarkers and Cardiac Remodeling in Patients with Diabetes Mellitus and Heart Failure. Life (Basel) 2023; 13:1778. [PMID: 37629635 PMCID: PMC10455594 DOI: 10.3390/life13081778] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a relatively new class of antidiabetic drugs that have shown favorable effects in heart failure (HF) patients, irrespective of the left ventricular ejection fraction (LVEF). Recent studies have demonstrated the beneficial effects of empagliflozin on cardiac function and structure; however, less is known about dapagliflozin. The purpose of the current work was to investigate the association between the use of dapagliflozin and cardiac biomarkers as well as the cardiac structure in a cohort of patients with HF and diabetes mellitus (DM). The present work was an observational study that included 118 patients (dapagliflozin group n = 60; control group n = 58) with HF and DM. The inclusion criteria included: age > 18 years, a history of DM and HF, regardless of LVEF, and hospitalization for HF exacerbation within the previous 6 months. The exclusion criteria were previous treatment with SGLT2i or glucagon-like peptide-1 receptor agonists, a GFR< 30 and life expectancy < 1 year. The evaluation of patients (at baseline, 6 and 12 months) included a clinical assessment, laboratory blood tests and echocardiography. The Mann-Whitney test was used for the comparison of continuous variables between the two groups, while Friedman's analysis of variance for repeated measures was used for the comparison of continuous variables. Troponin (p < 0.001) and brain natriuretic peptide (BNP) (p < 0.001) decreased significantly throughout the follow-up period in the dapagliflozin group, but not in the control group (p > 0.05 for both). The LV end-diastolic volume index (p < 0.001 for both groups) and LV end-systolic volume index (p < 0.001 for both groups) decreased significantly in the dapagliflozin and the control group, respectively. The LVEF increased significantly (p < 0.001) only in the dapagliflozin group, whereas the global longitudinal strain (GLS) improved in the dapagliflozin group (p < 0.001) and was impaired in the control group (p = 0.021). The left atrial volume index decreased in the dapagliflozin group (p < 0.001) but remained unchanged in the control group (p = 0.114). Lastly, the left ventricular mass index increased significantly both in the dapagliflozin (p = 0.003) and control group (p = 0.001). Dapagliflozin, an SGLT2i, was associated with a reduction in cardiac biomarkers and with reverse cardiac remodeling in patients with HF and DM.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | - Nikolaos Katsiadas
- Department of Cardiology, Konstantopoulio General Hospital, 14233 Nea Ionia, Greece
| | - Spyridon Skoularigkis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 41110 Larissa, Greece;
| | - Niki Skopeliti
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | | | - Alexandros Briasoulis
- Department of Therapeutics, Heart Failure and Cardio-Oncology Clinic, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Filippos Triposkiadis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
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23
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Strachinaru M, Roussoulières A, Manintveld OC. Sodium-glucose cotransporter 2 inhibitors for chronic heart failure: The ultimate solution? Eur J Heart Fail 2023; 25:1361-1363. [PMID: 37349853 DOI: 10.1002/ejhf.2942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/18/2023] [Indexed: 06/24/2023] Open
Affiliation(s)
- Mihai Strachinaru
- Department of Cardiology, Pulmonary Vascular Diseases and Heart failure Clinic, Brussels University Hospital-Erasme Hospital, Brussels, Belgium
- Department of Cardiology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ana Roussoulières
- Department of Cardiology, Pulmonary Vascular Diseases and Heart failure Clinic, Brussels University Hospital-Erasme Hospital, Brussels, Belgium
| | - Olivier C Manintveld
- Department of Cardiology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Rotterdam, The Netherlands
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24
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Tomasoni D, Adamo M, Metra M. August 2023 at a glance: Focus on epidemiology and medical therapy. Eur J Heart Fail 2023; 25:1177-1180. [PMID: 37644646 DOI: 10.1002/ejhf.3004] [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: 08/31/2023] 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
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