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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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Nardone M, Sridhar VS, Yau K, Odutayo A, Cherney DZI. Proximal versus distal diuretics in congestive heart failure. Nephrol Dial Transplant 2024; 39:1392-1403. [PMID: 38425090 PMCID: PMC11361814 DOI: 10.1093/ndt/gfae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Indexed: 03/02/2024] Open
Abstract
Volume overload represents a hallmark clinical feature linked to the development and progression of heart failure (HF). Alleviating signs and symptoms of volume overload represents a foundational HF treatment target that is achieved using loop diuretics in the acute and chronic setting. Recent work has provided evidence to support guideline-directed medical therapies, such as sodium glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor (MR) antagonists, as important adjunct diuretics that may act synergistically when used with background loop diuretics in people with chronic HF. Furthermore, there is growing interest in understanding the role of SGLT2 inhibitors, carbonic anhydrase inhibitors, thiazide diuretics, and MR antagonists in treating volume overload in patients hospitalized for acute HF, particularly in the setting of loop diuretic resistance. Thus, the current review demonstrates that: (i) SGLT2 inhibitors and MR antagonists confer long-term cardioprotection in chronic HF patients but it is unclear whether natriuresis or diuresis represents the primary mechanisms for this benefit, (ii) SGLT2 inhibitors, carbonic anhydrase inhibitors, and thiazide diuretics increase natriuresis in the acute HF setting, but implications on long-term outcomes remain unclear and warrants further investigation, and (iii) a multi-nephron segment approach, using agents that act on distinct segments of the nephron, potentiate diuresis to alleviate signs and symptoms of volume overload in acute HF.
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Affiliation(s)
- Massimo Nardone
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Vikas S Sridhar
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Kevin Yau
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Ayodele Odutayo
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - David Z I Cherney
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
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Lim JH, Kwon S, Seo YJ, Kim YH, Kwon H, Kim YS, Lee H, Kim YL, Kim CD, Park SH, Hwang D, Yun WS, Kim HK, Huh S, Lee JS, Yoo KD, Jeong JC, Lee J, Lee JP, Cho JH. Cardioprotective Effect of SGLT2 Inhibitor in Diabetic Kidney Transplant Recipients: A Multicenter Propensity Score Matched Study. Kidney Int Rep 2024; 9:2474-2483. [PMID: 39156155 PMCID: PMC11328785 DOI: 10.1016/j.ekir.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/09/2024] [Accepted: 05/20/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction Kidney transplantation (KT) improves the cardiovascular outcomes of patients with end-stage kidney disease. However, cardiovascular disease remains the leading cause of premature death and graft loss in KT recipients (KTRs) with diabetes. We evaluated the cardioprotective effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in KTRs with diabetes. Methods A total of 750 KTRs with diabetes were enrolled from 6 tertiary hospitals. Among them, 129 patients (17.2%) were prescribed SGLT2i. The primary outcome was the incidence of major adverse cardiovascular events (MACE), which comprised myocardial infarction (MI), death from cardiovascular causes, hospitalization for heart failure, and stroke. Multivariable Cox regression analysis and propensity score matching were used to investigate the effect of SGLT2i on clinical outcomes. Results In the matched cohort, MACE occurred in 5 patients (3.9%) in the SGLT2i group and 15 patients (11.8%) in the non-SGLT2i group, out of 127 patients in each group over 55.3 months. The incidence of MACE and MI was lower in the SGLT2i group than in the non-SGLT2i group (P = 0.036 and 0.008, respectively). In multivariate analysis, the SGLT2i group had a lower risk of MACE and MI than the non-SGLT2i group (adjusted hazard ratio [HR], 0.30 and 0.04; 95% confidence interval [CI], 0.10-0.88 and 0.004-0.40; P = 0.028 and 0.006, respectively). There was no difference in the incidence of urinary tract infection (UTI) between the 2 groups. Conclusion SGLT2i significantly decreased the risk of cardiovascular events in KTRs with diabetes, particularly lowering the incidence of MI and death from cardiovascular causes. SGLT2i can be used to reduce the burden of cardiovascular disease in KTRs with diabetes.
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Affiliation(s)
- Jeong-Hoon Lim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Soie Kwon
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Yu Jin Seo
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Young Hoon Kim
- Division of Kidney Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyunwook Kwon
- Division of Kidney Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Deokbi Hwang
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Woo-Sung Yun
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Hyung-Kee Kim
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Seung Huh
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jong Soo Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Kyung Don Yoo
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
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Liang B, Tang Y, Chen Q, Zhong J, Peng B, Sun J, Wu T, Zeng X, Feng Y, Yu Z, Zha L. Association between early central venous pressure measurement and all-cause mortality in critically ill patients with heart failure: A cohort of 11,241 patients. Heliyon 2024; 10:e33599. [PMID: 39040401 PMCID: PMC11260926 DOI: 10.1016/j.heliyon.2024.e33599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/13/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Background The timing of central venous pressure (CVP) measurement may play a crucial role in heart failure management, yet no studies have explored this aspect. Methods Clinical information pertaining to patients in critical condition with a diagnosis of heart failure was retrieved from the MIMIC-IV database. The association between initial measurements of central venous pressure (CVP) and the incidence of mortality from all causes was analyzed using the Cox proportional hazards approach. Subgroup analysis and propensity score matching were conducted for sensitivity analyses. Results This study included 11,241 participants (median age, 75 years; 44.70 % female). Utilizing restricted cubic spline and Kaplan-Meier survival analyses, it was determined that prognostic outcomes were better when CVP was measured within the initial 5-h window. Multivariate-adjusted 1-year (HR: 0.69; 95 % CI: 0.61-0.77), 90-day (HR: 0.70; 95 % CI: 0.62-0.80), and 30-day (HR: 0.67; 95 % CI: 0.57-0.78) all-cause mortalities were significantly lower in patients with early CVP measurement, which was proved robustly in subgroup analysis. Subsequent to the application of propensity score matching, a cohort of 1536 matched pairs was established, with the observed mortality rates continuing to be significantly lower among participants who underwent early CVP assessment. Conclusions Early CVP measurement (within 5 h) demonstrated an independent correlation with a decrease in both immediate and extended all-cause mortality rates among patients in critical condition suffering from heart failure.
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Affiliation(s)
- Benhui Liang
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yiyang Tang
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qin Chen
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiahong Zhong
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Baohua Peng
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jing Sun
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tingting Wu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaofang Zeng
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yilu Feng
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zaixin Yu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders (Xiang Ya), Changsha, Hunan, China
| | - Lihuang Zha
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders (Xiang Ya), Changsha, Hunan, China
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Hassan A, Samaan K, Asfour A, Baghdady Y, Samaan AA. Ventricular remodeling and hemodynamic changes in heart failure patients with non-ischemic dilated cardiomyopathy following dapagliflozin initiation. Egypt Heart J 2024; 76:76. [PMID: 38888761 PMCID: PMC11189362 DOI: 10.1186/s43044-024-00508-z] [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: 04/04/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND In heart failure with reduced ejection fraction (HFrEF), sodium-glucose co-transporter inhibitors (SGLT-2i) have persistently shown cardiovascular benefits through different trials. However, their impact on ventricular remodeling and cardiac hemodynamics has not been sufficiently studied. This study aimed to study how SGLT-2i initiation affects invasive hemodynamics and cardiac magnetic resonance imaging (CMR)-derived ventricular volumes, function, and fraction of the extracellular volume (ECV) in HFrEF patients with non-ischemic dilated cardiomyopathy (NIDCM). RESULTS In this study, 23 patients with HFrEF and a mean age of 42, including 82.6% males, all have NIDCM and underwent right heart catheterization and CMR at the initiation of dapagliflozin and at 6-month follow-up. The addition of dapagliflozin resulted in significant reductions in the following invasive hemodynamic parameters compared to baseline: left ventricular end-diastolic pressure (23.4 vs 19.7 mmHg, p = 0.003), mean pulmonary artery pressure (31.3 vs 27.7 mmHg, p = 0.03), and systemic vascular resistance (18 vs 15 Wood units, p = 0.047). Among the studied CMR-derived measurements, only the percentage of extracellular volume fraction was significantly less at follow-up (33.7 vs 32.16%, p = 0.001). Additionally, functional class showed significant improvement with a notable reduction of the NT-proBNP level and a considerable decrease in diuretic dose (median: 40 vs 80 mg, p = 0.01). CONCLUSION Adding dapagliflozin to patients with HFrEF due to NIDCM improved invasively measured hemodynamics and significantly reduced left ventricular extracellular volume fraction measured by CMR, with no significant change in ventricular volumes or ejection fraction.
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Affiliation(s)
- Ahmed Hassan
- Department of Cardiovascular Medicine, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Kerollos Samaan
- Department of Cardiovascular Medicine, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Asfour
- Department of Cardiovascular Medicine, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yasser Baghdady
- Department of Cardiovascular Medicine, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amir Anwar Samaan
- Department of Cardiovascular Medicine, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Karakasis P, Patoulias D, Giannakoulas G, Rosenkranz S, Fragakis N. Effect of sodium-glucose cotransporter-2 inhibitors on pulmonary arterial wedge pressure. Eur J Intern Med 2024; 124:147-149. [PMID: 38458878 DOI: 10.1016/j.ejim.2024.03.003] [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: 01/24/2024] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital Hippokration, Thessaloniki, Greece.
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Aristotle University of Thessaloniki, General Hospital Hippokration, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital Hippokration, Thessaloniki, Greece
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Berg-Hansen K, Gopalasingam N, Christensen KH, Ladefoged B, Andersen MJ, Poulsen SH, Borlaug BA, Nielsen R, Møller N, Wiggers H. Cardiovascular Effects of Oral Ketone Ester Treatment in Patients With Heart Failure With Reduced Ejection Fraction: A Randomized, Controlled, Double-Blind Trial. Circulation 2024; 149:1474-1489. [PMID: 38533643 PMCID: PMC11081479 DOI: 10.1161/circulationaha.123.067971] [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: 11/14/2023] [Accepted: 03/05/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Heart failure triggers a shift in myocardial metabolic substrate utilization, favoring the ketone body 3-hydroxybutyrate as energy source. We hypothesized that 14-day treatment with ketone ester (KE) would improve resting and exercise hemodynamics and exercise capacity in patients with heart failure with reduced ejection fraction. METHODS In a randomized, double-blind cross-over study, nondiabetic patients with heart failure with reduced ejection fraction received 14-day KE and 14-day isocaloric non-KE comparator regimens of 4 daily doses separated by a 14-day washout period. After each treatment period, participants underwent right heart catheterization, echocardiography, and blood sampling at plasma trough levels and after dosing. Participants underwent an exercise hemodynamic assessment after a second dosing. The primary end point was resting cardiac output (CO). Secondary end points included resting and exercise pulmonary capillary wedge pressure and peak exercise CO and metabolic equivalents. RESULTS We included 24 patients with heart failure with reduced ejection fraction (17 men; 65±9 years of age; all White). Resting CO at trough levels was higher after KE compared with isocaloric comparator (5.2±1.1 L/min versus 5.0±1.1 L/min; difference, 0.3 L/min [95% CI, 0.1-0.5), and pulmonary capillary wedge pressure was lower (8±3 mm Hg versus 11±3 mm Hg; difference, -2 mm Hg [95% CI, -4 to -1]). These changes were amplified after KE dosing. Across all exercise intensities, KE treatment was associated with lower mean exercise pulmonary capillary wedge pressure (-3 mm Hg [95% CI, -5 to -1] ) and higher mean CO (0.5 L/min [95% CI, 0.1-0.8]), significantly different at low to moderate steady-state exercise but not at peak. Metabolic equivalents remained similar between treatments. In exploratory analyses, KE treatment was associated with 18% lower NT-proBNP (N-terminal pro-B-type natriuretic peptide; difference, -98 ng/L [95% CI, -185 to -23]), higher left ventricular ejection fraction (37±5 versus 34±5%; P=0.01), and lower left atrial and ventricular volumes. CONCLUSIONS KE treatment for 14 days was associated with higher CO at rest and lower filling pressures, cardiac volumes, and NT-proBNP levels compared with isocaloric comparator. These changes persisted during exercise and were achieved on top of optimal medical therapy. Sustained modulation of circulating ketone bodies is a potential treatment principle in patients with heart failure with reduced ejection fraction. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05161650.
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Affiliation(s)
- Kristoffer Berg-Hansen
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
| | - Nigopan Gopalasingam
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
| | - Kristian Hylleberg Christensen
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
| | - Bertil Ladefoged
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
| | - Mads Jønsson Andersen
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic Hospital, Rochester, MN (B.A.B.)
| | - Roni Nielsen
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
| | - Niels Møller
- Department of Endocrinology and Metabolism (N.M.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
| | - Henrik Wiggers
- Department of Cardiology (K.B.-H., N.G., K.H.C., B.L., M.J.A., S.H.P., R.N., H.W.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark (K.B.-H., N.G., K.H.C., B.L., S.H.P., N.M., H.W.)
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Ameri P, Mercurio V, Pollesello P, Anker MS, Backs J, Bayes-Genis A, Borlaug BA, Burkhoff D, Caravita S, Chan SY, de Man F, Giannakoulas G, González A, Guazzi M, Hassoun PM, Hemnes AR, Maack C, Madden B, Melenovsky V, Müller OJ, Papp Z, Pullamsetti SS, Rainer PP, Redfield MM, Rich S, Schiattarella GG, Skaara H, Stellos K, Tedford RJ, Thum T, Vachiery JL, van der Meer P, Van Linthout S, Pruszczyk P, Seferovic P, Coats AJS, Metra M, Rosano G, Rosenkranz S, Tocchetti CG. A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function. Eur J Heart Fail 2024; 26:707-729. [PMID: 38639017 PMCID: PMC11182487 DOI: 10.1002/ejhf.3236] [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: 07/26/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.
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Affiliation(s)
- Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiac, Thoracic, and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Piero Pollesello
- Content and Communication, Branded Products, Orion Pharma, Espoo, Finland
| | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin (Campus CBF), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Backs
- Institute of Experimental Cardiology, University Hospital Heidelberg, University of Heidelberg and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS Ospedale San Luca, Milan, Italy
| | - Stephen Y Chan
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Frances de Man
- PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aránzazu González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Marco Guazzi
- University of Milan, Milan, Italy
- Cardiology Division, San Paolo University Hospital, Milan, Italy
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cristoph Maack
- Comprehensive Heart Failure Center (CHFC) and Medical Clinic I, University Clinic Würzburg, Würzburg, Germany
| | | | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Oliver J Müller
- Department of Internal Medicine V, University Hospital Schleswig-Holstein, and German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Zoltan Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Soni Savai Pullamsetti
- Department of Internal Medicine and Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig University, Giessen, Germany
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- Department of Medicine, St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | | | - Stuart Rich
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gabriele G Schiattarella
- Max-Rubner Center (CMR), Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Hall Skaara
- Pulmonary Hypertension Association Europe, Vienna, Austria
| | - Kostantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Heidelberg University, Mannheim, Germany
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site, Heidelberg and Mannheim, Germany
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Jean Luc Vachiery
- Department of Cardiology, Hopital Universitaire de Bruxelles Erasme, Brussels, Belgium
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité, BIH Center for Regenerative Therapies, University of Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK, partner site Berlin), Berlin, Germany
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade University Medical Center, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
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9
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McMurray JJV, Docherty KF, de Boer RA, Hammarstedt A, Kitzman DW, Kosiborod MN, Maria Langkilde A, Reicher B, Senni M, Shah SJ, Wilderäng U, Verma S, Solomon SD. Effect of Dapagliflozin Versus Placebo on Symptoms and 6-Minute Walk Distance in Patients With Heart Failure: The DETERMINE Randomized Clinical Trials. Circulation 2024; 149:825-838. [PMID: 38059368 DOI: 10.1161/circulationaha.123.065061] [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: 04/06/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors reduce the risk of worsening heart failure (HF) and cardiovascular death in patients with HF irrespective of left ventricular ejection fraction. It is important to determine whether therapies for HF improve symptoms and functional capacity. METHODS The DETERMINE (Dapagliflozin Effect on Exercise Capacity Using a 6-Minute Walk Test in Patients With Heart Failure) double-blind, placebo-controlled, multicenter trials assessed the efficacy of the sodium-glucose cotransporter 2 inhibitor dapagliflozin on the Total Symptom Score (TSS) and Physical Limitation Scale (PLS) of the Kansas City Cardiomyopathy Questionnaire (KCCQ) and 6-minute walk distance (6MWD) in 313 patients with HF with reduced ejection fraction (DETERMINE-Reduced) and in 504 patients with HF with preserved ejection fraction (DETERMINE-Preserved) with New York Heart Association class II or III symptoms and elevated natriuretic peptide levels. The primary outcomes were changes in the KCCQ-TSS, KCCQ-PLS, and 6MWD after 16 weeks of treatment. RESULTS Among the 313 randomized patients with HF with reduced ejection fraction, the median placebo-corrected difference in KCCQ-TSS from baseline at 16 weeks was 4.2 (95% CI, 1.0, 8.2; P=0.022) in favor of dapagliflozin. The median placebo-corrected difference in KCCQ-PLS was 4.2 (95% CI, 0.0, 8.3; P=0.058). The median placebo-corrected difference in 6MWD from baseline at 16 weeks was 3.2 meters (95% CI, -6.5, 13.0; P=0.69). In the 504 patients with HF with preserved ejection fraction, the median placebo-corrected 16-week difference in KCCQ-TSS and KCCQ-PLS was 3.2 (95% CI, 0.4, 6.0; P=0.079) and 3.1 (-0.1, 5.4; P=0.23), respectively. The median 16-week difference in 6MWD was 1.6 meters (95% CI, -5.9, 9.0; P=0.67). In an exploratory post hoc analysis of both trials combined (DETERMINE-Pooled), the median placebo-corrected difference from baseline at 16 weeks was 3.7 (1.5, 5.9; P=0.005) for KCCQ-TSS, 4.0 (0.3, 4.9; P=0.036) for KCCQ-PLS, and 2.5 meters (-3.5, 8.4; P=0.50) for 6MWD. CONCLUSIONS Dapagliflozin improved the KCCQ-TSS in patients with HF with reduced ejection fraction but did not improve KCCQ-PLS or 6MWD. Dapagliflozin did not improve these outcomes in patients with HF with preserved ejection fraction. In a post hoc analysis including all patients across the full spectrum of ejection fraction, there was a beneficial effect of dapagliflozin on KCCQ-TSS and KCCQ-PLS but not 6MWD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03877237 and NCT03877224.
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Affiliation(s)
- John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., K.F.D.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., K.F.D.)
| | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands (R.A.d.B.)
| | - Ann Hammarstedt
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Dalane W Kitzman
- Sections on Cardiovascular Medicine and Geriatrics/Gerontology, Wake Forest University School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Barry Reicher
- AstraZeneca BioPharmaceuticals Research & Development, Late-Stage Development, Cardiovascular, Renal and Metabolic, Gaithersburg, MD (B.R.)
| | - Michele Senni
- Cardiovascular Department, Papa Giovanni XXIII Hospital Bergamo, Italy (M.S.)
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Ulrica Wilderäng
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada (S.V.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.)
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10
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van de Bovenkamp AA, Geurkink KTJ, Oosterveer FT, de Man FS, Kok WE, Bronzwaer PN, Allaart CP, Nederveen AJ, van Rossum AC, Bakermans AJ, Handoko ML. Trimetazidine in heart failure with preserved ejection fraction: a randomized controlled cross-over trial. ESC Heart Fail 2023; 10:2998-3010. [PMID: 37530098 PMCID: PMC10567667 DOI: 10.1002/ehf2.14418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 08/03/2023] Open
Abstract
AIMS Impaired myocardial energy homeostasis plays an import role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). Left ventricular relaxation has a high energy demand, and left ventricular diastolic dysfunction has been related to impaired energy homeostasis. This study investigated whether trimetazidine, a fatty acid oxidation inhibitor, could improve myocardial energy homeostasis and consequently improve exercise haemodynamics in patients with HFpEF. METHODS AND RESULTS The DoPING-HFpEF trial was a phase II single-centre, double-blind, placebo-controlled, randomized cross-over trial. Patients were randomized to trimetazidine treatment or placebo for 3 months and switched after a 2-week wash-out period. The primary endpoint was change in pulmonary capillary wedge pressure, measured with right heart catheterization at multiple stages of bicycling exercise. Secondary endpoint was change in myocardial phosphocreatine/adenosine triphosphate, an index of the myocardial energy status, measured with phosphorus-31 magnetic resonance spectroscopy. The study included 25 patients (10/15 males/females; mean (standard deviation) age, 66 (10) years; body mass index, 29.8 (4.5) kg/m2 ); with the diagnosis of HFpEF confirmed with (exercise) right heart catheterization either before or during the trial. There was no effect of trimetazidine on the primary outcome pulmonary capillary wedge pressure at multiple levels of exercise (mean change 0 [95% confidence interval, 95% CI -2, 2] mmHg over multiple levels of exercise, P = 0.60). Myocardial phosphocreatine/adenosine triphosphate in the trimetazidine arm was similar to placebo (1.08 [0.76, 1.76] vs. 1.30 [0.95, 1.86], P = 0.08). There was no change by trimetazidine compared with placebo in the exploratory parameters: 6-min walking distance (mean change of -6 [95% CI -18, 7] m vs. -5 [95% CI -22, 22] m, respectively, P = 0.93), N-terminal pro-B-type natriuretic peptide (5 (-156, 166) ng/L vs. -13 (-172, 147) ng/L, P = 0.70), overall quality-of-life (KCCQ and EQ-5D-5L, P = 0.78 and P = 0.51, respectively), parameters for diastolic function measured with echocardiography and cardiac magnetic resonance, or metabolic parameters. CONCLUSIONS Trimetazidine did not improve myocardial energy homeostasis and did not improve exercise haemodynamics in patients with HFpEF.
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Affiliation(s)
- Arno A. van de Bovenkamp
- Department of CardiologyAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
| | - Kiki T. J. Geurkink
- Department of CardiologyAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Frank T.P. Oosterveer
- Department of Pulmonary MedicineAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Frances S. de Man
- Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
- Department of Pulmonary MedicineAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Wouter E.M. Kok
- Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
- Department of Clinical and Experimental CardiologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
| | | | - Cor P. Allaart
- Department of CardiologyAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
| | - Aart J. Nederveen
- Department of Radiology and Nuclear MedicineAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
| | - Albert C. van Rossum
- Department of CardiologyAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
| | - Adrianus J. Bakermans
- Department of Radiology and Nuclear MedicineAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
| | - M. Louis Handoko
- Department of CardiologyAmsterdam University Medical Centers, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Amsterdam Cardiovascular SciencesAmsterdamThe Netherlands
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11
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Borlaug BA, Reddy YNV, Braun A, Sorimachi H, Omar M, Popovic D, Alogna A, Jensen MD, Carter R. Cardiac and Metabolic Effects of Dapagliflozin in Heart Failure With Preserved Ejection Fraction: The CAMEO-DAPA Trial. Circulation 2023; 148:834-844. [PMID: 37534453 PMCID: PMC10529848 DOI: 10.1161/circulationaha.123.065134] [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: 04/11/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors reduce risk of hospitalization for heart failure in patients who have heart failure with preserved ejection fraction (HFpEF), but the hemodynamic mechanisms underlying these benefits remain unclear. This study sought to determine whether treatment with dapagliflozin affects pulmonary capillary wedge pressure (PCWP) at rest and during exercise in patients with HFpEF. METHODS This was a single-center, double-blinded, randomized, placebo-controlled trial testing the effects of 10 mg of dapagliflozin once daily in patients with HFpEF. Patients with New York Heart Association class II or III heart failure, ejection fraction ≥50%, and elevated PCWP during exercise were recruited. Cardiac hemodynamics were measured at rest and during exercise using high-fidelity micromanometers at baseline and after 24 weeks of treatment. The primary end point was a change from baseline in rest and peak exercise PCWPs that incorporated both measurements, and was compared using a mixed-model likelihood ratio test. Key secondary end points included body weight and directly measured blood and plasma volumes. Expired gas analysis was performed evaluate oxygen transport in tandem with arterial lactate sampling. RESULTS Among 38 patients completing baseline assessments (median age 68 years; 66% women; 71% obese), 37 completed the trial. Treatment with dapagliflozin resulted in reduction in the primary end point of change in PCWP at rest and during exercise at 24 weeks relative to treatment with placebo (likelihood ratio test for overall changes in PCWP; P<0.001), with lower PCWP at rest (estimated treatment difference [ETD], -3.5 mm Hg [95% CI, -6.6 to -0.4]; P=0.029) and maximal exercise (ETD, -5.7 mm Hg [95% CI, -10.8 to -0.7]; P=0.027). Body weight was reduced with dapagliflozin (ETD, -3.5 kg [95% CI, -5.9 to -1.1]; P=0.006), as was plasma volume (ETD, -285 mL [95% CI, -510 to -60]; P=0.014), but there was no significant effect on red blood cell volume. There were no differences in oxygen consumption at 20-W or peak exercise, but dapagliflozin decreased arterial lactate at 20 W (-0.70 ± 0.77 versus 0.37 ± 1.29 mM; P=0.006). CONCLUSIONS In patients with HFpEF, treatment with dapagliflozin reduces resting and exercise PCWP, along with the favorable effects on plasma volume and body weight. These findings provide new insight into the hemodynamic mechanisms of benefit with sodium-glucose cotransporter-2 inhibitors in HFpEF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04730947.
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Affiliation(s)
- Barry A. Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yogesh N. V. Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amanda Braun
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hidemi Sorimachi
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Gumma University Graduate School of Medicine, Maebashi, Gumma, Japan
| | - Massar Omar
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Dejana Popovic
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Cardiology, University Clinical Center of Serbia
| | - Alessio Alogna
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- German Heart Center of the Charité, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Michael D. Jensen
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Rickey Carter
- Department of Quantitative Health Sciences, Division of Clinical Trials & Biostatistics, Mayo Clinic, Jacksonville, Florida
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12
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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.
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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
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13
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Packer M. Lack of durable natriuresis and objective decongestion following SGLT2 inhibition in randomized controlled trials of patients with heart failure. Cardiovasc Diabetol 2023; 22:197. [PMID: 37533009 PMCID: PMC10399057 DOI: 10.1186/s12933-023-01946-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/28/2023] [Indexed: 08/04/2023] Open
Abstract
Patients with heart failure have increased cardiac filling pressures, circulating natriuretic peptides, and physical signs of fluid retention, which are related to sodium retention by the kidneys and are alleviated by conventional diuretics. Sodium-glucose cotransporter 2 (SGLT2) inhibitors interfere with sodium and glucose reabsorption in the proximal renal tubule, but they evoke a marked counterregulatory activation of sodium and water reabsorption in distal nephron segments, which opposes and negates any diuretic effect. Nevertheless, it has been postulated that SGLT2 inhibitors modulate the volume set point, leading selectively to decongestion in patients with fluid overload. This hypothesis was tested in a review of 15 randomized controlled trials of SGLT2 inhibitors in patients with heart failure, with 7 trials focusing on urinary volume within the first week, and 8 trials focusing on objective decongestion at 12 weeks. In trials < 1 week, SGLT2 inhibition increased urine volume in the first 24 h, but typically without a change in urinary sodium excretion, and this diuresis was not sustained. In 8 trials of 12 weeks' duration, none reported alleviation of edema, ascites or pulmonary rales. The 2 trials that evaluated changes in left ventricular filling pressure noted no or small changes (1-2 mm Hg); the two trials that measured interstitial lung water or total blood volume found no effect; and 6 of the 7 trials found no decrease in circulating natriuretic peptides. Therefore, randomized controlled trials do not indicate that SGLT2 inhibitors produce a durable natriuresis or objective decongestion in patients with heart failure.
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Affiliation(s)
- Milton Packer
- Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, TX, 75226, USA.
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14
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Böhm M, Butler J, Krawczyk M, Mahfoud F, Haring B, Filippatos G, Ferreira JP, Pocock SJ, Brueckmann M, Ofstad AP, Schüler E, Wanner C, Verma S, Packer M, Anker SD. Liver tests, cardiovascular outcomes and effects of empagliflozin in patients with heart failure and preserved ejection fraction: The EMPEROR-Preserved trial. Eur J Heart Fail 2023; 25:1375-1383. [PMID: 37278451 DOI: 10.1002/ejhf.2922] [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: 01/27/2023] [Revised: 04/17/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
AIM The prognostic implication of elevated liver tests in heart failure with preserved ejection fraction (HFpEF) is uncertain. This analysis investigates the association of liver markers with hospitalization for heart failure (HHF) and cardiovascular death (CVD), and the treatment effect of empagliflozin across the range of liver marker levels. METHODS AND RESULTS The double-blind, placebo-controlled EMPEROR-Preserved (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure with Preserved Ejection Fraction) enrolled 5988 patients with HFpEF (ejection fraction >40%). Patients in New York Heart Association class II-IV and elevated N-terminal pro-B-type natriuretic peptide were randomized to receive empagliflozin 10 mg daily or placebo in addition to usual therapy. Patients with significant liver disease were excluded. The primary endpoint was time to first adjudicated HHF or CVD. We explored the association of liver function abnormalities with heart failure outcomes in patients on placebo, the effects of empagliflozin on liver tests and the treatment effects of empagliflozin on heart failure outcomes across categories of liver laboratory values. High alkaline phosphatase (p trend < 0.0001), low albumin (p trend < 0.0001) and high bilirubin (p = 0.02) were associated with poorer outcomes for HHF or CVD, while high aspartate aminotransferase was not, and high alanine aminotransferase was associated with better outcomes. Empagliflozin had no significant effects on liver tests compared to placebo except for albumin which was significantly increased. The treatment effect of empagliflozin on outcomes was not modified by liver tests. CONCLUSION Abnormalities of liver function tests are associated differently with heart failure outcomes. Salutary effects of empagliflozin on liver tests were not observed although albumin increased. The treatment benefits of empagliflozin were not affected by baseline values of liver parameters.
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
- Cape Heart Institute, Cape Town, South Africa
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Marcin Krawczyk
- Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Bernhard Haring
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
- Cape Heart Institute, Cape Town, South Africa
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - João Pedro Ferreira
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Nancy, France
- Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- Cardiovascular R&D Centre - UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Anne Pernille Ofstad
- Medical Department, Boehringer Ingelheim Norway KS, Asker, Norway
- Oslo Diabetes Research Center, Oslo, Norway
| | | | - Christoph Wanner
- Medizinische Klinik und Poliklinik 1, Schwerpunkt Nephrologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, and Departments of Surgery, and Pharmacology and Toxicology, University of Toronto, Toronto, ONT, Canada
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - 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
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15
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Packer M, Wilcox CS, Testani JM. Critical Analysis of the Effects of SGLT2 Inhibitors on Renal Tubular Sodium, Water and Chloride Homeostasis and Their Role in Influencing Heart Failure Outcomes. Circulation 2023; 148:354-372. [PMID: 37486998 PMCID: PMC10358443 DOI: 10.1161/circulationaha.123.064346] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/25/2023] [Indexed: 07/26/2023]
Abstract
SGLT2 (sodium-glucose cotransporter 2) inhibitors interfere with the reabsorption of glucose and sodium in the early proximal renal tubule, but the magnitude and duration of any ensuing natriuretic or diuretic effect are the result of an interplay between the degree of upregulation of SGLT2 and sodium-hydrogen exchanger 3, the extent to which downstream compensatory tubular mechanisms are activated, and (potentially) the volume set point in individual patients. A comprehensive review and synthesis of available studies reveals several renal response patterns with substantial variation across studies and clinical settings. However, the common observation is an absence of a large acute or chronic diuresis or natriuresis with these agents, either when given alone or combined with other diuretics. This limited response results from the fact that renal compensation to these drugs is rapid and nearly complete within a few days or weeks, preventing progressive volume losses. Nevertheless, the finding that fractional excretion of glucose and lithium (the latter being a marker of proximal sodium reabsorption) persists during long-term treatment with SGLT2 inhibitors indicates that pharmacological tolerance to the effects of these drugs at the level of the proximal tubule does not meaningfully occur. This persistent proximal tubular effect of SGLT2 inhibitors can be hypothesized to produce a durable improvement in the internal set point for volume homeostasis, which may become clinically important during times of fluid expansion. However, it is difficult to know whether a treatment-related change in the volume set point actually occurs or contributes to the effect of these drugs to reduce the risk of major heart failure events. SGLT2 inhibitors exert cardioprotective effects by a direct effect on cardiomyocytes that is independent of the presence of or binding to SGLT2 or the actions of these drugs on the proximal renal tubule. Nevertheless, changes in the volume set point mediated by SGLT2 inhibitors might potentially act cooperatively with the direct favorable molecular and cellular effects of these drugs on cardiomyocytes to mediate their benefits on the development and clinical course of heart failure.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX (M.P.)
- Imperial College London, United Kingdom (M.P.)
| | - Christopher S. Wilcox
- Division of Nephrology and Hypertension, Kidney, and Vascular Research Center, Georgetown University, Washington, DC (C.S.W.)
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (J.M.T.)
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16
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Sfairopoulos D, Liu T, Zhang N, Tse G, Bazoukis G, Letsas K, Goudis C, Milionis H, Vrettos A, Korantzopoulos P. Association between sodium-glucose cotransporter-2 inhibitors and incident atrial fibrillation/atrial flutter in heart failure patients with reduced ejection fraction: a meta-analysis of randomized controlled trials. Heart Fail Rev 2023; 28:925-936. [PMID: 36282460 PMCID: PMC10289933 DOI: 10.1007/s10741-022-10281-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) and atrial flutter (AFL) are associated with adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF). We investigated the effects of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on the incidence of AF and/or AFL in HFrEF patients. PubMed and ClinicalTrials.gov were systematically searched until March 2022 for randomized controlled trials (RCTs) that enrolled patients with HFrEF. A total of six RCTs with 9467 patients were included (N = 4731 in the SGLT2i arms; N = 4736 in the placebo arms). Compared to placebo, SGLT2i treatment was associated with a significant reduction in the risk of AF [relative risk (RR) 0.62, 95% confidence interval CI 0.44-0.86; P = 0.005] and AF/AFL (RR 0.64, 95% CI 0.47-0.87; P = 0.004). Subgroup analysis showed that empagliflozin use resulted in a significant reduction in the risk of AF (RR 0.55, 95% CI 0.34-0.89; P = 0.01) and AF/AFL (RR 0.50, 95% CI 0.32-0.77; P = 0.002). By contrast, dapagliflozin use was not associated with a significant reduction in the risk of AF (RR 0.69, 95% CI 0.43-1.11; P = 0.12) or AF/AFL (RR 0.82, 95% CI 0.53-1.27; P = 0.38). Additionally, a "shorter" duration (< 1.5 years) of treatment with SGLT2i remained associated with a reduction in the risk of AF (< 1.5 years; RR 0.58, 95% CI 0.36-0.91; P = 0.02) and AF/AFL (< 1.5 years; RR 0.52, 95% CI 0.34-0.80; P = 0.003). In conclusion, SGLT2i therapy was associated with a significant reduction in the risk of AF and AF/AFL in patients with HFrEF. These results reinforce the value of using SGLT2i in this setting.
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Affiliation(s)
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Nan Zhang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
- Kent and Medway Medical School, Kent, UK
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
| | - Konstantinos Letsas
- Laboratory of Cardiac Electrophysiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Christos Goudis
- Department of Cardiology, Serres General Hospital, 45110, Serres, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Apostolos Vrettos
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK
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17
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Panico C, Bonora B, Camera A, Chilelli NC, Prato GD, Favacchio G, Grancini V, Resi V, Rondinelli M, Zarra E, Pintaudi B. Pathophysiological basis of the cardiological benefits of SGLT-2 inhibitors: a narrative review. Cardiovasc Diabetol 2023; 22:164. [PMID: 37391739 PMCID: PMC10314539 DOI: 10.1186/s12933-023-01855-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/10/2023] [Indexed: 07/02/2023] Open
Abstract
In recent years, GLP-1 receptor agonists (GLP-1RA), and SGLT-2 inhibitors (SGLT-2i) have become available, which have become valuable additions to therapy for type 2 diabetes as they are associated with low risk for hypoglycemia and cardiovascular benefits. Indeed, SGLT-2i have emerged as a promising class of agents to treat heart failure (HF). By inhibiting SGLT-2, these agents lead to excretion of glucose in urine with subsequent lowering of plasma glucose, although it is becoming clear that the observed benefits in HF cannot be explained by glucose-lowering alone. In fact, multiple mechanisms have been proposed to explain the cardiovascular and renal benefits of SGLT-2i, including hemodynamic, anti-inflammatory, anti-fibrotic, antioxidant, and metabolic effects. Herein, we review the available evidence on the pathophysiology of the cardiological benefits of SGLT-2i. In diabetic heart disease, in both clinical and animal models, the effect of SGLT-2i have been shown to improve diastolic function, which is even more evident in HF with preserved ejection fraction. The probable pathogenic mechanisms likely involve damage from free radicals, apoptosis, and inflammation, and therefore fibrosis, many of which have been shown to be improved by SGLT-2i. While the effects on systolic function in models of diabetic heart disease and HF with preserved ejection fraction is limited and contrasting, it is a key element in patients with HF and reduced ejection fraction both with and without diabetes. The significant improvement in systolic function appears to lead to subsequent structural remodeling of the heart with a reduction in left ventricle volume and a consequent reduction in pulmonary pressure. While the effects on cardiac metabolism and inflammation appear to be consolidated, greater efforts are still warranted to further define the entity to which these mechanisms contribute to the cardiovascular benefits of SGLT-2i.
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Affiliation(s)
- Cristina Panico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | - Benedetta Bonora
- Department of Medicine, Division of Metabolic Diseases, University of Padova, Via Giustiniani 2, Padua, 35128, Italy
| | | | - Nino Cristiano Chilelli
- Diabetology and Internal Medicine, Hospital of Cittadella, AULSS 6 Euganea (Padua), Padua, Italy
| | - Giuliana Da Prato
- Divisione di Endocrinologia, Diabetologia e Malattie del Metabolismo, Dipartimento di Medicina, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Maggiore, Verona, Italy
| | - Giuseppe Favacchio
- U.O di Endocrinologia e Diabetologia, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Valeria Grancini
- Endocrinology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Veronica Resi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Rondinelli
- Diabetes Endocrine and Metabolic Diseases Unit, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Emanuela Zarra
- S.C. Medicina Diabetologia, Dipartimento di Continuità di Cura e Fragilità, ASST Spedali Civili, Brescia, Italy
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18
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Zhu Y, Zhang JL, Jin H, Ji Y, Wang FF. The effect of SGLT2i on in-hospital acute heart failure risk in acute myocardial infarction patients-a retrospective study. Front Cardiovasc Med 2023; 10:1158507. [PMID: 37260943 PMCID: PMC10228823 DOI: 10.3389/fcvm.2023.1158507] [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: 02/15/2023] [Accepted: 05/03/2023] [Indexed: 06/02/2023] Open
Abstract
Background and aims The roles of sodium-glucose cotransporter 2 inhibitor (SGLT2i) in acute heart failure (AHF) risk after acute myocardial infarction (AMI) remain unclear. In this study, we explored the correlation between SGLT2i administration and short-term in-hospital AHF risk in AMI patients. Methods This single-center, retrospective, and observational study included 990 AMI patients comprising 386 non-ST-segment elevation myocardial infarction (NSTEMI) and 604 segment elevation myocardial infarction (STEMI) patients enrolled from January 2019 to March 2022. Demographic information, clinical characteristics, medical treatment, and laboratory examination results during hospitalization were extracted from an electronic medical record system. The primary outcome was defined as all-cause AHF during hospitalization. Results In NSTEMI patients, a significantly lower proportion received SGLT2i treatment in the AHF group compared with the non-AHF group. During hospitalization, SGLT2i significantly reduced brain natriuretic peptide levels both in STEMI and NSTEMI patients. Multivariate logistic regression and stratification analyses suggested that SGLT2i is associated with reduced in-hospital AHF risk, and has a strong protective effect against AHF in NSTEMI patients with hypertension. Furthermore, SGLT2i significantly reduced the risk of in-hospital AHF for both patients with diabetes and non-diabetes. Conclusions SGLT2i can reduce the risk of AHF in AMI patients during hospitalization.
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Affiliation(s)
- Yi Zhu
- Department of Cardiology, The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Jia-li Zhang
- Department of Gastroenterology Centre, The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Hong Jin
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuan Ji
- Department of Cardiology, The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Fang-fang Wang
- Department of Cardiology, The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University, Changzhou, China
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19
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Garascia A, Palazzini M, Tedeschi A, Sacco A, Oliva F, Gentile P. Advanced heart failure: from definitions to therapeutic options. Eur Heart J Suppl 2023; 25:C283-C291. [PMID: 37125285 PMCID: PMC10132575 DOI: 10.1093/eurheartjsupp/suad028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Advanced heart failure (AHF) represents an ominous stage of heart failure (HF), where the expected prognosis remains poor regardless of the improvement in medical knowledge. In this review, we summarize the definition, prognosis, physiopathology, and clinical/therapeutic management of the disease, focusing on the fast and timely referral of the patient to the AHF facilities. We provide an insight of the diagnostic and therapeutic 'work up' performed in an Italian AHF hub, implying a deep phenotypical patients characterization in order to evaluate candidacy to the therapeutic gold standards as heart transplantation (HTx) and left ventricular assist device (LVAD).
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Affiliation(s)
- Andrea Garascia
- De Gasperis Cardio Center, Ospedale Niguarda, Piazza Ospedale Maggiore 3, Milano, Italia
| | - Matteo Palazzini
- De Gasperis Cardio Center, Ospedale Niguarda, Piazza Ospedale Maggiore 3, Milano, Italia
| | - Andrea Tedeschi
- De Gasperis Cardio Center, Ospedale Niguarda, Piazza Ospedale Maggiore 3, Milano, Italia
| | - Alice Sacco
- De Gasperis Cardio Center, Ospedale Niguarda, Piazza Ospedale Maggiore 3, Milano, Italia
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Ospedale Niguarda, Piazza Ospedale Maggiore 3, Milano, Italia
| | - Piero Gentile
- De Gasperis Cardio Center, Ospedale Niguarda, Piazza Ospedale Maggiore 3, Milano, Italia
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20
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Oates CP, Santos-Gallego CG, Smith A, Basyal B, Moss N, Kawamura I, Musikantow DR, Turagam MK, Miller MA, Whang W, Dukkipati SR, Reddy VY, Koruth JS. SGLT2 inhibitors reduce sudden cardiac death risk in heart failure: Meta-analysis of randomized clinical trials. J Cardiovasc Electrophysiol 2023; 34:1277-1285. [PMID: 36950852 DOI: 10.1111/jce.15894] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/15/2023] [Accepted: 03/20/2023] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Multiple randomized controlled trials have demonstrated sodium-glucose cotransporter-2 inhibitors (SGLT2i) decrease the composite endpoint of cardiovascular death or heart failure hospitalizations in all heart failure patients. It is uncertain whether SGLT2i impacts the risk of sudden cardiac death in patients with heart failure. METHODS A comprehensive search was performed to identify relevant data published before August 28, 2022. Trials were included if: (1) all patients had clinical heart failure (2) SGLT2i and placebo were compared (3) all patients received conventional medical therapy and (4) reported outcomes of interest (sudden cardiac death [SCD], ventricular arrhythmias, atrial arrhythmias). RESULTS SCD was reported in seven of the eleven trials meeting selection criteria: 10 796 patients received SGLT2i and 10 796 received placebo. SGLT2i therapy was associated with a significant reduction in the risk of SCD (risk ratios [RR]: 0.68; 95% confidence intervals [CI]: 0.48-0.95; p = .03; I2 = 0%). Absent dedicated rhythm monitoring, there were no significant differences in the incidence of sustained ventricular arrhythmias not associated with SCD (RR: 1.03; 95% CI: 0.83-1.29; p = .77; I2 = 0%) or atrial arrhythmias (RR: 0.91; 95% CI: 0.77-1.09; p = .31; I2 = 29%) between patients receiving an SGLT2i versus placebo. CONCLUSION SGLT2i therapy is associated with a reduced risk of SCD in patients with heart failure receiving contemporary medical therapy. Prospective trials are needed to determine the long-term impact of SGLT2i therapy on atrial and ventricular arrhythmias.
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Affiliation(s)
- Connor P Oates
- MedStar Heart and Vascular Institute, Georgetown University-Washington Hospital Center, Washington, District of Columbia, USA
| | - Carlos G Santos-Gallego
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex Smith
- MedStar Heart and Vascular Institute, Georgetown University-Washington Hospital Center, Washington, District of Columbia, USA
| | - Binaya Basyal
- MedStar Heart and Vascular Institute, Georgetown University-Washington Hospital Center, Washington, District of Columbia, USA
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Iwanari Kawamura
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel R Musikantow
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohit K Turagam
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marc A Miller
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Whang
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Srinivas R Dukkipati
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacob S Koruth
- Helmsley Center for Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Khan J, Graham FJ, Masini G, Iaconelli A, Friday JM, Lang CC, Pellicori P. Congestion and Use of Diuretics in Heart Failure and Cardiomyopathies: a Practical Guide. Curr Cardiol Rep 2023; 25:411-420. [PMID: 37074565 DOI: 10.1007/s11886-023-01865-y] [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] [Accepted: 03/19/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE OF REVIEW Heart failure is a highly prevalent condition caused by many different aetiologies and characterised by cardiac dysfunction and congestion. Once developed, congestion leads to signs (peripheral oedema) and symptoms (breathlessness on exertion), adverse cardiac remodelling, and an increased risk of hospitalisation and premature death. This review summarises strategies that could enable early identification and a more objective management of congestion in patients with heart failure. RECENT FINDINGS For patients with suspected or diagnosed heart failure, combining an echocardiogram with assessment of great veins, lungs, and kidneys by ultrasound might facilitate recognition and quantification of congestion, the management of which is still difficult and highly subjective. Congestion is a one of the key drivers of morbidity and mortality in patients with heart failure and is often under-recognised. The use of ultrasound allows for a timely, simultaneous identification of cardiac dysfunction and multiorgan congestion; ongoing and future studies will clarify how to tailor diuretic treatments in those with or at risk of heart failure.
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Affiliation(s)
| | - Fraser J Graham
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Gabriele Masini
- Cardiothoracic and Vascular Department, University of Pisa, Pisa, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Jocelyn M Friday
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Chim C Lang
- NHS Tayside, Dundee, UK
- Department of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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22
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Oduah MT, Sundaram V, Reddy YNV. Epicardial Fat in Heart Failure with Preserved Ejection Fraction: Bad Actor or Just Lying Around? Card Fail Rev 2023; 9:e06. [PMID: 37397241 PMCID: PMC10311396 DOI: 10.15420/cfr.2022.25] [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: 08/04/2022] [Accepted: 11/04/2022] [Indexed: 07/04/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly recognised to be strongly associated with obesity and abnormalities in fat distribution. Epicardial fat has been associated with abnormal haemodynamics in HFpEF, with potential for direct mechanical effects on the heart causing constriction-like physiology and local myocardial remodelling effects from secretion of inflammatory and profibrotic mediators. However, patients with epicardial fat generally have more systemic and visceral adipose tissue making determination of causality between epicardial fat and HFpEF complex. In this review, we will summarise the evidence for epicardial fat being either directly causal in HFpEF pathogenesis or merely being a correlate of worse systemic inflammatory and generalised adiposity. We will also discuss therapies that directly target epicardial fat and may have potential for treating HFpEF and elucidating the independent role of epicardial fat in its pathogenesis.
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Affiliation(s)
| | - Varun Sundaram
- Division of Cardiovascular Diseases, Louis Stokes Cleveland Department of Veterans Affairs Medical CenterCleveland, OH, US
| | - Yogesh NV Reddy
- Department of Cardiovascular Disease, Mayo ClinicRochester, MN, US
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23
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Rask KA, Deis T, Larsson JE, Rossing K, Gustafsson F. Hyponatremia in Stable Patients with Advanced Heart Failure: Association to Hemodynamics and Outcome. Cardiology 2023; 148:187-194. [PMID: 36972577 DOI: 10.1159/000529967] [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: 09/27/2022] [Accepted: 02/27/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Hyponatremia is associated with worse outcomes in patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF). However, it is unclear whether the worse prognosis is driven by hemodynamic derangement and how this potentially could be associated with hyponatremia. METHODS The study included 502 patients with HFrEF evaluated for advanced HF therapies, who underwent a right heart catheterization (RHC). Hyponatremia was defined as p-Na ≤136 mmol/L. The risk of all-cause mortality and a composite endpoint including mortality, left ventricular assist device (LVAD) implantation, implantation of total artificial heart (TAH), or heart transplantation (HTx) was evaluated using Cox regression analyses and Kaplan-Meier models. RESULTS Included patients were predominantly men 79% and had a median age of 54 years (IQR: 43-62). A third (165) of the patients had hyponatremia. In both univariate and multivariate regression analyses, p-Na was associated with increased central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and mean pulmonary artery pressure (mPAP) but not with cardiac index. Hyponatremia was significantly associated with the combined endpoint (HR: 1.36 [95% CI, 1.07-1.74]; p = 0.01), but not all-cause mortality in adjusted Cox models. CONCLUSION In stable HFrEF patients evaluated for advanced HF therapies, lower p-Na was associated with more deranged invasive hemodynamic measurements. Hyponatremia remained significantly associated with the combined endpoint but not all-cause mortality in adjusted Cox models. The study suggests that the increased mortality associated with hyponatremia in HFrEF patients could partly be driven by hemodynamic derangement.
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Affiliation(s)
- Karoline Amalie Rask
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Tania Deis
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Johan Erik Larsson
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
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24
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Heegaard B, Deis T, Rossing K, Ersbøll M, Kistorp C, Gustafsson F. Diabetes mellitus and hemodynamics in advanced heart failure. Int J Cardiol 2023; 379:60-65. [PMID: 36907448 DOI: 10.1016/j.ijcard.2023.03.015] [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: 01/30/2023] [Revised: 02/24/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The presence of diabetes in patients with heart failure (HF) is associated with a worse prognosis. It is unclear if hemodynamics in HF patients with DM differ from those of non-diabetic patients and how this might influence outcome. This study aims to discover the impact of DM on hemodynamics in HF patients. METHODS Consecutive patients (n = 598) with HF and reduced ejection fraction (LVEF ≤40%) undergoing invasive hemodynamic evaluation were included (non-DM: n = 473, DM: n = 125). Hemodynamic parameters included pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), cardiac index (CI) and mean arterial pressure (MAP). Mean follow-up was 9.5 ± 5.1 years. RESULTS Patients with DM (82.7% male, mean age 57.1 ± 10.1 years, mean HbA1c 60 ± 21 mmol/mol) had higher PCWP, mPAP, CVP and higher MAP. Adjusted analysis demonstrated that DM patients had higher PCWP and CVP. Increasing HbA1c-values were correlated with higher PCWP (p = 0.017) and CVP (p = 0.043). CONCLUSION Patients with DM, especially those with poor glycemic control, have higher filling pressures. This may be a feature of diabetic cardiomyopathy, however, other unknown mechanisms beyond hemodynamic factors are likely to explain the increased mortality associated with diabetes in HF.
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Affiliation(s)
- Benedicte Heegaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Tania Deis
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Mads Ersbøll
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark.
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25
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Forsyth P, Beezer J, Bateman J. Holistic approach to drug therapy in a patient with heart failure. Heart 2023:heartjnl-2022-321764. [PMID: 36898707 DOI: 10.1136/heartjnl-2022-321764] [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] [Indexed: 03/12/2023] Open
Abstract
Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.
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Affiliation(s)
- Paul Forsyth
- Pharmacy, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Janine Beezer
- Pharmacy, South Tyneside and Sunderland Royal Hospital, Sunderland, UK
| | - Joanne Bateman
- Pharmacy, Countess of Chester Hospital NHS Foundation Trust, Chester, Cheshire West and Chester, UK
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Chung CC, Lin YK, Chen YC, Kao YH, Yeh YH, Trang NN, Chen YJ. Empagliflozin suppressed cardiac fibrogenesis through sodium-hydrogen exchanger inhibition and modulation of the calcium homeostasis. Cardiovasc Diabetol 2023; 22:27. [PMID: 36747205 PMCID: PMC9903522 DOI: 10.1186/s12933-023-01756-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/26/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The novel sodium-glucose co-transporter 2 inhibitor (SGLT2i) potentially ameliorates heart failure and reduces cardiac arrhythmia. Cardiac fibrosis plays a pivotal role in the pathophysiology of HF and atrial myopathy, but the effect of SGLT2i on fibrogenesis remains to be elucidated. This study investigated whether SGLT2i directly modulates fibroblast activities and its underlying mechanisms. METHODS AND RESULTS Migration, proliferation analyses, intracellular pH assay, intracellular inositol triphosphate (IP3) assay, Ca2+ fluorescence imaging, and Western blotting were applied to human atrial fibroblasts. Empagliflozin (an SGLT2i, 1, or 5 μmol/L) reduced migration capability and collagen type I, and III production. Compared with control cells, empagliflozin (1 μmol/L)- treated atrial fibroblasts exhibited lower endoplasmic reticulum (ER) Ca2+ leakage, Ca2+ entry, inositol trisphosphate (IP3), lower expression of phosphorylated phospholipase C (PLC), and lower intracellular pH. In the presence of cariporide (an Na+-H+ exchanger (NHE) inhibitor, 10 μmol/L), control and empagliflozin (1 μmol/L)-treated atrial fibroblasts revealed similar intracellular pH, ER Ca2+ leakage, Ca2+ entry, phosphorylated PLC, pro-collagen type I, type III protein expression, and migration capability. Moreover, empagliflozin (10 mg/kg/day orally for 28 consecutive days) significantly increased left ventricle systolic function, ß-hydroxybutyrate and decreased atrial fibrosis, in isoproterenol (100 mg/kg, subcutaneous injection)-induced HF rats. CONCLUSIONS By inhibiting NHE, empagliflozin decreases the expression of phosphorylated PLC and IP3 production, thereby reducing ER Ca2+ release, extracellular Ca2+ entry and the profibrotic activities of atrial fibroblasts.
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Affiliation(s)
- Cheng-Chih Chung
- grid.412896.00000 0000 9337 0481Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Yung-Kuo Lin
- grid.412896.00000 0000 9337 0481Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Yao-Chang Chen
- grid.260565.20000 0004 0634 0356Department of Biomedical Engineering, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, No. 250, Wu-Hsing Street, 11031, Taipei, Taiwan. .,Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Yung-Hsin Yeh
- grid.413801.f0000 0001 0711 0593Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nguyen Ngoc Trang
- grid.414163.50000 0004 4691 4377Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Yi-Jen Chen
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. .,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, No. 250, Wu-Hsing Street, 11031, Taipei, Taiwan.
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Mechanisms of SGLT2 Inhibitors in Heart Failure and Their Clinical Value. J Cardiovasc Pharmacol 2023; 81:4-14. [PMID: 36607775 DOI: 10.1097/fjc.0000000000001380] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/08/2022] [Indexed: 01/07/2023]
Abstract
ABSTRACT Sodium-glucose cotransporter 2 (SGLT2) inhibitors are widely used to treat diabetes mellitus. Abundant evidence has shown that SGLT2 inhibitors can reduce hospitalization for heart failure (HF) in patients with or without diabetes. An increasing number of studies are being conducted on the mechanisms of action of SGLT2 inhibitors in HF. Our review summarizes a series of clinical trials on the cardioprotective effects of SGLT2 inhibitors in the treatment of HF. We have summarized several classical SGLT2 inhibitors in cardioprotection research, including empagliflozin, dapagliflozin, canagliflozin, ertugliflozin, and sotagliflozin. In addition, we provided a brief overview of the safety and benefits of SGLT2 inhibitors. Finally, we focused on the mechanisms of SGLT2 inhibitors in the treatment of HF, including ion-exchange regulation, volume regulation, ventricular remodeling, and cardiac energy metabolism. Exploring the mechanisms of SGLT2 inhibitors has provided insight into repurposing these diabetic drugs for the treatment of HF.
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Fujiki S, Tanaka A, Imai T, Shimabukuro M, Uehara H, Nakamura I, Matsunaga K, Suzuki M, Kashimura T, Minamino T, Inomata T, Node K. Body fluid regulation via chronic inhibition of sodium-glucose cotransporter-2 in patients with heart failure: a post hoc analysis of the CANDLE trial. Clin Res Cardiol 2023; 112:87-97. [PMID: 35729430 DOI: 10.1007/s00392-022-02049-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND In patients with chronic heart failure (CHF) and type 2 diabetes (T2D), sodium-glucose cotransporter-2 (SGLT2) inhibition improves cardiorenal outcomes, but details of the effects on distinct subsets of body fluid volume remain incomplete. METHODS This was a post hoc analysis of patients with CHF and T2D in the CANDLE trial (UMIN000017669), an investigator-initiated, multi-center, randomized open-label trial that compared the effect of canagliflozin (100 mg, n = 113) with glimepiride (starting dose: 0.5 mg, n = 120) on changes in N-terminal pro-brain natriuretic peptide. The estimated plasma volume (ePV, calculated with the Straus formula) and estimated extracellular volume (eEV, determined by the body surface area) were compared between treatment groups at weeks 4, 12, and 24. RESULTS Among 233 patients analyzed, 166 (71.2%) had an ejection fraction (EF) > 50%. Reductions in ePV and eEV were observed only in the canagliflozin group until week 12 (change from baseline at week 12, ePV; - 7.63%; 95% confidence interval [CI], - 10.71 to - 4.55%, p < 0.001, eEV; - 123.15 mL; 95% CI, - 190.38 to - 55.92 mL, p < 0.001). While ePV stopped falling after week 12, eEV continued to fall until week 24 ([change from baseline at week 24] - [change from baseline at week 12], ePV; 1.01%; 95%CI, - 2.30-4.32%, p = 0.549, eEV; - 125.15 mL; 95% CI, - 184.35 to - 65.95 mL, p < 0.001). CONCLUSIONS Maintenance of a modest reduction in ePV and continuous removal of eEV via chronic SGLT2 inhibition suggests that favorable body fluid regulation contributes to the cardiorenal benefits of SGLT2 inhibitors in patients with CHF, irrespective of EF. TRIAL REGISTRATION UMIN000017669.
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Affiliation(s)
- Shinya Fujiki
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Takumi Imai
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Hiroki Uehara
- Division of Cardiology, Urasoe General Hospital, Urasoe, Japan
| | - Ikuko Nakamura
- Department of Cardiovascular Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Kazuo Matsunaga
- Department of Internal Medicine, Imari-Arita Kyoritsu Hospital, Matsuura, Japan
| | - Makoto Suzuki
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Takeshi Kashimura
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuo-ku, Niigata, 951-8510, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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The Therapeutic Role of SGLT-2 Inhibitors in Acute Heart Failure: From Pathophysiologic Mechanisms to Clinical Evidence with Pooled Analysis of Relevant Studies across Safety and Efficacy Endpoints of Interest. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122062. [PMID: 36556427 PMCID: PMC9782870 DOI: 10.3390/life12122062] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
(1) Background: Sodium-glucose co-transporter-2 (SGLT-2) inhibitors constitute a novel drug class with remarkable cardiovascular benefits for patients with chronic heart failure (HF). Recently, this class has been utilized in acute HF as an additional treatment option to classic diuretics, which remain the cornerstone of treatment. (2) Methods: We attempted to identify those pathophysiologic mechanisms targeted by SGLT-2 inhibitors, which could be of benefit to patients with acute HF. We then conducted a comprehensive review of the literature within the PubMed database in order to identify relevant studies, both randomized controlled trials (RCTs) and observational studies, assessing the safety and efficacy of SGLT-2 inhibitors in acute HF. (3) Results: SGLT-2 inhibitors induce significant osmotic diuresis and natriuresis, decrease interstitial fluid volume and blood pressure, improve left ventricular (LV) function, ameliorate LV remodeling and prevent atrial arrhythmia occurrence, mechanisms that seem to be beneficial in acute HF. However, currently available studies, including six RCTs and two real-world studies, provide conflicting results concerning the true efficacy of SGLT-2 inhibitors, including "hard" surrogate endpoints. (4) Conclusions: Current evidence appears insufficient to substantiate the use of SGLT-2 inhibitors in acute HF. Further trials are required to shed more light on this issue.
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Frampton JE. Empagliflozin: A Review in Symptomatic Chronic Heart Failure. Drugs 2022; 82:1591-1602. [DOI: 10.1007/s40265-022-01778-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 11/16/2022]
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SGLT2 Inhibitors Improve Cardiac Failure by Reducing Whole-Body Oxygen Demand: A Hypothesis. Clin Drug Investig 2022; 42:1025-1030. [DOI: 10.1007/s40261-022-01220-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
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Ehsan P, Aburumman RN, Muthanna SI, Menon SR, Vithani V, Sutariya B, Montenegro DM, Chukwu M, Penumetcha SS. Sodium-Glucose Co-transporter 2 Inhibitors/Gliflozins: A New Miracle Therapy for Heart Failure Patients Irrespective of Diabetes Status? Cureus 2022; 14:e31777. [PMID: 36579255 PMCID: PMC9780697 DOI: 10.7759/cureus.31777] [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: 09/10/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022] Open
Abstract
Despite the existence of effective medicines, heart failure continues to be the largest cause of illness and death worldwide. As a prospective family of drugs with potential cardiovascular advantages in non-diabetic patients, sodium-glucose co-transporter 2 inhibitors (SGLT2-I) have recently come to the forefront. In this comprehensive study, we assessed the favorable cardiovascular outcomes of SGLT2-I in three sizable, randomized trials with both diabetic and non-diabetic populations. The results from these studies revealed a substantial reduction in heart failure hospitalizations and cardiovascular and all-cause deaths. To further support our assertion that SGLT2-I has the potential to be a novel addition to the standard treatment plan for heart failure, we also tried to assemble several post hoc and prespecified studies of the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) study. The details of two clinical investigations that supported their use in acute decompensated heart failure were also examined, along with the most plausible mechanism of action generating their cardioprotective effects. Additionally, positive cardiovascular advantages were addressed in chronic heart failure with both preserved and reduced ejection fractions. The role of SGLT2-I in ST-elevation myocardial infarction (STEMI) and hypertrophic cardiomyopathy (HOCM) patients is currently being studied, and this research has the potential to be revolutionary. The purpose of this systematic review is to compile all information that supports the use of this life-saving drug in patients who do not have diabetes so that cardiac care can be improved globally.
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Affiliation(s)
- Paghunda Ehsan
- Internal Medicine, Hayatabad Medical Complex, Peshawar, PAK
- Internal Medicine, Lady Reading Hospital, Peshawar, PAK
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rawia N Aburumman
- Internal Medicine, Mutah University, Amman, JOR
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shivani Ishwarya Muthanna
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Vydehi Institute of Medical Sciences and Research Center, Bangalore, IND
| | - Swathi Radhakrishnan Menon
- Pediatrics, Smt. Kashibai Navale Medical College and General Hospital, Pune, IND
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vruti Vithani
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Government Medical College, Surat, IND
| | - Bansi Sutariya
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Government Medical College, Surat, IND
| | - Diana M Montenegro
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Michael Chukwu
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Surgery, Pilgrim Hospital, Boston, GBR
| | - Sai Sri Penumetcha
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, India, IND
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33
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Packer M. Critical Reanalysis of the Mechanisms Underlying the Cardiorenal Benefits of SGLT2 Inhibitors and Reaffirmation of the Nutrient Deprivation Signaling/Autophagy Hypothesis. Circulation 2022; 146:1383-1405. [PMID: 36315602 PMCID: PMC9624240 DOI: 10.1161/circulationaha.122.061732] [Citation(s) in RCA: 163] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/10/2022] [Indexed: 02/06/2023]
Abstract
SGLT2 (sodium-glucose cotransporter 2) inhibitors produce a distinctive pattern of benefits on the evolution and progression of cardiomyopathy and nephropathy, which is characterized by a reduction in oxidative and endoplasmic reticulum stress, restoration of mitochondrial health and enhanced mitochondrial biogenesis, a decrease in proinflammatory and profibrotic pathways, and preservation of cellular and organ integrity and viability. A substantial body of evidence indicates that this characteristic pattern of responses can be explained by the action of SGLT2 inhibitors to promote cellular housekeeping by enhancing autophagic flux, an effect that may be related to the action of these drugs to produce simultaneous upregulation of nutrient deprivation signaling and downregulation of nutrient surplus signaling, as manifested by an increase in the expression and activity of AMPK (adenosine monophosphate-activated protein kinase), SIRT1 (sirtuin 1), SIRT3 (sirtuin 3), SIRT6 (sirtuin 6), and PGC1-α (peroxisome proliferator-activated receptor γ coactivator 1-α) and decreased activation of mTOR (mammalian target of rapamycin). The distinctive pattern of cardioprotective and renoprotective effects of SGLT2 inhibitors is abolished by specific inhibition or knockdown of autophagy, AMPK, and sirtuins. In the clinical setting, the pattern of differentially increased proteins identified in proteomics analyses of blood collected in randomized trials is consistent with these findings. Clinical studies have also shown that SGLT2 inhibitors promote gluconeogenesis, ketogenesis, and erythrocytosis and reduce uricemia, the hallmarks of nutrient deprivation signaling and the principal statistical mediators of the ability of SGLT2 inhibitors to reduce the risk of heart failure and serious renal events. The action of SGLT2 inhibitors to augment autophagic flux is seen in isolated cells and tissues that do not express SGLT2 and are not exposed to changes in environmental glucose or ketones and may be related to an ability of these drugs to bind directly to sirtuins or mTOR. Changes in renal or cardiovascular physiology or metabolism cannot explain the benefits of SGLT2 inhibitors either experimentally or clinically. The direct molecular effects of SGLT2 inhibitors in isolated cells are consistent with the concept that SGLT2 acts as a nutrient surplus sensor, and thus, its inhibition causes enhanced nutrient deprivation signaling and its attendant cytoprotective effects, which can be abolished by specific inhibition or knockdown of AMPK, sirtuins, and autophagic flux.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX. Imperial College, London, United Kingdom
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Deis T, Rossing K, Ersbøll MK, Wolsk E, Gustafsson F. Uric acid in advanced heart failure: relation to central haemodynamics and outcome. Open Heart 2022; 9:openhrt-2022-002092. [DOI: 10.1136/openhrt-2022-002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
ObjectiveThe role of hyperuricaemia as a prognostic maker has been established in chronic heart failure (HF) but limited information on the association between plasma uric acid (UA) levels and central haemodynamic measurements is available.MethodsA retrospective study on patients with advanced HF referred for right heart catherisation. Regression analyses were constructed to investigate the association between UA and haemodynamic variables. Cox models were created to investigate if UA was a significant predictor of adverse outcome where log1.1(UA) was used to estimate the effect on outcome associated with a 10% increase in UA levels.ResultsA total of 228 patients were included (77% males, age 49±12 years, mean left ventricular ejection fraction (LVEF) of 17%±8%). Median UA was 0.48 (0.39–0.61) mmol/L. UA level was associated to pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) in univariable (both p<0.001) and multivariable regression analysis (p<0.004 and p=0.025 for PCWP and CI). When constructing multivariable Cox models including PCWP, CI, central venous pressure, age, estimated glomerular filtration rate (eGFR), use of loop diuretics and LVEF, log1.1(UA) independently predicted the combined endpoint (left ventricular assist device, total artificial heart implantation, heart transplantation or all-cause mortality) (hazard ratio (HR): 1.10 (1.03–1.17), p=0.004) as well as all-cause mortality (HR: 1.15 (1.06–1.25), p=0.001).ConclusionsElevated UA is associated with greater haemodynamic impairment in advanced HF. In adjusted Cox models (age, eGFR, LVEF and haemodynamics), UA predicts the combined endpoint and all-cause mortality in long-term follow-up.
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Athiyaman S, Randhi B, Gutlapalli SD, Pu J, Zaidi MF, Patel M, Atluri LM, Gonzalez NA, Sakhamuri N, Venugopal S. A Systematic Review Exploring the Cardiovascular and Renal Effects of Empagliflozin in Patients With Heart Failure With Reduced Ejection Fraction. Cureus 2022; 14:e29896. [PMID: 36348895 PMCID: PMC9632915 DOI: 10.7759/cureus.29896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
The major cause of death in the United States is heart disease. The global burden of illness and mortality from heart failure is substantial. Despite recent innovations in the treatment of heart failure, the prognosis is still poor. To identify, evaluate, and summarize the findings of all relevant studies of a drug that is equally efficacious but rather cost-effective, empagliflozin compared to the other sodium-glucose cotransporter-2 (SGLT2) inhibitors was studied. It is licensed by the Food and Drug Administration (FDA), acts by preventing the reabsorption of glucose from the kidney, and exhibits promising advantages in heart failure. We systematically explored PubMed, PubMed Central (PMC), and Medical Literature Analysis and Retrieval System Online (MEDLINE) for randomized controlled trials (RCTs) and observational studies related to cardiovascular and renal outcomes of empagliflozin in patients with heart failure with reduced ejection fraction (HFrEF). After performing scoping search and search strategy, studies were screened for quality assessment using the Cochrane risk of bias assessment tool. We screened 60 articles by titles, abstract, and exclusion and inclusion criteria, after which eight final randomized controlled trials (RCTs) with 18,659 participants treated with empagliflozin and placebo were used for the systematic review. This systematic review's objective is to investigate and explore the full range of empagliflozin's effects and advantages on cardiac structure, function, and hemodynamics and renal function in patients with heart failure with reduced ejection fraction (EF) in order to better understand the drug's effects and related mechanisms.
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Affiliation(s)
- Sreekartthik Athiyaman
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bhawna Randhi
- Medicine, NRI Medical College, Chinakakani, IND
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Dheeraj Gutlapalli
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jingxiong Pu
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maheen F Zaidi
- Medicine, Aga Khan University, Karachi, PAK
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maithily Patel
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lakshmi Malvika Atluri
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Surgery, Dr. Pinnamaneni Siddhartha Institute of Medical Science, Gannavaram, IND
| | - Natalie A Gonzalez
- Pediatrics, Medical University of Graz, Graz, AUT
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Navya Sakhamuri
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sathish Venugopal
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Adamson C, Cowan LM, de Boer RA, Diez M, Drożdż J, Dukát A, Inzucchi SE, Køber L, Kosiborod MN, Ljungman CE, Martinez FA, Ponikowski P, Sabatine MS, Lindholm D, Bengtsson O, Boulton DW, Greasley PJ, Langkilde AM, Sjöstrand M, Solomon SD, McMurray JJ, Jhund PS. Liver tests and outcomes in heart failure with reduced ejection fraction: findings from DAPA-HF. Eur J Heart Fail 2022; 24:1856-1868. [PMID: 36054568 PMCID: PMC9805158 DOI: 10.1002/ejhf.2649] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Reflecting both increased venous pressure and reduced cardiac output, abnormal liver tests are common in patients with severe heart failure and are associated with adverse clinical outcomes. We aimed to investigate the prognostic significance of abnormal liver tests in ambulatory patients with heart failure with reduced ejection fraction (HFrEF), explore any treatment interaction between bilirubin and sodium-glucose cotransporter 2 (SGLT2) inhibitors and examine change in liver tests with SGLT2 inhibitor treatment. METHODS AND RESULTS We explored these objectives in the Dapagliflozin And Prevention of Adverse outcomes in Heart Failure (DAPA-HF) trial, with focus on bilirubin. We calculated the incidence of cardiovascular death or worsening heart failure by bilirubin tertile. Secondary cardiovascular outcomes were examined, along with the change in liver tests at the end-of-study visit. Baseline bilirubin was available in 4720 patients (99.5%). Participants in the highest bilirubin tertile (T3) have more severe HFrEF (lower left ventricular ejection fraction, higher N-terminal pro-B-type natriuretic peptide [NT-proBNP] and worse New York Heart Association class), had a greater burden of atrial fibrillation but less diabetes. Higher bilirubin (T3 vs. T1) was associated with worse outcomes even after adjustment for other predictive variables, including NT-proBNP and troponin T (adjusted hazard ratio for the primary outcome 1.73 [95% confidence interval 1.37-2.17], p < 0.001; and 1.52 [1.12-2.07], p = 0.01 for cardiovascular death). Baseline bilirubin did not modify the benefits of dapagliflozin. During follow-up, dapagliflozin had no effect on liver tests. CONCLUSION Bilirubin concentration was an independent predictor of worse outcomes but did not modify the benefits of dapagliflozin in HFrEF. Dapagliflozin was not associated with change in liver tests. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT03036124.
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Affiliation(s)
- Carly Adamson
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Lorna M. Cowan
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Rudolf A. de Boer
- Department of CardiologyUniversity Medical Center and University of GroningenGroningenThe Netherlands
| | - Mirta Diez
- Division of CardiologyInstitute Cardiovascular de Buenos AiresBuenos AiresArgentina
| | | | - Andre Dukát
- Fifth Department of Internal MedicineComenius University in BratislavaBratislavaSlovakia
| | | | - Lars Køber
- Department of Cardiology, RigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart InstituteUniversity of MissouriKansas CityMOUSA
- The George Institute for Global HealthUniversity of New South WalesSydneyNSWAustralia
| | - Charlotta E.A. Ljungman
- Institute of Medicine, Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University HospitalWroclaw Medical UniversityWroclawPoland
| | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMAUSA
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - David W. Boulton
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&DAstraZenecaGaithersburgMDUSA
| | - Peter J. Greasley
- Early Research and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&DAstraZenecaGothenburgSweden
| | - Scott D. Solomon
- Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMAUSA
| | | | - Pardeep S. Jhund
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
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37
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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.
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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.
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38
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Tanaka A, Imai T, Shimabukuro M, Taguchi I, Sezai A, Toyoda S, Watada H, Ako J, Node K. Association between serum insulin levels and heart failure-related parameters in patients with type 2 diabetes and heart failure treated with canagliflozin: a post-hoc analysis of the randomized CANDLE trial. Cardiovasc Diabetol 2022; 21:151. [PMID: 35941584 PMCID: PMC9358857 DOI: 10.1186/s12933-022-01589-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Insulin resistance and hyperinsulinemia in patients with type 2 diabetes (T2D) are adversely associated with the development and worsening of heart failure (HF). Herein, we sought to investigate the effect of canagliflozin on insulin concentrations and the associations of changes in insulin concentrations with HF-related clinical parameters in patients with T2D and HF. Methods This was a post-hoc analysis of the investigator-initiated, multicenter, open-label, randomized, controlled CANDLE trial for patients with T2D and chronic HF (UMIN000017669). The endpoints were the effects of 24 weeks of canagliflozin treatment, relative to glimepiride treatment, on insulin concentrations and the relationship between changes in insulin concentrations and clinical parameters of interest, including New York Heart Association (NYHA) classification. The effects of canagliflozin on those parameters were also analyzed by baseline insulin level. Results Among the participants in the CANDLE trial, a total of 129 patients (canagliflozin, n = 64; glimepiride, n = 65) who were non-insulin users with available serum insulin data both at baseline and week 24 were included in this analysis. Overall, the mean age was 69.0 ± 9.4 years; 75% were male; the mean HbA1c was 6.8 ± 0.7%; and the mean left ventricular ejection fraction was 59.0 ± 14.1%, with parameters roughly balanced between treatment groups. Canagliflozin treatment significantly reduced insulin concentrations at week 24 (p < 0.001), and the between-group difference (canagliflozin minus glimepiride) in those changes was − 3.52 mU/L (95% confidence interval, − 4.85 to − 2.19; p < 0.001). Decreases in insulin concentrations, irrespective of baseline insulin level, were significantly associated with improvement in NYHA class in patients treated with canagliflozin. Conclusion Our findings suggest that canagliflozin treatment in patients with T2D and HF ameliorated excess insulin overload, contributing to the improvement of clinical HF status. Trial registration: University Medical Information Network Clinical Trial Registry, number 000017669, Registered on May 25, 2015. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01589-3.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Takumi Imai
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Akira Sezai
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Hirotaka Watada
- Department of Metabolism & Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
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39
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Jensen J, Omar M, Ali M, Frederiksen PH, Kistorp C, Tuxen C, Andersen CF, Larsen JH, Ersbøll MK, Køber L, Gustafsson F, Faber J, Forman JL, Møller JE, Schou M. The effect of empagliflozin on contractile reserve in heart failure: Prespecified sub-study of a randomized, double-blind, and placebo-controlled trial. Am Heart J 2022; 250:57-65. [PMID: 35513022 DOI: 10.1016/j.ahj.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/30/2022] [Accepted: 04/23/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 inhibitors improve cardiac structure but most studies suggest no change in left ventricular (LV) systolic function at rest. Whether sodium-glucose co-transporter-2 inhibitors improve LV contractile reserve is unknown. We investigated the effect of empagliflozin on LV contractile reserve in patients with heart failure (HF) and reduced ejection fraction. METHODS Prespecified sub-study of the Empire HF trial, a double-blind, placebo-controlled, and randomized trial. Patients with LV ejection fraction (LVEF) ≤ 40% on guideline-directed HF therapy were randomized (1:1) to empagliflozin 10 mg or placebo for 12 weeks. The treatment effect on contractile reserve was assessed by low dose dobutamine stress echocardiography. RESULTS In total, 120 patients were included. The mean age was 68 (SD 10) years, 83% were male, and the mean LVEF was 38 (SD 10) %. Respectively 60 (100%) and 59 (98%) patients in the empagliflozin and placebo groups completed stress echocardiography. No statistically significant effect of empagliflozin was observed for the contractile reserve assessed by LV-GLS (adjusted mean absolute change, empagliflozin vs placebo, 0.7% [95% confidence interval {CI} -0.5 to 2.0, P = .25]) or LVEF (adjusted mean absolute change, empagliflozin vs placebo, 2.2% [95% CI -1.4 to 5.8, P = .22]) from baseline to 12 weeks. LV-GLS contractile reserve was associated with accelerometer-measured daily activity level (coefficient -24 accelerometer counts [95% CI -46 to -1.8, P = .03]). CONCLUSIONS Empagliflozin for 12 weeks added to guideline-directed HF therapy did not improve LV contractile reserve in patients with HF and reduced ejection fraction.
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Affiliation(s)
- Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Steno Diabetes Center Odense, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mulham Ali
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter H Frederiksen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Tuxen
- Department of Cardiology, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Camilla F Andersen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Julie H Larsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens Faber
- Department of Internal Medicine, Center of Endocrinology and Metabolism, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Julie Lyng Forman
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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40
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Jensen J, Omar M, Kistorp C, Gustafsson F, Køber L, Møller JE, Schou M. Sodium-glucose co-transporter-2 inhibitors in heart failure with reduced ejection fraction: Current evidence and future perspectives. Basic Clin Pharmacol Toxicol 2022; 131:5-17. [PMID: 35510595 DOI: 10.1111/bcpt.13739] [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: 11/26/2021] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The sodium-glucose co-transporter-2 (SGLT2) inhibitors were developed as glucose-lowering drugs to treat type 2 diabetes (T2D). However, significant reductions in clinical outcomes have now been demonstrated in patients with heart failure with reduced ejection fraction (HFrEF), irrespective of the presence of T2D. Multiple hypotheses have been proposed for the underlying mechanisms, and the data to support these proposals are emerging. OBJECTIVES To review the clinical outcome data with SGLT2 inhibitors in HFrEF and the data to support the mechanisms for these clinical effects. METHODS Literature review was supported by a PubMed search for relevant articles up to 19 April 2022. FINDINGS Current data support increased diuresis and reverse cardiac remodelling as important mechanisms for the reductions in heart failure hospitalizations and mortality observed with SGLT2 inhibitors (empagliflozin or dapagliflozin) in patients with HFrEF. Alteration in intrarenal haemodynamic is likely contributing to the observed renoprotective effect of SGLT2 inhibitors. CONCLUSIONS Solid clinical data support the current recommendations to use empagliflozin or dapagliflozin in HFrEF. The underlying mechanisms likely include changes in cardiac and intrarenal haemodynamic. Yet, these mechanisms do not seem to solely explain the observed magnitude of clinical effect with SGLT2 inhibitors in HFrEF, and other mechanisms may contribute.
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Affiliation(s)
- Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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41
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Meta-Analysis Evaluating the Effect of Sodium-Glucose Co-Transporter-2 Inhibitors on Pulmonary Artery Pressure Indices. Am J Cardiol 2022; 172:169-170. [PMID: 35382927 DOI: 10.1016/j.amjcard.2022.03.009] [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: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 11/23/2022]
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42
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Deis T, Rossing K, Gustafsson F. Aortic Pulsatility Index: A New Haemodynamic Measure with Prognostic Value in Advanced Heart Failure. Card Fail Rev 2022; 8:e18. [PMID: 35620383 PMCID: PMC9127634 DOI: 10.15420/cfr.2022.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/27/2022] [Indexed: 11/04/2022] Open
Abstract
Aim: To test if the newly described haemodynamic variable, aortic pulsatility index (API), predicts long-term prognosis in advanced heart failure (HF). Methods: A single-centre study on 453 HF patients (median age: 51 years; left ventricular ejection fraction [LVEF]: 19% ± 9%) referred for right heart catheterisation. API was calculated as pulse pressure/pulmonary capillary wedge pressure. Results: Log(API) correlated significantly with central venous pressure (CVP; p<0.001) and cardiac index (p<0.001) in univariable regression analysis. CVP remained associated with log(API) in a multivariable analysis including cardiac index, heart rate, log(NT-proBNP [N-terminal proB-type natriuretic peptide]), LVEF, New York Heart Association (NYHA) class III or IV and sex (p=0.01). In univariable Cox models, log(API) was a significant predictor of freedom from the combined endpoint of death, left ventricular assist device implantation, total artificial heart implantation or heart transplantation (HR 0.33; (95% CI [0.22–0.49]); p<0.001) and all-cause mortality (HR 0.56 (95% CI [0.35–0.90]); p=0.015). After adjusting for age, sex, NYHA class III or IV and estimated glomerular filtration rate in multivariable Cox models, log(API) remained a significant predictor for the combined endpoint (HR 0.33; 95% CI [0.20–0.56]; p<0.001) and all-cause mortality (HR 0.49; 95% CI [0.26–0.96]; p=0.034). Conclusion: API was strongly associated with right-sided filling pressure and independently predicted freedom from the combined endpoint and all-cause mortality.
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Affiliation(s)
- Tania Deis
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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43
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Das BB. Therapeutic Approaches in Heart Failure with Preserved Ejection Fraction (HFpEF) in Children: Present and Future. Paediatr Drugs 2022; 24:235-246. [PMID: 35501560 DOI: 10.1007/s40272-022-00508-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/29/2022]
Abstract
For a long time, pediatric heart failure (HF) with preserved systolic function (HFpEF) has been noted in patients with cardiomyopathies and congenital heart disease. HFpEF is infrequently reported in children and instead of using the HFpEF terminology the HF symptoms are attributed to diastolic dysfunction. Identifying HFpEF in children is challenging because of heterogeneous etiologies and unknown pathophysiological mechanisms. Advances in echocardiography and cardiac magnetic resonance imaging techniques have further increased our understanding of HFpEF in children. However, the literature does not describe the incidence, etiology, clinical features, and treatment of HFpEF in children. At present, treatment of HFpEF in children is extrapolated from clinical trials in adults. There are significant differences between pediatric and adult HF with reduced ejection fraction, supported by a lack of adequate response to adult HF therapies. Evidence-based clinical trials in children are still not available because of the difficulty of conducting trials with a limited number of pediatric patients with HF. The treatment of HFpEF in children is based upon the clinician's experience, and the majority of children receive off-level medications. There are significant differences between pediatric and adult HFpEF pharmacotherapies in many areas, including side-effect profiles, underlying pathophysiologies, the β-receptor physiology, and pharmacokinetics and pharmacodynamics. This review describes the present and future treatments for children with HFpEF compared with adults. This review also highlights the need to urgently test new therapies in children with HFpEF to demonstrate the safety and efficacy of drugs and devices with proven benefits in adults.
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Affiliation(s)
- Bibhuti B Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 N State St., Jackson, MS, 39216, USA.
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44
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Wolsk E, Jürgens M, Schou M, Ersbøll M, Hasbak P, Kjær A, Zerahn B, Brandt NH, Gæde PH, Rossing P, Faber J, Inzucchi SE, Kistorp CM, Gustafsson F. Randomized Controlled Trial of the Hemodynamic Effects of Empagliflozin in Patients With Type 2 Diabetes at High Cardiovascular Risk: The SIMPLE Trial. Diabetes 2022; 71:812-820. [PMID: 35061894 DOI: 10.2337/db21-0721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022]
Abstract
Treatment with the sodium-glucose cotransporter 2 inhibitor (SGLT-2i) empagliflozin significantly reduces cardiovascular events in patients with type 2 diabetes (T2D); however, the mechanisms behind the reduction in cardiovascular (CV) events are unknown. We investigated whether SGLT-2i treatment affected central hemodynamics during rest and exercise in 34 patients with diabetes in this investigator-initiated, randomized, placebo-controlled, double-blinded trial. The primary end point was change in pulmonary capillary wedge pressure (PCWP) at a submaximal ergometer workload (25 W) after 13 weeks of SGLT-2i treatment (25 mg once daily) compared with placebo. Secondary end points included changes in resting hemodynamics. Baseline and follow-up hemodynamic assessments were performed at rest, submaximal exercise (25 W), and peak exercise using right heart catheterization. Treatment with empagliflozin for 13 weeks in patients with T2D at high CV risk did not reduce left heart filling pressure more than placebo at submaximal exercise. At rest, we observed that empagliflozin reduced PCWP at a magnitude of clinical significance.
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Affiliation(s)
- Emil Wolsk
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Jürgens
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Mads Ersbøll
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Philip Hasbak
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster of Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Andreas Kjær
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster of Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Copehagen, Denmark
| | - Niels Høgh Brandt
- Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Copehagen, Denmark
| | - Peter Haulund Gæde
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
| | | | - Jens Faber
- Department of Medicine, Herlev Hospital, Herlev, Denmark
| | | | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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45
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Mullens W, Martens P, Testani JM, Tang WHW, Skouri H, Verbrugge FH, Fudim M, Iacoviello M, Franke J, Flammer AJ, Palazzuoli A, Barragan PM, Thum T, Marcos MC, Miró Ò, Rossignol P, Metra M, Lassus J, Orso F, Jankowska EA, Chioncel O, Milicic D, Hill L, Seferovic P, Rosano G, Coats A, Damman K. Renal effects of guideline directed medical therapies in heart failure - a consensus document from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2022; 24:603-619. [PMID: 35239201 DOI: 10.1002/ejhf.2471] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, University Hasselt, Belgium.,Cleveland Clinic, Cleveland, Ohio, United States of America
| | | | | | - Hadi Skouri
- American University of Beirut Medical Center-Beirut, Lebanon
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussel, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Marat Fudim
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Andreas J Flammer
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences Le Scotte Hospital Siena, Italy.,School of Nursing and Midwifery, Queen's University, Belfast, Northern Ireland
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany.,Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Marta Cobo Marcos
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Patrick Rossignol
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116, and F-CRIN INI-CRCT, Nancy, France
| | | | - Johan Lassus
- Heart and Lung Center, Cardiology, University of Helsinki and Helsinki University Hospital
| | | | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University AND Institute of Heart Diseases, University Hospital in Wroclaw, Poland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Davor Milicic
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Centre Zagreb, Zagreb, Croatia
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Petar Seferovic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | | | | | - Kevin Damman
- University of Groningen, University Medical Center Groningen, The Netherlands
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46
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Weisert M, Su JA, Menteer J, Shaddy RE, Kantor PF. Drug Treatment of Heart Failure in Children: Gaps and Opportunities. Paediatr Drugs 2022; 24:121-136. [PMID: 35084696 DOI: 10.1007/s40272-021-00485-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/11/2022]
Abstract
Medical therapy for pediatric heart failure is based on a detailed mechanistic understanding of the underlying causes, which are diverse and unlike those encountered in most adult patients. Diuresis and improved perfusion are the immediate goals of care in the child with acute decompensated heart failure. Conversion to maintenance oral therapy for heart failure is based on the results of landmark studies in adults, as well as recent pediatric clinical trials and heart failure guidelines. There will continue to be an important role for newer drugs, some of which are in active trials in adults, and some of which are already approved for use in children. The need to plan for clinical trials in children during drug development for heart failure is emphasized.
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Affiliation(s)
- Molly Weisert
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jennifer A Su
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jondavid Menteer
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Robert E Shaddy
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Paul F Kantor
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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Omar M, Jensen J, Kistorp C, Højlund K, Videbæk L, Tuxen C, Larsen JH, Andersen CF, Gustafsson F, Køber L, Schou M, Møller JE. The effect of empagliflozin on growth differentiation factor 15 in patients with heart failure: a randomized controlled trial (Empire HF Biomarker). Cardiovasc Diabetol 2022; 21:34. [PMID: 35219331 PMCID: PMC8882292 DOI: 10.1186/s12933-022-01463-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/09/2022] [Indexed: 02/07/2023] Open
Abstract
Background Plasma growth differentiation factor-15 (GDF-15) biomarker levels increase in response to inflammation and tissue injury, and increased levels of GDF-15 are associated with increased risk of mortality in patients with heart failure with reduced ejection fraction (HFrEF). Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which improve outcome in HFrEF, have been shown to increase plasma GDF-15 in diabetic patients. We aimed to investigate the effect of empagliflozin on GDF-15 in HFrEF patients. Methods This Empire HF Biomarker substudy was from the multicentre, randomized, double-blind, placebo-controlled Empire HF trial that included 190 patients from June 29, 2017, to September 10, 2019. Stable ambulatory HFrEF patients with ejection fraction of ≤ 40% were randomly assigned (1:1) to empagliflozin 10 mg once daily, or matching placebo for 12 weeks. Changes from baseline to 12 weeks in plasma levels of GDF-15, high-sensitive C-reactive protein (hsCRP), and high-sensitive troponin T (hsTNT) were assessed. Results A total of 187 patients who were included in this study, mean age was 64 ± 11 years; 85% male, 12% with type 2 diabetes, mean ejection fraction 29 ± 8, with no differences between the groups. Baseline median plasma GDF-15 was 1189 (918–1720) pg/mL with empagliflozin, and 1299 (952–1823) pg/mL for placebo. Empagliflozin increased plasma GDF-15 compared to placebo (adjusted between-groups treatment effect; ratio of change (1·09 [95% confidence interval (CI), 1.03–1.15]: p = 0.0040). The increase in plasma GDF15 was inversely associated with a decrease in left ventricular end-systolic (R = – 0.23, p = 0.031), and end-diastolic volume (R = – 0.29, p = 0.0066). There was no change in plasma hsCRP (1.09 [95%CI, 0.86–1.38]: p = 0.48) or plasma hsTNT (1.07 [95%CI, 0.97–1.19]: p = 0.18) compared to placebo. Patients with diabetes and treated with metformin demonstrated no increase in plasma GDF-15 with empagliflozin, p for interaction = 0·01. Conclusion Empagliflozin increased plasma levels of GDF-15 in patients with HFrEF, with no concomitant increase in hsTNT nor hsCRP. Trial registration: The Empire HF trial is registered with ClinicalTrials.gov, NCT03198585. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01463-2.
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48
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Junger C, Prochaska JH, Gori T, Schulz A, Binder H, Daiber A, Koeck T, Rapp S, Lackner KJ, Munzel T, Wild PS. Rationale and design of the effects of EMpagliflozin on left ventricular DIAstolic function in diabetes (EmDia) study. J Cardiovasc Med (Hagerstown) 2021; 23:191-197. [PMID: 34939776 DOI: 10.2459/jcm.0000000000001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background Data of the EMPA-REG OUTCOME study have demonstrated a beneficial effect of the sodium-glucose cotransporter 2 inhibitor empagliflozin on cardiovascular outcome in patients with type 2 diabetes. The reduction in cardiovascular mortality and hospitalization due to heart failure might be in part explained by the direct effects of empagliflozin on cardiac diastolic function. The EmDia trial investigates the short-term effects of empagliflozin compared to placebo on the left ventricular E/E' ratio as a surrogate of left ventricular diastolic function. Methods and Results EmDia is a single-center, randomized, double-blind, two-arm, placebo-controlled, parallel group study of phase IV. Individuals with diabetes mellitus type 2 (T2DM) are randomized 1:1 to receive empagliflozin 10 mg per day or a placebo for 12 weeks. The main inclusion criteria are diagnosed as T2DM with stable glucose-lowering and/or dietary treatment, elevated HbA1c level (6.5-10.0% if receiving glucose-lowering therapy, or 6.5-9.0% if drug-naive), and diastolic cardiac dysfunction with left ventricular E/E'>=8. The primary end point is the difference of the change in the E/E' ratio by treatment groups after 12 weeks. Secondary end points include assessment of the effect of empagliflozin on left ventricular systolic function, measures of vascular structure and function, as well as humoral cardiovascular biomarkers (i.e. brain natriuretic peptide, troponin, C-reactive protein). In addition, the multidimensional biodatabase enables explorative analyses of molecular biomarkers to gain insights into possible mechanisms of the effects of empagliflozin on human health in a systems medicine-oriented, multiomics approach. Conclusion By evaluating the short-term effect of empagliflozin with a comprehensive biobanking program, the EmDia Study offers an opportunity to primarily assess the effects on diastolic function but also to examine effects on clinical and molecular cardiovascular traits. Trial registration ClinicalTrials.gov; NCT02932436. Registration date, 2016/10/13.
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Affiliation(s)
- Claus Junger
- Preventive Cardiology and Preventive Medicine, Department of Cardiology.,Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main
| | - Jurgen H Prochaska
- Preventive Cardiology and Preventive Medicine, Department of Cardiology.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main.,Center for Thrombosis and Hemostasis (CTH)
| | - Tommaso Gori
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main.,Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology
| | - Harald Binder
- Institute of Medical Biometry and Statistics, University of Freiburg, Freiburg
| | - Andreas Daiber
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main.,Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz
| | - Thomas Koeck
- Preventive Cardiology and Preventive Medicine, Department of Cardiology.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Department of Cardiology
| | - Karl J Lackner
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main.,Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Munzel
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main.,Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz
| | - Philipp S Wild
- Preventive Cardiology and Preventive Medicine, Department of Cardiology.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main.,Center for Thrombosis and Hemostasis (CTH)
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49
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Kolwelter J, Bosch A, Jung S, Stabel L, Kannenkeril D, Ott C, Bramlage P, Schiffer M, Achenbach S, Schmieder RE. Effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on vascular function in patients with chronic heart failure. ESC Heart Fail 2021; 8:5327-5337. [PMID: 34544205 PMCID: PMC8712907 DOI: 10.1002/ehf2.13622] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 09/04/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS Impairment of vascular function contributes to the progression of chronic heart failure (HF) by increasing the afterload. Treatment with selective sodium-glucose cotransporter 2 (SGLT2) inhibitors improves the prognosis of HF, but the precise mechanisms remain unclear. The aim of this study was to analyse the effect of empagliflozin on vascular function in patients with HF. METHODS AND RESULTS In an investigator initiated, double-blind, randomized, placebo-controlled, parallel-group, clinical study, patients with HF NYHA II-III and an ejection fraction of 49% or less were randomized 2:1 to receive empagliflozin 10 mg once daily or placebo for 3 months. A total of 74 patients (15% female), aged 66 ± 9 years, with a mean ejection fraction of 39 ± 8% and a median NTproBNP of 558 pg/mL (IQR 219-1051 pg/mL), were included. Vascular parameters such as central systolic blood pressure (cSBP), central pulse pressure (cPP), forward (FPH), and reflected pressure pulse height (RPH) decreased under resting conditions after 1 and 3 months (1 month: cSBP -6.4 ± 8.3 mmHg, P < 0.001, cPP -3.0 ± 6.6 mmHg, P = 0.004, FPH -2.5 ± 4.5 mmHg, P = 0.001, RPH -1.6 ± 3.0 mmHg, P = 0.001; 3 months: cSBP -4.6 ± 8.4 mmHg, P = 0.001, cPP -3.1 ± 4.8 mmHg, P < 0.001, FPH -1.7 ± 3.7 mmHg, P = 0.004, RPH -1.4 ± 2.5 mmHg, P = 0.001) in patients treated with empagliflozin (n = 45). In accordance, cSBP and cPP decreased in patients with empagliflozin treatment under 24 h ambulatory conditions after 1 and 3 months (1 month: cSBP -4.8 ± 10.1 mmHg, P = 0.003, cPP -2.0 ± 5.7 mmHg, P = 0.026; 3 months: cSBP -4.7 ± 9.0 mmHg, P = 0.002, cPP -2.1 ± 6.4 mmHg, P = 0.044). In the placebo group, there was no significant change after 1 and 3 months. The decrease in cSBP under resting conditions (-5.7 ± 2.4 mmHg, P = 0.019) after 1 month and in cSBP (-6.0 ± 2.6, P = 0.027) as well as in pulse wave velocity (-0.5 ± 0.2 m/s, P = 0.021) under 24 h ambulatory conditions after 3 months was greater in the empagliflozin group than in the placebo group. CONCLUSIONS We found an improvement of vascular function after treatment with empagliflozin that indicates decreased afterload of the left ventricle and may contribute to the beneficial effects of SGLT2 inhibition in HF.
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Affiliation(s)
- Julie Kolwelter
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
- Department of CardiologyUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)ErlangenGermany
| | - Agnes Bosch
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
| | - Susanne Jung
- Department of CardiologyUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)ErlangenGermany
| | - Lena Stabel
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
| | - Dennis Kannenkeril
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
| | - Christian Ott
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive MedicineCloppenburgGermany
| | - Mario Schiffer
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
| | - Stephan Achenbach
- Department of CardiologyUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)ErlangenGermany
| | - Roland E. Schmieder
- Department of Nephrology and HypertensionUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nuremberg (FAU)Ulmenweg 18Erlangen91054Germany
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50
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Butt JH, Adamson C, Docherty KF, de Boer RA, Petrie MC, Inzucchi SE, Kosiborod MN, Maria Langkilde A, Lindholm D, Martinez FA, Bengtsson O, Schou M, O'Meara E, Ponikowski P, Sabatine MS, Sjöstrand M, Solomon SD, Jhund PS, McMurray JJV, Køber L. Efficacy and Safety of Dapagliflozin in Heart Failure With Reduced Ejection Fraction According to N-Terminal Pro-B-Type Natriuretic Peptide: Insights From the DAPA-HF Trial. Circ Heart Fail 2021; 14:e008837. [PMID: 34802253 DOI: 10.1161/circheartfailure.121.008837] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Effective therapies for HFrEF usually reduce NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, and it is important to establish whether new treatments are effective across the range of NT-proBNP. METHODS We evaluated both these questions in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) trial. Patients in New York Heart Association functional class II to IV with a left ventricular ejection fraction ≤40% and a NT-proBNP level ≥600 pg/mL (≥600 ng/L; ≥400 pg/mL if hospitalized for HF within the previous 12 months or ≥900 pg/mL if atrial fibrillation/flutter) were eligible. The primary outcome was the composite of an episode of worsening HF or cardiovascular death. RESULTS Of the 4744 randomized patients, 4742 had an available baseline NT-proBNP measurement (median, 1437 pg/mL [interquartile range, 857-2650 pg/mL]). Compared with placebo, treatment with dapagliflozin significantly reduced NT-proBNP from baseline to 8 months (absolute least-squares mean reduction, -303 pg/mL [95% CI, -457 to -150 pg/mL]; geometric mean ratio, 0.92 [95% CI, 0.88-0.96]). Dapagliflozin reduced the risk of worsening HF or cardiovascular death, irrespective of baseline NT-proBNP quartile; the hazard ratio for dapagliflozin versus placebo, from lowest to highest quartile was 0.43 (95% CI, 0.27-0.67), 0.77 (0.56-1.04), 0.78 (0.60-1.01), and 0.78 (0.64-0.95); P for interaction=0.09. Consistent benefits were observed for all-cause mortality. Compared with placebo, dapagliflozin increased the proportion of patients with a meaningful improvement (≥5 points) in Kansas City Cardiomyopathy Questionnaire total symptom score (P for interaction=0.99) and decreased the proportion with a deterioration ≥5 points (P for interaction=0.87) across baseline NT-proBNP quartiles. CONCLUSIONS In patients with HFrEF, dapagliflozin reduced NT-proBNP by 300 pg/mL after 8 months of treatment compared with placebo. In addition, dapagliflozin reduced the risk of worsening HF and death, and improved symptoms, across the spectrum of baseline NT-proBNP levels included in DAPA-HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (J.H.B., L.K.)
| | - Carly Adamson
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center and University of Groningen, the Netherlands (R.A.d.B.)
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT (S.E.I.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | | | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Herlev, Denmark (M. Schou)
| | - Eileen O'Meara
- Montreal Heart Institute, Université de Montréal, Quebec, Canada (E.O.)
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland (P.P.)
| | - Marc S Sabatine
- TIMI Study Group (M.S.S.), Brigham and Women's Hospital, Boston, MA.,Division of Cardiovascular Medicine (M.S.S., S.D.S.), Brigham and Women's Hospital, Boston, MA
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., O.B., M. Sjöstrand)
| | - Scott D Solomon
- Division of Cardiovascular Medicine (M.S.S., S.D.S.), Brigham and Women's Hospital, Boston, MA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (C.A., K.F.D., M.C.P., P.S.J., J.J.V.M.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (J.H.B., L.K.)
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