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Asil H, Demiryürek AT, Düzen IV, Büyükcelebi O, Saracaloglu A, Demirkiran C, Demiryürek Ş. Effects of empagliflozin and dapagliflozin on serum humanin, MOTS-c levels, nitrosative stress, and ferroptosis parameters in diabetic patients with heart failure. Eur J Pharmacol 2024; 982:176934. [PMID: 39182552 DOI: 10.1016/j.ejphar.2024.176934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/05/2024] [Accepted: 08/22/2024] [Indexed: 08/27/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors produce cardioprotective effects on heart failure (HF), even in the absence of diabetes. However, the underlying mechanisms of this cardioprotective effect remain unexplored. The purpose of this study was to examine the effects of SGLT2 inhibitors on serum MOTS-c, humanin levels, nitrosative stress, and ferroptosis parameters in diabetic patients with HF with reduced ejection fraction (HFrEF). A total of 74 adult diabetic patients with HFrEF and 37 healthy controls were included in this prospective study. Half of the patients were using SGLT2 inhibitors (empagliflozin or dapagliflozin) for at least two months. Serum nitric oxide and 3-nitrotyrosine levels were markedly higher in diabetic patients with HFrEF than the control (P < 0.001), but these elevations were inhibited with SGLT2 inhibitors. Although SGLT2 inhibitors had no marked effect on humanin levels, they significantly augmented MOTS-c levels when compared to the control. SGLT2 inhibitors augmented GPX4 but inhibited ACSL4 levels when compared to diabetic patients with HF. However, TFRC levels were increased in the patient group (P < 0.001 for all) but not modified with SGLT2 inhibitors. Our results suggest that increased nitrosative stress is significantly depressed by SGLT2 inhibitors. This study was the first to show that SGLT2 inhibitors can stimulate MOTS-c, but not humanin, in diabetic patients with HFrEF. SGLT2 inhibitors reduced ferroptosis through elevation of GPX4 and suppression of ACSL4 levels. Our data suggest that SGLT2 inhibitors could produce cardioprotective effects through relieving ferroptosis, inhibiting nitosative stress, and stimulating mitochondrial MOTS-c release.
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Affiliation(s)
- Hatice Asil
- Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | | | - Irfan Veysel Düzen
- Department of Cardiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Osman Büyükcelebi
- Department of Cardiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Ahmet Saracaloglu
- Department of Medical Pharmacology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Cahit Demirkiran
- Department of Medical Pharmacology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Şeniz Demiryürek
- Department of Physiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
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Aissaoui H, Pichard S, Gaulupeau V, Gautron E, Wajchert T, Assayag F, Gilles F, Duvillier P, Georges JL, Gibault-Genty G. [Preliminary evaluation of the interest of a therapeutic optimization cell on the titration of treatments for heart failure with reduced left ventricular ejection fraction and the quality of life of patients]. Ann Cardiol Angeiol (Paris) 2024; 73:101802. [PMID: 39317082 DOI: 10.1016/j.ancard.2024.101802] [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: 07/28/2024] [Accepted: 08/20/2024] [Indexed: 09/26/2024]
Abstract
INTRODUCTION A multidisciplinary therapeutic optimization unit (COT) was created in January 2023 at Versailles Hospital, aimed at therapeutic optimisation of patients with chronic heart failure with reduced left ventricular ejection fraction. The objective of the study was to assess the impact of the first year of COT activity on the sequential implementation and titration of heart failure treatments, the clinical evolution, and improvement of patients' quality of life. METHODS This prospective study included consecutive patients treated by the COT after hospitalisation for acute heart failure, from January to December 2023. Clinical, biological, titration, and tolerance data were analysed. Quality of life was assessed at baseline and at the end of the follow-up by COT, using standardized SF-12 and EQ-5D questionnaires. RESULTS We included 90 patients (men 73%, mean age 67 years). The mean left ventricular ejection fraction was 34 ± 10 %. At final visit (median number of visits 4 ; median follow-up duration 156 days), 76.7% of patients achieved optimisation with respect to maximum individually tolerated doses, but only 13.3% with respect to theoretical maximum doses for the four therapeutic classes. At 1-year follow up, total mortality was 4.4% (4/90), and 9 patients (10%) were rehospitalised unplanned for acute heart failure. COT monitoring was associated with significant improvement in NYHA class, left ventricular ejection fraction, and SF-12 and EQ-5D-5L quality of life scores. CONCLUSION Although titration of heart failure treatments remained suboptimal, significant improvement was observed for NYHA class, left ventricular ejection fraction, and patient quality of life parameters.
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Affiliation(s)
- Hanane Aissaoui
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Stéphane Pichard
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Violaine Gaulupeau
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Elodie Gautron
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Thibault Wajchert
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Franck Assayag
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Floriane Gilles
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Paul Duvillier
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Jean-Louis Georges
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Géraldine Gibault-Genty
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
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Soares RR, Viggiani LF, Reis Filho JM, Joviano-Santos JV. Cardioprotection of Canagliflozin, Dapagliflozin, and Empagliflozin: Lessons from preclinical studies. Chem Biol Interact 2024; 403:111229. [PMID: 39244185 DOI: 10.1016/j.cbi.2024.111229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 08/12/2024] [Accepted: 09/04/2024] [Indexed: 09/09/2024]
Abstract
Clinical and preclinical studies have elucidated the favorable effects of Inhibitors of Sodium-Glucose Cotransporter-2 (iSGLT2) in patients and animal models with type 2 diabetes. Notably, these inhibitors have shown significant benefits in reducing hospitalizations and mortality among patients with heart failure. However, despite their incorporation into clinical practice for indications beyond diabetes, the decision-making process regarding their use often lacks a systematic approach. The selection of iSGLT2 remains arbitrary, with only a limited number of studies simultaneously exploring the different classes of them. Currently, no unique guideline establishes their application in both clinical and basic research. This review delves into the prevalent use of iSGLT2 in animal models previously subjected to induced cardiac stress. We have compiled key findings related to cardioprotection across various animal models, encompassing diverse dosages and routes of administration. Beyond their established role in diabetes management, iSGLT2 has demonstrated utility as agents for safeguarding heart health and cardioprotection can be class-dependent among the iSGLT2. These findings may serve as valuable references for other researchers. Preclinical studies play a pivotal role in ensuring the safety of novel compounds or treatments for potential human use. By assessing side effects, toxicity, and optimal dosages, these studies offer a robust foundation for informed decisions, identifying interventions with the highest likelihood of success and minimal risk to patients. The insights gleaned from preclinical studies, which play a crucial role in highlighting areas of knowledge deficiency, can guide the exploration of novel mechanisms and strategies involving iSGLT2.
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Affiliation(s)
- Rayla Rodrigues Soares
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Laboratório de Investigações NeuroCardíacas, Ciências Médicas de Minas Gerais (LINC CMMG), Belo Horizonte, Minas Gerais, Brazil
| | - Larissa Freitas Viggiani
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Laboratório de Investigações NeuroCardíacas, Ciências Médicas de Minas Gerais (LINC CMMG), Belo Horizonte, Minas Gerais, Brazil
| | - Juliano Moreira Reis Filho
- Post-Graduate Program in Health Sciences, Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Julliane V Joviano-Santos
- Post-Graduate Program in Health Sciences, Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Laboratório de Investigações NeuroCardíacas, Ciências Médicas de Minas Gerais (LINC CMMG), Belo Horizonte, Minas Gerais, Brazil.
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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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Shafqat A, Masters MC, Tripathi U, Tchkonia T, Kirkland JL, Hashmi SK. Long COVID as a disease of accelerated biological aging: An opportunity to translate geroscience interventions. Ageing Res Rev 2024; 99:102400. [PMID: 38945306 DOI: 10.1016/j.arr.2024.102400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/12/2024] [Accepted: 06/27/2024] [Indexed: 07/02/2024]
Abstract
It has been four years since long COVID-the protracted consequences that survivors of COVID-19 face-was first described. Yet, this entity continues to devastate the quality of life of an increasing number of COVID-19 survivors without any approved therapy and a paucity of clinical trials addressing its biological root causes. Notably, many of the symptoms of long COVID are typically seen with advancing age. Leveraging this similarity, we posit that Geroscience-which aims to target the biological drivers of aging to prevent age-associated conditions as a group-could offer promising therapeutic avenues for long COVID. Bearing this in mind, this review presents a translational framework for studying long COVID as a state of effectively accelerated biological aging, identifying research gaps and offering recommendations for future preclinical and clinical studies.
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Affiliation(s)
- Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Mary Clare Masters
- Division of Infectious Diseases, Northwestern University, Chicago, IL, USA
| | - Utkarsh Tripathi
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA
| | - Tamara Tchkonia
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA; Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Research and Innovation Center, Department of Health, Abu Dhabi, UAE; College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
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Chandramohan D, Simhadri PK, Jena N, Palleti SK. Strategies for the Management of Cardiorenal Syndrome in the Acute Hospital Setting. HEARTS 2024; 5:329-348. [DOI: 10.3390/hearts5030024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
Cardiorenal syndrome (CRS) is a life-threatening disorder that involves a complex interplay between the two organs. Managing this multifaceted syndrome is challenging in the hospital and requires a multidisciplinary approach to tackle the many manifestations and complications. There is no universally accepted algorithm to treat patients, and therapeutic options vary from one patient to another. The mainstays of therapy involve the stabilization of hemodynamics, decongestion using diuretics or renal replacement therapy, improvement of cardiac output with inotropes, and goal-directed medical treatment with renin–angiotensin–aldosterone system inhibitors, beta-blockers, and other medications. Mechanical circulatory support is another viable option in the armamentarium of agents that improve symptoms in select patients.
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Affiliation(s)
- Deepak Chandramohan
- Department of Internal Medicine/Nephrology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Prathap Kumar Simhadri
- Department of Nephrology, Advent Health/FSU College of Medicine, Daytona Beach, FL 32117, USA
| | - Nihar Jena
- Department of Internal Medicine/Cardiovascular Medicine, Trinity Health Oakland/Wayne State University, Pontiac, MI 48341, USA
| | - Sujith Kumar Palleti
- Department of Internal Medicine/Nephrology, LSU Health Shreveport, Shreveport, LA 71103, USA
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Álvarez-Zaballos S, Martínez-Sellés M. Impact of Sex and Diabetes in Patients with Heart Failure. Curr Heart Fail Rep 2024; 21:389-395. [PMID: 38698294 DOI: 10.1007/s11897-024-00666-w] [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] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is a complex clinical syndrome with a growing global health burden. This review explores the intersection of HF, diabetes mellitus, and sex, highlighting epidemiological patterns, pathophysiological mechanisms, and treatment implications. RECENT FINDINGS Despite similar HF prevalence in men and women, diabetes mellitus (DM) appears to exert a more pronounced impact on HF outcomes in women. Pathophysiological differences involve cardiovascular risk factors, severe left ventricular dysfunction, and coronary artery disease, as well as hormonal influences and inflammatory markers. Diabetic cardiomyopathy introduces a sex-specific challenge, with women experiencing common adverse outcomes related to increased fibrosis and myocardial remodeling. Treatment strategies, particularly sodium-glucose cotransporter 2 inhibitors, exhibit cardiovascular benefits, but their response may differ in women. The link between HF and DM is bidirectional, with diabetes significantly increasing the risk of HF, and vice versa. Additionally, the impact of diabetes on mortality appears more pronounced in women than in men, leading to a modification of the traditional gender gap observed in HF outcomes. A personalized approach is crucial, and further research to improve outcomes in the complex interplay of HF, diabetes, and sex is needed.
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Affiliation(s)
- Sara Álvarez-Zaballos
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.
- Universidad Europea, Universidad Complutense, Madrid, Spain.
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Savage P, Watson C, Coburn J, Cox B, Shahmohammadi M, Grieve D, Dixon L. Impact of SGLT2 inhibition on markers of reverse cardiac remodelling in heart failure: Systematic review and meta-analysis. ESC Heart Fail 2024. [PMID: 39056515 DOI: 10.1002/ehf2.14993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/13/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
INTRODUCTION Several landmark randomized-controlled trials (RCTs) have demonstrated the efficacy of sodium-glucose co-transport 2 (SGLT2) inhibitors in reducing all-cause mortality, cardiovascular (CV) mortality and heart failure (HF) hospitalizations. Much interest surrounds their mechanism of action and whether they have direct effects on reverse cardiac remodelling. Therefore, we conducted a meta-analysis of placebo controlled RCTs evaluating the impact of SGLT2 inhibition on imaging derived markers of reverse cardiac remodelling in patients with HF. METHODS We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and Cochrane Collaboration. Data interrogation of each major database including PubMed, EMBASE, MEDLINE and Cochrane Library was performed. RCTs evaluating HF patients >18 years comparing SGLT2 inhibitor versus placebo-control were included. Outcome measures included left ventricular end-diastolic volume and volume index (LVEDV/LVEDVi), left ventricular end-systolic volume and volume index (LVSDV/LVSDVi), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMi), left atrial volume index (LAVi) and left ventricular global longitudinal strain (LV GLS). Studies with an HF with preserved ejection fraction population were excluded from analysis of parameters, which would be significantly affected by baseline LVEF, such as volumes and LVEF. The mean difference and standard error were extracted from each study and a random effects model used pool the mean difference and standard error across studies. A pre-specified sub-group analysis was performed to stratify results according to imaging modality used (cardiac magnetic resonance imaging and echocardiography). This study is registered on PROSPERO: CRD42023482722. RESULTS Seven randomized, placebo-controlled trials in patients with HF comprising a total population of 657 patients were included. Overall LVEF of included studies ranged from 29 ± 8.0% to 55.5 ± 4.2%. In studies included in analysis of HFrEF parameters, baseline LVEF ranged from 29 ± 8% to 45.5 ± 12%. Pooled data demonstrated SGLT2 inhibition, compared with placebo control, resulted in significant improvements in mean difference of LVEDV [-11.62 ml (95% confidence interval, CI -17.90 to -5.25; z = 3.67, P = 0.0004)], LVEDVi [-6.08 ml (95% CI -9.96 to -2.20; z = 3.07; P = 0.002)], LVESV [-12.47 ml (95% CI -19.12 to -5.82; z = 3.68; P = 0.0002)], LVESVi [-6.02 ml (95% CI -10.34 to -1.70; z = 2.73; P = 0.006)], LVM [-9.77 g (95% CI -17.65 to -1.89; z = 2.43; P = 0.02)], LVMi (-3.52 g [95% CI -7.04 to 0.01; z = 1.96; P = 0.05)] and LVEF [+2.54 mL (95% CI 1.10 to 3.98; z = 3.62; P = 0.0005)]. No significant difference in GLS (n = 327) [+0.42% (95%CI -0.19 to 1.02; P = 0.18)] or LAVi [-3.25 ml (95% CI -8.20 to 1.69; z = 1.29; P = 0.20)] was noted. CONCLUSION This meta-analysis provides additional data and insight into the effects of SGLT2 inhibition on reverse cardiac remodelling in patients with HF. Compared with placebo control, we found that treatment with a SGLT2 inhibitor produced significant improvements in several markers of reverse cardiac remodelling.
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Affiliation(s)
- Patrick Savage
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Chris Watson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - Brian Cox
- Royal Victoria Hospital, Belfast, UK
| | | | - David Grieve
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lana Dixon
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Royal Victoria Hospital, Belfast, UK
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Ezhumalai B, Modi R, Panchanatham M, Kaliyamoorthy D. The contemporary role of sodium-glucose co-transporter 2 inhibitor (SGLT2i) and angiotensin receptor-neprilysin inhibitor (ARNI) in the management of heart failure: State-of-the-art review. Indian Heart J 2024; 76:229-239. [PMID: 39009078 PMCID: PMC11451353 DOI: 10.1016/j.ihj.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 05/11/2024] [Accepted: 07/12/2024] [Indexed: 07/17/2024] Open
Abstract
Novel therapies for heart failure with reduced ejection fraction (HFrEF) are angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose co-transporter 2 inhibitor (SGLT2i), etc. The purpose of this review is to determine the effects of ARNI and SGLT2i in heart failure (HF), compare the impact of SGLT2i with ARNI, and finally evaluate the current data regarding the combination of these two drugs in HF. Various trials on the respective medications have shown some significant reduction in all-cause mortality and cardiovascular (CV) death. The combination of these drugs has shown more CV benefits than monotherapy. There is emerging data about these two drugs in patients with heart failure with preserved ejection fraction (HFpEF). At present, there are less head-to-head comparison trials of these two drugs. This review provides insights on the current evidence, comparative efficacy, and combination therapy of ARNI and SGLT2i in managing HF, focussing on HFrEF and HFpEF.
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Affiliation(s)
- Babu Ezhumalai
- Department of Cardiology, Apollo Speciality Hospitals Vanagaram, Chennai, India.
| | - Ranjan Modi
- Department of Cardiology, Indraprastha Apollo Hospitals, New Delhi, India
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Fang Y, Chen L, Sun S, Ran X. Sodium-Glucose Transporter 2 Inhibitors in Heart Failure: An Overview of Systematic Reviews. J Cardiovasc Dev Dis 2024; 11:198. [PMID: 39057618 PMCID: PMC11276734 DOI: 10.3390/jcdd11070198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Several studies have shown that sodium-dependent glucose transporter 2 inhibitors can be used in the treatment of heart failure. This article summarized systematic reviews of sodium-dependent glucose transporter 2 inhibitors in the treatment of heart failure in order to evaluate efficacy and safety. Methods: We systematically searched eight electronic databases from inception to July 2023. We used Assessment of Multiple Systematic Reviews 2 to evaluate the methodological quality, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 to assess report quality, Risk of Bias in Systematic Review to assess the risk of bias, and Grading of Recommendations Assessment, Development, and Evaluation to rate the quality of evidence. Outcome: A total of 36 systematic reviews were included. Our results were classified as clear evidence of benefit: hospitalization for heart failure; possible benefit: cardiovascular death (mortality) and renal outcome composite; clear evidence of no effect or equivalence: atrial arrhythmias, ventricular arrhythmia, atrial fibrillation, and hypotension; possible harm: genital infection; insufficient evidence to draw a conclusion: atrial flutter, major adverse cardiovascular events, urinary tract infection, acute kidney injury, hypoglycemia, and bone fracture. Conclusions: Sodium-dependent glucose transporter 2 inhibitors are beneficial for the treatment of heart failure, especially in terms of heart failure hospitalization.
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Affiliation(s)
- Yixuan Fang
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.F.); (L.C.); (S.S.)
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Lihong Chen
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.F.); (L.C.); (S.S.)
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Shiyi Sun
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.F.); (L.C.); (S.S.)
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xingwu Ran
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.F.); (L.C.); (S.S.)
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu 610041, China
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11
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Blumer V, Januzzi JL, Lindenfeld J, Solomon SD, Psotka MA, Carson PE, Bristow MR, Abraham WT, Gandotra C, Saville BR, O'Connor C, Fiuzat M. Heart Failure Drug Development Over the Eras: From the Heart Failure Collaboratory. JACC. HEART FAILURE 2024:S2213-1779(24)00416-5. [PMID: 39001743 DOI: 10.1016/j.jchf.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/02/2024] [Accepted: 03/28/2024] [Indexed: 07/15/2024]
Abstract
Over the past decade, the field of heart failure (HF) has witnessed remarkable progress in drug development, resulting in the approval of numerous groundbreaking drugs by the U.S. Food and Drug Administration. To address some of these challenges, the U.S. Food and Drug Administration has issued guidance documents that have been critical in contemporary HF drug development; however, there are still many challenges in need of investigation. This article leverages efforts of the Heart Failure Collaboratory and the scientific community to discuss the critical need for innovative trial designs, important concepts in clinical trials in the modern era, and the utilization of big data to accelerate HF drug development. At this inflection point in HF drug development, it is imperative that, as a global scientific community, we foster increased collaboration among researchers, clinicians, patients, and regulatory bodies. Only through such unified efforts can we navigate the complexities of HF, accelerate the development process, and ultimately deliver effective therapies that transform patient outcomes.
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Affiliation(s)
- Vanessa Blumer
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Michael R Bristow
- Division of Cardiology, University of Colorado Anschutz Medial Campus, Aurora, Colorado, USA
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Charu Gandotra
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | | | - Christopher O'Connor
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
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12
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Fernandez-Patron C, Lopaschuk GD, Hardy E. A self-reinforcing cycle hypothesis in heart failure pathogenesis. NATURE CARDIOVASCULAR RESEARCH 2024; 3:627-636. [PMID: 39196226 DOI: 10.1038/s44161-024-00480-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/25/2024] [Indexed: 08/29/2024]
Abstract
Heart failure is a progressive syndrome with high morbidity and mortality rates. Here, we suggest that chronic exposure of the heart to risk factors for heart failure damages heart mitochondria, thereby impairing energy production to levels that can suppress the heart's ability to pump blood and repair mitochondria (both energy-consuming processes). As damaged mitochondria accumulate, the heart becomes deprived of energy in a 'self-reinforcing cycle', which can persist after the heart is no longer chronically exposed to (or after antagonism of) the risk factors that initiated the cycle. Together with other previously described pathological mechanisms, this proposed cycle can help explain (1) why heart failure progresses, (2) why it can recur after cessation of treatment, and (3) why heart failure is often accompanied by dysfunction of multiple organs. Ideally, therapy of heart failure syndrome would be best attempted before the self-reinforcing cycle is triggered or designed to break the self-reinforcing cycle.
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Affiliation(s)
- Carlos Fernandez-Patron
- Cardiovascular Research Centre, Department of Biochemistry, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
| | - Gary D Lopaschuk
- Cardiovascular Research Centre, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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13
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Lan X, Zhu H, Cao Y, Hu Y, Fan X, Zhang K, Wu M. Effects of different sodium-glucose cotransporter 2 inhibitors in heart failure with reduced or preserved ejection fraction: a network meta-analysis. Front Cardiovasc Med 2024; 11:1379765. [PMID: 38845687 PMCID: PMC11153861 DOI: 10.3389/fcvm.2024.1379765] [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: 01/31/2024] [Accepted: 04/22/2024] [Indexed: 06/09/2024] Open
Abstract
Background This systematic review and meta-analysis aimed to explore the effects of different sodium-glucose cotransporter-2 inhibitors (SGLT2i) on prognosis and cardiac structural remodeling in patients with heart failure (HF). Methods Relevant studies published up to 20 March 2024 were retrieved from PubMed, EMBASE, Web of Science, and Cochrane Library CNKI, China Biomedical Literature Service, VIP, and WanFang databases. We included randomized controlled trials of different SGLT2i and pooled the prognosis data of patients with HF. We compared the efficacy of different SGLT2i in patients with HF and conducted a sub-analysis based on left ventricular ejection fraction (LVEF). Results We identified 77 randomized controlled trials involving 43,561 patients. The results showed that SGLT2i significantly enhanced outcomes in HF, including a composite of hospitalizations for HF and cardiovascular death, individual hospitalizations for HF, Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, left atrial volume index (LAVi), and LVEF among all HF patients (P < 0.05) compared to a placebo. Sotagliflozin was superior to empagliflozin [RR = 0.88, CI (0.79-0.97)] and dapagliflozin [RR = 0.86, CI (0.77-0.96)] in reducing hospitalizations for HF and CV death. Dapagliflozin significantly reduced hospitalizations [RR = 0.51, CI (0.33-0.80)], CV death [RR = 0.73, CI (0.54-0.97)], and all-cause mortality [RR = 0.69, CI (0.48-0.99)] in patients with HF with reduced ejection fraction (HFrEF). SGLT2i also plays a significant role in improving cardiac remodeling and quality of life (LVMi, LVEDV, KCQQ) (P < 0.05). Among patients with HF with preserved ejection fraction (HFpEF), SGLT2i significantly improved cardiac function in HFpEF patients (P < 0.05). In addition, canagliflozin [RR = 0.09, CI (0.01-0.86)] demonstrated greater safety compared to sotagliflozin in a composite of urinary and reproductive infections of HFpEF patients. Conclusion Our systematic review showed that SGLT2i generally enhances the prognosis of patients with HF. Sotagliflozin demonstrated superiority over empagliflozin and dapagliflozin in a composite of hospitalization for HF and CV death in the overall HF patients. Canagliflozin exhibited greater safety compared to sotagliflozin in a composite of urinary and reproductive infections of HFpEF. Overall, the efficacy of SGLT2i was greater in HFrEF patients than in HFpEF patients.
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Affiliation(s)
- Xiaohua Lan
- Graduate School of Hebei North University, Zhangjiakou, Hebei, China
- Department of Geriatrics, Air Force Medical Center, Air Force Medical University, PLA, Beijing, China
| | - Huijing Zhu
- Graduate School of Hebei North University, Zhangjiakou, Hebei, China
| | - Yanjie Cao
- Department of Geriatrics, Air Force Medical Center, Air Force Medical University, PLA, Beijing, China
| | - Yue Hu
- Graduate School of China Medical University, Shenyang, Liaoning, China
| | - Xingman Fan
- Graduate School of Hebei North University, Zhangjiakou, Hebei, China
| | - Kaijie Zhang
- Graduate School of Hebei North University, Zhangjiakou, Hebei, China
| | - Mengdi Wu
- Graduate School of China Medical University, Shenyang, Liaoning, China
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14
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Rahhal A, Hamamyh T, Chapra A, Zaza KJ, Najim M, Hemadneh M, Faraj H, Kanjo W, Yasin A, Toba H, Mohammed W, Hamad MK, Al-Tikrety N, Baraa Habib M, Awaisu A, Mahfouz A, Alyafei S, Arabi AR, Patel A, Al-Hijji M. Sodium-glucose cotransporter-2 inhibitors improve cardiovascular outcomes post-acute coronary syndrome complicated by acute heart failure. Front Cardiovasc Med 2024; 11:1383669. [PMID: 38832317 PMCID: PMC11144919 DOI: 10.3389/fcvm.2024.1383669] [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: 02/07/2024] [Accepted: 04/24/2024] [Indexed: 06/05/2024] Open
Abstract
Background Acute coronary syndrome (ACS) remains a risk factor for heart failure (HF). Therefore, we aimed to assess the cardioprotective role of sodium-glucose cotransporter-2 (SGLT2) inhibitors post-ACS in patients with acute HF (AHF) and diabetes. Methods We conducted a retrospective observational cohort study employing propensity score matching. This study involved patients with diabetes admitted with ACS complicated by AHF, defined as either new clinical HF requiring diuretics during the index admission or having an ejection fraction (EF) of <40%. The study population was divided into two groups; (1) SGLT2 inhibitor users and (2) SGLT2 inhibitor non-users. The Cox proportional hazard regression analysis was used to evaluate the outcomes. Results A total of 465 patients (93% male; mean age, 55 ± 10 years) were included in this study. Using a 1 : 1 propensity score matching, 78 patients were included per arm with an absolute standardized difference of <0.1 for all baseline characteristics. The use of SGLT2 inhibitors resulted in lower composite outcomes of ACS, HF hospitalization, and all-cause mortality at 1 month and 12 months [1 month: 2.6% vs. 11.5%, HR = 0.20 (0.04-0.94), p = 0.041; 12 months: 14.1% vs. 23.1%, HR = 0.46 (0.22-0.99), p = 0.046]. Conclusion The findings suggest that SGLT2 inhibitors may confer cardioprotective effects in ACS-induced AHF, thereby widening the spectrum for indications of SGLT2 inhibitors.
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Affiliation(s)
- Alaa Rahhal
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Tahseen Hamamyh
- Cardiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ammar Chapra
- Cardiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Khaled J. Zaza
- Anesthesiology, Intensive Care and Perioperative Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Mostafa Najim
- Internal Medicine Department, Rochester Regional Health, New York, NY, United States
| | - Mohammad Hemadneh
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Hazem Faraj
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Wael Kanjo
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Yasin
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Haneen Toba
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Wafa Mohammed
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Nawras Al-Tikrety
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Mhd Baraa Habib
- Cardiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, Qatar University, Doha, Qatar
| | - Ahmed Mahfouz
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Sumaya Alyafei
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rahman Arabi
- Interventional Cardiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Patel
- Heart Failure Department, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Al-Hijji
- Interventional Cardiology Department, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
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15
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Yankah RK, Anku EK, Eligar V. Sodium-Glucose Cotransporter-2 Inhibitors and Cardiovascular Protection Among Patients With Type 2 Diabetes Mellitus: A Systematic Review. J Diabetes Res 2024; 2024:9985836. [PMID: 38766320 PMCID: PMC11102109 DOI: 10.1155/2024/9985836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/13/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Background: Accumulating evidence has demonstrated the positive effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors in managing patients with type 2 diabetes mellitus (T2DM). SGLT2 inhibitors protect patients with T2DM from cardiovascular complications and are generally safe. Aim: The aim of this study is to assess the cardiovascular effects of SGLT2 inhibitors in patients with T2DM. Methods: A systematic review was conducted using published English literature in PubMed and Google Scholar databases. Results: Most of the studies showed significant positive cardiovascular effects of SGLT2 inhibitors in patients with and without established cardiovascular disease (CVD). Empagliflozin reduced the risk of cardiovascular death, hospitalization for heart failure (HHF), cardiovascular death or heart failure, and major adverse cardiovascular events (MACE) such as nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death regardless of the number of cardiovascular risk factors. The effects of empagliflozin on cardiovascular events and mortality in patients with coronary artery bypass graft (CABG) were assessed. Further, the efficacy of empagliflozin in three different phenotypic groups, namely, younger patients with shorter duration of T2DM and highest glomerular filtration rate, women without coronary artery disease, and older adults with advanced coronary artery disease plus several comorbidities, was also assessed. The effects of canagliflozin were evaluated in patients with and without a history of CVD and with different body weights, and in those with and without prior heart failure. Treatment with canagliflozin based on multivariable-predicted cardiovascular risk factors prevented heart failure events more than treatment based on glycated hemoglobin and albuminuria alone. The efficacy of dapagliflozin was evaluated in patients with or at risk of atherosclerotic cardiovascular disease (ASCVD), heart failure status, and left ventricular ejection fraction (LVEF), as well as the elderly population. A reduction in HHF or cardiovascular death and insignificant reduction in MACE were noted. Furthermore, significant reduction in the risk of cardiovascular death and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF) was also observed. Sotagliflozin was studied for its cardiovascular outcomes in patients with chronic kidney disease with or without albuminuria and resulted in a reduction in cardiovascular-related deaths and HHF. Conclusion: SGLT2 inhibitors have beneficial cardiovascular effects in patients with T2DM and should be incorporated into their management.
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Affiliation(s)
- Richard K. Yankah
- Diabetes Specialist Clinic, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Eric K. Anku
- Dietherapy and Nutrition Unit, Cape Coast Teaching Hospital, P. O. Box CC 1363, Cape Coast, Ghana
| | - Vinay Eligar
- Department of Diabetes and Endocrinology, Imperial College London Diabetes Centre, Abu Dhabi, UAE
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16
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Shafiq A, Hameed I, Biegus J, Fudim M, Khan MS. Empagliflozin in the treatment of heart failure. Future Cardiol 2024; 20:251-261. [PMID: 38865086 PMCID: PMC11318725 DOI: 10.1080/14796678.2024.2360818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/24/2024] [Indexed: 06/13/2024] Open
Abstract
Heart failure (HF) affects more than 60 million individuals globally. Empagliflozin is currently approved for type 2 diabetes and chronic HF. Clinical trials have demonstrated that empagliflozin reduces the composite end point of hospitalizations for HF and mortality and improves the quality of life irrespective of left ventricular ejection fraction. Empagliflozin is a once-daily medication with minimal drug-drug interactions and does not require titration. Empagliflozin causes mild weight loss and does not significantly reduce blood pressure. Empagliflozin acts as an enabler for other HF drugs by reducing the risk of hyperkalemia. Empagliflozin is also beneficial for chronic kidney disease which exists commonly with HF. This review outlines the pharmacokinetics, pharmacodynamics, safety, and efficacy of empagliflozin in HF across various sub-groups and settings.
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Affiliation(s)
- Aimen Shafiq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ishaque Hameed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC 27708, USA
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17
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Marton A, Saffari SE, Rauh M, Sun RN, Nagel AM, Linz P, Lim TT, Takase-Minegishi K, Pajarillaga A, Saw S, Morisawa N, Yam WK, Minegishi S, Totman JJ, Teo S, Teo LLY, Ng CT, Kitada K, Wild J, Kovalik JP, Luft FC, Greasley PJ, Chin CWL, Sim DKL, Titze J. Water Conservation Overrides Osmotic Diuresis During SGLT2 Inhibition in Patients With Heart Failure. J Am Coll Cardiol 2024; 83:1386-1398. [PMID: 38599715 DOI: 10.1016/j.jacc.2024.02.020] [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: 12/06/2023] [Revised: 02/08/2024] [Accepted: 02/08/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors are believed to improve cardiac outcomes due to their osmotic diuretic potential. OBJECTIVES The goal of this study was to test the hypothesis that vasopressin-driven urine concentration overrides the osmotic diuretic effect of glucosuria induced by dapagliflozin treatment. METHODS DAPA-Shuttle1 (Hepato-renal Regulation of Water Conservation in Heart Failure Patients With SGLT-2 Inhibitor Treatment) was a single-center, double-blind, randomized, placebo-controlled trial, in which patients with chronic heart failure NYHA functional classes I/II and reduced ejection fraction were randomly assigned to receive dapagliflozin 10 mg daily or placebo (1:1) for 4 weeks. The primary endpoint was change from baseline in urine osmolyte concentration. Secondary endpoints included changes in copeptin levels and solute free water clearance. RESULTS Thirty-three randomized, sodium-glucose cotransporter 2 inhibitor-naïve participants completed the study, 29 of whom (placebo: n = 14; dapagliflozin: n = 15) provided accurate 24-hour urine collections (mean age 59 ± 14 years; left ventricular ejection fraction 31% ± 9%). Dapagliflozin treatment led to an isolated increase in urine glucose excretion by 3.3 mmol/kg/d (95% CI: 2.51-4.04; P < 0.0001) within 48 hours (early) which persisted after 4 weeks (late; 2.7 mmol/kg/d [95% CI: 1.98-3.51]; P < 0.0001). Dapagliflozin treatment increased serum copeptin early (5.5 pmol/L [95% CI: 0.45-10.5]; P < 0.05) and late (7.8 pmol/L [95% CI: 2.77-12.81]; P < 0.01), leading to proportional reductions in free water clearance (early: -9.1 mL/kg/d [95% CI: -14 to -4.12; P < 0.001]; late: -11.0 mL/kg/d [95% CI: -15.94 to -6.07; P < 0.0001]) and elevated urine concentrations (late: 134 mmol/L [95% CI: 39.28-229.12]; P < 0.01). Therefore, urine volume did not significantly increase with dapagliflozin (mean difference early: 2.8 mL/kg/d [95% CI: -1.97 to 7.48; P = 0.25]; mean difference late: 0.9 mL/kg/d [95% CI: -3.83 to 5.62]; P = 0.70). CONCLUSIONS Physiological-adaptive water conservation eliminated the expected osmotic diuretic potential of dapagliflozin and thereby prevented a glucose-driven increase in urine volume of approximately 10 mL/kg/d · 75 kg = 750 mL/kg/d. (Hepato-renal Regulation of Water Conservation in Heart Failure Patients With SGLT-2 Inhibitor Treatment [DAPA-Shuttle1]; NCT04080518).
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Affiliation(s)
- Adriana Marton
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore; Department of Internal Medicine 4-Nephrology and Hypertension, Paracelsus Private Medical School Nuremberg, Nuremberg, Germany.
| | | | - Manfred Rauh
- Research Laboratory, Division of Paediatrics, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ruo-Ning Sun
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore
| | - Armin M Nagel
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany; German Cancer Research Center (DKFZ), Division of Medical Physics in Radiology, Heidelberg, Germany
| | - Peter Linz
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Tzy Tiing Lim
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | | | | | - Sharon Saw
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Norihiko Morisawa
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Wan Keat Yam
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Shintaro Minegishi
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - John J Totman
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore; Radiography and Medical Imaging Department, Fatima College of Health Sciences, Abu Dhabi, United Arab Emirates
| | - Serena Teo
- Clinical Imaging Research Centre, Centre for Translational Medicine, Singapore
| | - Louis L Y Teo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Choon Ta Ng
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Johannes Wild
- Center for Cardiology, Cardiology I, Johannes Gutenberg-University, Mainz, Germany
| | - Jean-Paul Kovalik
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore
| | - Friedrich C Luft
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine, Medical Faculty of the Charité, Berlin, Germany
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Calvin W L Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - David K L Sim
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Jens Titze
- Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore; III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA.
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18
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Lang FM, Teruya S, Weinsaft A, Cuomo M, Santos AM, Nalbandian A, Bampatsias D, Maurer MS. Sodium-glucose cotransporter 2 inhibitors for transthyretin amyloid cardiomyopathy: Analyses of short-term efficacy and safety. Eur J Heart Fail 2024; 26:938-947. [PMID: 38488292 PMCID: PMC11141726 DOI: 10.1002/ejhf.3198] [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: 08/28/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS Despite their potential, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have not been well-studied in transthyretin amyloid cardiomyopathy (ATTR-CM) as randomized trials have excluded patients with this morbid disease. We performed a retrospective study assessing the short-term efficacy and safety of SGLT2i in ATTR-CM. METHODS AND RESULTS We screened consecutive patients seen at a tertiary care centre and identified 87 ATTR-CM patients treated with SGLT2i and 95 untreated control patients. Endpoints included changes in weight, loop diuretic dose, and cardiac/renal biomarkers. The median age of the overall population was 79 (interquartile range [IQR] 11) years. Nearly 90% of patients were male, and 93% were on a transthyretin stabilizer. Control patients demonstrated generally less severe disease at baseline compared to SGLT2i-treated patients, with lower median Columbia risk score (p < 0.001). Median follow-up time was 5.6 (IQR 5.2) and 8.4 (IQR 2.1) months in the SGLT2i and control cohorts, respectively. Compared with controls, SGLT2i treatment was associated with significantly greater reductions from baseline in weight, loop diuretic dose, and uric acid during follow-up (p < 0.001). While no significant between-group differences were observed on cardiac biomarkers, estimated glomerular filtration rate was significantly reduced versus controls 1 month after SGLT2i initiation (p = 0.002), but no significant differences were observed at later timepoints. Results were similar in a propensity score-matched analysis (n = 42 per cohort). A total of 10 (11.5%) patients discontinued SGLT2i, most commonly due to genitourinary symptoms. CONCLUSION Sodium-glucose cotransporter 2 inhibitors were well tolerated by most patients with ATTR-CM and appeared to improve volume status and combat diuretic resistance. Randomized studies are needed to confirm these findings.
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Affiliation(s)
- Frederick M. Lang
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Sergio Teruya
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Ariel Weinsaft
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Margaret Cuomo
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Alfonsina Mirabal Santos
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Ani Nalbandian
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Dimitrios Bampatsias
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
| | - Mathew S. Maurer
- Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY 10032
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Hullon D, Taherifard E, Al-Saraireh TH. The effect of the four pharmacological pillars of heart failure on haemoglobin level. Ann Med Surg (Lond) 2024; 86:1575-1583. [PMID: 38463117 PMCID: PMC10923357 DOI: 10.1097/ms9.0000000000001773] [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: 11/28/2023] [Accepted: 01/21/2024] [Indexed: 03/12/2024] Open
Abstract
Anaemia, a condition characterized by low levels of haemoglobin, is frequently observed in patients with heart failure (HF). Guideline-directed medical therapy improves HF outcomes by using medications like beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, along with mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors. In this study, we aimed to review the pathophysiology of anaemia in patients with HF and present the current evidence regarding the relationship between the main recommended medications for these patients and haemoglobin levels. The authors conducted a comprehensive search in the medical literature for relevant original clinical articles in which the four pharmacological pillars of HF were given to the patients; we, then, assessed whether the association of use of these medications and haemoglobin level or development of anaemia was provided. These common medications have been shown in the literature that may exacerbate or ameliorate anaemia. Besides, it has been shown that even in the case that they result in the development of anaemia, their use is associated with positive effects that outweigh this potential harm. The literature also suggests that among patients receiving medications with negative effects on the level of haemoglobin, there was no difference in the rate of mortality between anaemic and non-anaemic patients when both were on treatment for anaemia; this point highlights the importance of the detection and treatment of anaemia in these patients. Further research is needed to explore these relationships and identify additional strategies to mitigate the risk of anaemia in this population.
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Affiliation(s)
| | - Erfan Taherifard
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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20
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Kurozumi A, Shishido K, Yamashita T, Sato D, Uchida S, Koyama E, Tamaki Y, Hayashi T, Miyashita H, Yokoyama H, Ochiai T, Yamaguchi M, Moriyama N, Tobita K, Matsumoto T, Mizuno S, Yamanaka F, Tanaka Y, Murakami M, Takahashi S, Saito S. Sodium-Glucose Cotransporter-2 Inhibitors Stabilize Coronary Plaques in Acute Coronary Syndrome With Diabetes Mellitus. Am J Cardiol 2024; 214:47-54. [PMID: 38215815 DOI: 10.1016/j.amjcard.2023.12.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/13/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are widely used in cardiology and are effective in treating acute coronary syndrome (ACS). Their effects on unstable plaque in patients with ACS remains unclear. This study aimed to examine the effectiveness of SGLT2is in coronary plaque based on optical coherence tomography (OCT) images and the prognosis of ACS with type 2 diabetes mellitus. This retrospective study included 109 patients in the total cohort and 29 patients in the OCT cohort. Based on SGLT2i administration after ACS, the total cohort was categorized into non-SGLT2i (n = 69) and SGLT2i (n = 40) groups. The OCT cohort had 15 and 14 patients in the non-SGLT2i and SGLT2i groups, respectively. The OCT images of unstable plaque were analyzed in nonstented lesions during ACS catheterization and at the 6-month follow-up. The total cohort was assessed after 1 year for major adverse cardiovascular events, including all-cause mortality, revascularization, cerebrovascular disease, and heart failure hospitalization. SGLT2is improved unstable lesions with a significantly thicker fibrous cap (48 ± 15 μm vs 26 ± 24 μm, p = 0.005), reduced lipid arc (-29 ± 12° vs -18 ± 14°, p = 0.028), higher % decrease in total lipid arc (-35 ± 13% vs -19 ± 18%, p = 0.01), and lower major adverse cardiovascular event incidence (log-rank p = 0.023, hazard ratio 4.72 [1.08 to 20.63]) and revascularization rate (adjusted hazard ratio 6.77 [1.08 to 42.52]) than the non-SGLT2i group. In conclusion, SGLT2is can improve the markers of plaque stability and may improve the prognosis in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Atsumasa Kurozumi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Koki Shishido
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan.
| | | | - Daisuke Sato
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Syuhei Uchida
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Eiji Koyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yusuke Tamaki
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takahiro Hayashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hirokazu Miyashita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hiroaki Yokoyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Tomoki Ochiai
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masashi Yamaguchi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Noriaki Moriyama
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takashi Matsumoto
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yutaka Tanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Masato Murakami
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Shigeru Saito
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
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21
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Ostrominski JW, Vaduganathan M. Chapter 2: Clinical and Mechanistic Potential of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors in Heart Failure with Preserved Ejection Fraction. Am J Med 2024; 137:S9-S24. [PMID: 37160196 DOI: 10.1016/j.amjmed.2023.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/18/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as an important approach for the treatment of heart failure in patients with or without diabetes. Although the precise mechanisms underpinning their clinical impact remain incompletely resolved, mechanistic studies and insights from major clinical trials have demonstrated the impact of SGLT2 inhibitors on numerous cardio-renal-metabolic pathways of relevance to heart failure with preserved ejection fraction (HFpEF), which, in the contemporary era, constitutes approximately half of all patients with heart failure. Despite rates of morbidity and mortality that are commensurate with those of heart failure with reduced ejection fraction, disease-modifying therapies have comparatively been severely lacking. As such, HFpEF remains among the greatest unmet needs in cardiovascular medicine. Within the past decade, HFpEF has been established as a highly integrated disorder, involving not only the cardiovascular system, but also the lungs, kidneys, skeletal muscle, and adipose tissue. Given their multisystem impact, SGLT2i offer unique promise in addressing the complex pathophysiology of HFpEF, and in recent randomized controlled trials, were shown to significantly reduce heart failure events and cardiovascular death in patients with HFpEF. Herein, we discuss several proposed mechanisms of clinical benefit of SGLT2i in HFpEF.
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Affiliation(s)
- John W Ostrominski
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass.
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22
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Spacht WA, Lau ES. A disease of her own? Unique features of heart failure in women. Climacteric 2024; 27:32-40. [PMID: 37768321 PMCID: PMC10843094 DOI: 10.1080/13697137.2023.2256673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
Heart failure (HF) is a significant and growing public health challenge for women. Compared with men, women tend to develop HF later in life and are more likely to experience HF with preserved ejection fraction. There are also significant sex differences in outcomes, with women reporting lower quality of life but overall better survival versus men. In this review, we summarize sex differences in traditional HF risk factors, such as hypertension, diabetes, obesity and coronary artery disease, as well as female-specific HF risk factors including menopause, pregnancy and adverse pregnancy outcomes, and breast cancer therapy. While our understanding of the sex-specific efficacy of HF therapy remains limited by the underrepresentation of women in major clinical trials, there is a suggestion of preferential benefit of specific agents for women. Further work is required to better understand the pathophysiology of HF in women uniquely and to increase representation of women in clinical trials.
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Affiliation(s)
| | - Emily S. Lau
- Cardiovascular Research Center and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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23
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Savage P, Dixon L, Grieve D, Watson C. SGLT2 Inhibition in Heart Failure: Clues to Cardiac Effects? Cardiol Rev 2024:00045415-990000000-00189. [PMID: 38189526 DOI: 10.1097/crd.0000000000000637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Following the publication of several landmark clinical trials such as dapagliflozin in patients with heart failure and reduced ejection fraction, dapagliflozin evaluation to improve the lives of patients with preserved ejection fraction heart failure, and empagliflozin outcome trial in patients with chronic heart failure with preserved ejection fraction, sodium-glucose cotransport 2 inhibitors have been rapidly incorporated as a guideline-directed therapy in the treatment of heart failure. Moreover, their benefits appear to extend across the spectrum of left ventricular dysfunction which in some respects, can be seen as the holy grail of heart failure pharmacotherapy. Despite its plethora of proven cardioprotective benefits, the mechanisms by which it exerts these effects remain poorly understood, however, it is clear that these extend beyond that of promotion of glycosuria and natriuresis. Several hypotheses have emerged over the years including modification of cardiovascular risk profile via weight reduction, improved glucose homeostasis, blood pressure control, and natriuretic effect; however, these mechanisms do not fully explain the potent effects of the drug demonstrated in large-scale randomized trials. Other mechanisms may be at play, specifically the down-regulation of inflammatory pathways, improved myocardial sodium homeostasis, modulation of profibrotic pathways, and activation of nutrient deprivation signaling pathways promoting autophagic flux. This review seeks to summarize the cardioprotective benefits demonstrated in major clinical trials and provide a succinct review of the current theories of mechanisms of action, based on the most recent evidence derived from both clinical and laboratory data.
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Affiliation(s)
| | - Lana Dixon
- From the Royal Victoria Hospital Cardiology Department
| | - David Grieve
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, Northern Ireland
| | - Chris Watson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, Northern Ireland
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24
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Aldafas R, Crabtree T, Alkharaiji M, Vinogradova Y, Idris I. Sodium-glucose cotransporter-2 inhibitors (SGLT2) in frail or older people with type 2 diabetes and heart failure: a systematic review and meta-analysis. Age Ageing 2024; 53:afad254. [PMID: 38287703 PMCID: PMC10825241 DOI: 10.1093/ageing/afad254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/09/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) reduce cardio-metabolic and renal outcomes in patients with type 2 diabetes (T2D) but their efficacy and safety in older or frail individuals remains unclear. METHODS We searched PubMed, Scopus, Web of Science, Cochrane CENTRA and Google Scholar and selected randomised controlled trials and observational studies comparing SGLT2Is versus placebo/other glucose-lowering agent for people with frailty or older individuals (>65 years) with T2D and heart failure (HF). Extracted data on the change in HbA1c % and safety outcomes were pooled in a random-effects meta-analysis model. RESULTS We included data from 20 studies (22 reports; N = 77,083 patients). SGLT2Is did not significantly reduce HbA1c level (mean difference -0.13, 95%CI: -0.41 to 0.14). SGLT2Is were associated with a significant reduction in the risk of all-cause mortality (risk ratio (RR) 0.81, 95%CI: -0.69 to 0.95), cardiac death (RR 0.80, 95%CI: -0.94 to 0.69) and hospitalisation for heart failure (HHF) (RR 0.69, 95%CI: 0.59-0.81). However, SGLT2Is did not demonstrate significant effect in reducing in the risk of macrovascular events (acute coronary syndrome or cerebral vascular occlusion), renal progression/composite renal endpoint, acute kidney injury, worsening HF, atrial fibrillation or diabetic ketoacidosis. CONCLUSIONS In older or frail patients with T2D and HF, SGLT2Is are consistently linked with a decrease in total mortality and the overall burden of cardiovascular (CV) events, including HHF events and cardiac death, but not protective for macrovascular death or renal events. Adverse events were more difficult to quantify but the risk of diabetic ketoacidosis or acute kidney injury was not significantly increase.
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Affiliation(s)
- Rami Aldafas
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Tomas Crabtree
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
| | - Mohammed Alkharaiji
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham NG2 7RD, UK
| | - Iskandar Idris
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, NIHR, Nottingham BRC, University of Nottingham, Derby, UK
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25
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Song B, Zhang H, Zhou B. RETRACTED ARTICLE: Effects of Dapagliflozin on myocardial remodeling, inflammatory factors, and cardiac events in heart failure with preserved ejection fraction. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:629. [PMID: 37368031 DOI: 10.1007/s00210-023-02590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/17/2023] [Indexed: 06/28/2023]
Affiliation(s)
- BoFan Song
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Anhui, 230022, Hefei, People's Republic of China
| | - Hao Zhang
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Anhui, 230022, Hefei, People's Republic of China
| | - Birong Zhou
- Department of Cardiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Anhui, 230022, Hefei, People's Republic of China.
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Verma S, Mudaliar S, Greasley PJ. Potential Underlying Mechanisms Explaining the Cardiorenal Benefits of Sodium-Glucose Cotransporter 2 Inhibitors. Adv Ther 2024; 41:92-112. [PMID: 37943443 PMCID: PMC10796581 DOI: 10.1007/s12325-023-02652-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/17/2023] [Indexed: 11/10/2023]
Abstract
There is a bidirectional pathophysiological interaction between the heart and the kidneys, and prolonged physiological stress to the heart and/or the kidneys can cause adverse cardiorenal complications, including but not limited to subclinical cardiomyopathy, heart failure and chronic kidney disease. Whilst more common in individuals with Type 2 diabetes, cardiorenal complications also occur in the absence of diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were initially approved to reduce hyperglycaemia in patients with Type 2 diabetes. Recently, these agents have been shown to significantly improve cardiovascular and renal outcomes in patients with and without Type 2 diabetes, demonstrating a robust reduction in hospitalisation for heart failure and reduced risk of progression of chronic kidney disease, thus gaining approval for use in treatment of heart failure and chronic kidney disease. Numerous potential mechanisms have been proposed to explain the cardiorenal effects of SGLT2i. This review provides a simplified summary of key potential cardiac and renal mechanisms underlying the cardiorenal benefits of SGT2i and explains these mechanisms in the clinical context. Key mechanisms related to the clinical effects of SGLT2i on the heart and kidneys explained in this publication include their impact on (1) tissue oxygen delivery, hypoxia and resultant ischaemic injury, (2) vascular health and function, (3) substrate utilisation and metabolic health and (4) cardiac remodelling. Knowing the mechanisms responsible for SGLT2i-imparted cardiorenal benefits in the clinical outcomes will help healthcare practitioners to identify more patients that can benefit from the use of SGLT2i.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
| | - Sunder Mudaliar
- Endocrinology/Diabetes Section, Veterans Affairs Medical Centre, San Diego, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Palanca A, Ampudia-Blasco FJ, Calderón JM, Sauri I, Martinez-Hervás S, Trillo JL, Redón J, Real JT. Comparison of GLP-1 receptor agonists and other Glucose-Lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and Obesity: A Spanish Real-World Population-Based study. Diabetes Res Clin Pract 2024; 207:111071. [PMID: 38142748 DOI: 10.1016/j.diabres.2023.111071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
AIMS Assess the impact of glucagon-like peptide receptor agonists (GLP-1RA) compared to other glucose-lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and obesity in a Spanish metropolitan area. METHODS A retrospective population-based type 2 diabetes cohort was identified from the Valencia Clinic-Malvarrosa Department electronic databases (2014-2019). Study groups included GLP-1RA, sodium-glucose co-transporter-2 inhibitors (SGLT2i), Insulin, and Miscellany (other glucose-lowering agents). 1:1:1:1 propensity score matching was conducted. The primary outcome was a composite of major adverse cardiovascular events (4-point MACE) comprising myocardial infarction, stroke, all-cause mortality, and heart failure. Secondary outcomes included individual 4-point MACE components. Hazard ratios were estimated using Cox regression analyses against the Miscellany group. RESULTS From 26,944 subjects, 1,848 adults were selected per group. GLP-1RA did not show a significant reduction in 4-point MACE risk (HR 1.05 [95%CI 0.82-1.34]). SGLT2i significantly reduced the risk of heart failure (HR 0.16 [95%CI 0.05-0.54]) and atrial fibrillation (HR 0.58, [95%CI 0.35-0.95]). The Insulin group exhibited a higher risk for 4-point MACE and most individual outcomes compared to GLP-1RA and SGLT2i. CONCLUSIONS Our findings do not provide evidence of a reduced cardiovascular risk, as assessed by 4-point MACE, with GLP-1RA. In contrast, SGLT2i demonstrated protective effects against heart failure and atrial fibrillation.
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Affiliation(s)
- Ana Palanca
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain.
| | - F Javier Ampudia-Blasco
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain.
| | | | | | - Sergio Martinez-Hervás
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
| | - José Luis Trillo
- Department of Health of Valencia Clínico-Malvarrosa, Valencia, Spain
| | - Josep Redón
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - José T Real
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
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28
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Dhingra NK, Verma S, Butler J, Anker SD, Ferreira JP, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Zaremba-Pechmann L, Böhm M, Nordaby M, Brueckmann M, Pocock SJ, Zannad F, Packer M. Efficacy and Safety of Empagliflozin According to Background Diuretic Use in HFrEF: Post-Hoc Analysis of EMPEROR-Reduced. JACC. HEART FAILURE 2024; 12:35-46. [PMID: 37715769 DOI: 10.1016/j.jchf.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND The EMPEROR-Reduced (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction) trial established the efficacy of empagliflozin in reducing heart failure (HF) outcomes among patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVES The authors examined the outcomes of EMPEROR-Reduced as a function of background diuretic therapy. METHODS The EMPEROR-Reduced trial was a double-blind, randomized controlled trial of placebo vs empagliflozin 10 mg among 3,730 HFrEF patients. Herein, the population was stratified into 4 groups: no diuretic and diuretic dose equivalent to furosemide <40, 40, and >40 mg daily at baseline. RESULTS A total of 3,656 patients from the EMPEROR-Reduced trial were available for analysis. Of those patients, 482 (13.2%) were receiving no diuretic therapy, and 731 (20.0%), 1,411 (38.6%), and 1,032 (28.2%) were receiving <40 mg, 40 mg, and >40 mg, respectively. The efficacy of empagliflozin on the primary outcome (time to first event of hospitalization for HF or cardiovascular [CV] death) was consistent regardless of background diuretic therapy (>40 mg: HR: 0.88 [95% CI: 0.71-1.10]; 40 mg: HR: 0.65 [95% CI: 0.51-0.82]; <40 mg: HR: 0.65 [95% CI: 0.46-0.92]); no diuretic agents: HR: 0.78 [95% CI: 0.47-1.29]; Ptrend test = 0.192). Baseline diuretic doses did not influence the effect of empagliflozin on body weight, systolic blood pressure, NT-proBNP, or hematocrit at 52 weeks. The safety profile of empagliflozin vs placebo was unaffected by baseline diuretic dose; however, independently of treatment allocation, total rates of adverse events were higher among patients with higher baseline doses of diuretic agents. CONCLUSIONS Empagliflozin exhibits a consistent effect on time to CV death or HF hospitalization and an unaltered safety profile regardless of baseline diuretic therapy. (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977).
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Affiliation(s)
- Nitish K Dhingra
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; University of Mississippi, Jackson, Mississippi, USA
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Nancy, France; Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France; UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-NUS Medical School, Singapore
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Scotland, United Kingdom
| | | | - Michael Böhm
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Nancy, France; Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA; Imperial College, London, United Kingdom
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Domingo M, Ruiz-Cueto M, Teis A, Lupón J, Alonso N, Bayés-Genís A. SGLT2i and loop diuretic withdrawal or downtitration in heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:943-945. [PMID: 37331585 DOI: 10.1016/j.rec.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023]
Affiliation(s)
- Mar Domingo
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - María Ruiz-Cueto
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Albert Teis
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Josep Lupón
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Nuria Alonso
- Servei d'Endocrinología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Servei de Cardiología, Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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30
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Ikeda S, Sato K, Takeda M, Shinozaki M, Miki K, Hirano M, Fukuda K, Shiba N. Oncostatin M mediates cardioprotection via angiogenesis in ischemic heart disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 35:100331. [PMID: 38511182 PMCID: PMC10946052 DOI: 10.1016/j.ahjo.2023.100331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 03/22/2024]
Abstract
Objective Oncostatin M (OSM) is an inflammatory cytokine belonging to the interleukin-6 family member, which plays an important role in various cardiovascular diseases. We recently reported increased serum OSM levels in patients with coronary artery disease. However, the specific role in HF with ischemic heart disease (IHD) remains unclear. Methods and results A total of 120 patients with HF and 48 control subjects were enrolled in this study. Serum OSM levels were measured using a sandwich technique immunoassay during the compensated state. The results revealed significantly higher serum OSM levels in HF patients compared to controls. Importantly, HF patients with IHD had higher OSM levels, and those with collateral flow showed the even higher levels, indicating a potential involvement in angiogenesis. Furthermore, a positive correlation was found between serum OSM levels and levels of vascular endothelial growth factor (VEGF). In vitro experiments demonstrated that recombinant OSM upregulated VEGF production in cultured human coronary artery endothelial cells. We additionally observed that endogenous OSM levels were enhanced through exercise. Lastly, we identified the potential of SGLT2 inhibitors to enhance OSM production. Conclusions Serum OSM levels were elevated in HF patients, particularly in those with IHD Our data indicated that endogenous OSM induces VEGF production in the heart, suggesting the activation of angiogenesis, which can be further enhanced by exercise or SGLT2 inhibitors.
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Affiliation(s)
- Shohei Ikeda
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Koichi Sato
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Morihiko Takeda
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Mariko Shinozaki
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Keita Miki
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Michinori Hirano
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Koji Fukuda
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Nobuyuki Shiba
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan
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31
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Pandey AK, Bhatt DL, Pandey A, Marx N, Cosentino F, Pandey A, Verma S. Mechanisms of benefits of sodium-glucose cotransporter 2 inhibitors in heart failure with preserved ejection fraction. Eur Heart J 2023; 44:3640-3651. [PMID: 37674356 DOI: 10.1093/eurheartj/ehad389] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/07/2023] [Accepted: 05/29/2023] [Indexed: 09/08/2023] Open
Abstract
For decades, heart failure with preserved ejection fraction (HFpEF) proved an elusive entity to treat. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have recently been shown to reduce the composite of heart failure hospitalization or cardiovascular death in patients with HFpEF in the landmark DELIVER and EMPEROR-Preserved trials. While improvements in blood sugar, blood pressure, and attenuation of kidney disease progression all may play some role, preclinical and translational research have identified additional mechanisms of these agents. The SGLT2 inhibitors have intriguingly been shown to induce a nutrient-deprivation and hypoxic-like transcriptional paradigm, with increased ketosis, erythropoietin, and autophagic flux in addition to altering iron homeostasis, which may contribute to improved cardiac energetics and function. These agents also reduce epicardial adipose tissue and alter adipokine signalling, which may play a role in the reductions in inflammation and oxidative stress observed with SGLT2 inhibition. Emerging evidence also indicates that these drugs impact cardiomyocyte ionic homeostasis although whether this is through indirect mechanisms or via direct, off-target effects on other ion channels has yet to be clearly characterized. Finally, SGLT2 inhibitors have been shown to reduce myofilament stiffness as well as extracellular matrix remodelling/fibrosis in the heart, improving diastolic function. The SGLT2 inhibitors have established themselves as robust, disease-modifying therapies and as recent trial results are incorporated into clinical guidelines, will likely become foundational in the therapy of HFpEF.
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Affiliation(s)
- Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, 90 Main Street West, Hamilton, Ontario L8P 1H6, Canada
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Avinash Pandey
- Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada
| | - Nikolaus Marx
- Department of Internal Medicine, University Hospital Aachen, RWTH Aachen University, Templergraben 55, 52062 Aachen, Germany
| | - Francesco Cosentino
- Division of Cardiology, Department of Medicine, Solna, Karolinska Institutet, Norrbacka S1:02, Stockholm, SE 17177, Sweden
- Heart, Vascular and Neuro Theme, Department of Cardiology, Karolinska University Hospital, Anna Steckséns gata 41, 171 64 Solna, Sweden
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada
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32
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Riaz M, Smith SM, Dietrich EA, Winchester DE, Guo J, Park H. Comparative effectiveness of sodium-glucose cotransporter-2 inhibitors among patients with heart failure with preserved ejection fraction. Pharmacotherapy 2023; 43:1024-1031. [PMID: 37459069 DOI: 10.1002/phar.2853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended by the American Heart Association for management of heart failure with preserved ejection fraction (HFpEF), but little is known about their in-class comparative effectiveness in real-world settings. OBJECTIVES To assess the in-class comparative effectiveness of SGLT2i for preventing HF-related and all-cause hospitalizations among patients with HFpEF. METHODS Using MarketScan® Commercial and Medicare Supplemental research databases (2012-2020), this cohort study included adults with HFpEF treated with SGLT2i. Stabilized inverse probability treatment weighted Cox proportional hazards regression was used to compare HF-related and all-cause hospitalizations in three pairwise comparisons: dapagliflozin versus canagliflozin, empagliflozin versus canagliflozin, and dapagliflozin versus empagliflozin. Subgroup and sensitivity analyses were conducted to assess robustness of the main analysis. RESULTS In total, 3629 SGLT2i users (881 dapagliflozin, 1120 canagliflozin, and 1628 empagliflozin) were included. Compared with canagliflozin, dapagliflozin was associated with decreased risk of HF-related hospitalization (adjusted hazard ratio [aHR], 0.75; 95% confidence interval [CI], 0.56-1.01) and all-cause hospitalization (aHR, 0.84; 95% CI 0.73-0.97). Compared with canagliflozin, empagliflozin was associated with 55% decreased risk of HF-related hospitalization (aHR, 0.45; 95% CI 0.34-0.59) and 18% decreased risk of all-cause hospitalization (aHR, 0.82; 95% CI 0.73-0.93). Compared with empagliflozin, dapagliflozin was associated with 50% increased risk of HF-related hospitalization (aHR, 1.50; 95% CI 1.09-2.07) and a statistically nonsignificant increase in the risk of all-cause hospitalization (aHR, 1.05; 95% CI 0.92-1.20). CONCLUSIONS Compared with canagliflozin or dapagliflozin use, empagliflozin use was associated with decreased risk of HF-related and all-cause hospitalizations. Compared with canagliflozin, dapagliflozin was associated with a reduced risk of HF-related and all-cause hospitalizations.
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Affiliation(s)
- Munaza Riaz
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Lahore College for Women University, Lahore, Pakistan
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Ikeda Y, Iwakawa M, Kiyokawa H, Nakagami T, Kanzaki S, Ogawa A, Tabata T, Takahashi M, Kinoshita T, Shimizu K. A Case of Young Obese Heart Failure Patient Using Multidisciplinary Treatment Centered on the Fantastic Four Improved Cardio Ankle Vascular Index and Cardiac Function. Int Med Case Rep J 2023; 16:545-549. [PMID: 37727446 PMCID: PMC10506602 DOI: 10.2147/imcrj.s424567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023] Open
Abstract
Obesity-induced heart failure (HF) in young people is a serious problem. The treatments for HF have developed in recent years. The following four basic HF drugs have been widely recognized as the "Fantastic Four": beta-adrenergic blocking agents, mineralocorticoid receptor antagonists (MRA), sodium glucose transporter 2 inhibitors (SGLT2 inhibitors), and angiotensin receptor neprilysin inhibitors (ARNI). However, the interaction between the heart and blood vessels has not received much attention. The cardio-ankle vascular index (CAVI) is an arterial stiffness index that is unaffected by blood pressure at the time of measurement. A 34-year-old obese man was admitted with dyspnea and edema. His cardiac function was severely impaired, and CAVI was increased. After administration of multidisciplinary HF treatment centered on the "Fantastic Four", his cardiac function and CAVI improved dramatically in a short time period. This case suggests the importance of improvement both cardiac and vascular function for the treatment of HF.
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Affiliation(s)
- Yuki Ikeda
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Masahiro Iwakawa
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Hajime Kiyokawa
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Takahiro Nakagami
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Shinya Kanzaki
- Department of Rehabilitation, Toho University Sakura Medical Center, Chiba, Japan
| | - Akihiro Ogawa
- Department of Rehabilitation, Toho University Sakura Medical Center, Chiba, Japan
| | - Tsuyoshi Tabata
- Department of Clinical Functional Physiology, Toho University Sakura Medical Center, Chiba, Japan
| | - Mao Takahashi
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Toshio Kinoshita
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
- Department of Clinical Functional Physiology, Toho University Sakura Medical Center, Chiba, Japan
| | - Kazuhiro Shimizu
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
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34
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Su J, Luo Y, Hu S, Tang L, Ouyang S. Advances in Research on Type 2 Diabetes Mellitus Targets and Therapeutic Agents. Int J Mol Sci 2023; 24:13381. [PMID: 37686185 PMCID: PMC10487533 DOI: 10.3390/ijms241713381] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Diabetes mellitus is a chronic multifaceted disease with multiple potential complications, the treatment of which can only delay and prolong the terminal stage of the disease, i.e., type 2 diabetes mellitus (T2DM). The World Health Organization predicts that diabetes will be the seventh leading cause of death by 2030. Although many antidiabetic medicines have been successfully developed in recent years, such as GLP-1 receptor agonists and SGLT-2 inhibitors, single-target drugs are gradually failing to meet the therapeutic requirements owing to the individual variability, diversity of pathogenesis, and organismal resistance. Therefore, there remains a need to investigate the pathogenesis of T2DM in more depth, identify multiple therapeutic targets, and provide improved glycemic control solutions. This review presents an overview of the mechanisms of action and the development of the latest therapeutic agents targeting T2DM in recent years. It also discusses emerging target-based therapies and new potential therapeutic targets that have emerged within the last three years. The aim of our review is to provide a theoretical basis for further advancement in targeted therapies for T2DM.
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Affiliation(s)
- Jingqian Su
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, Fujian Normal University, Fuzhou 350117, China; (J.S.); (Y.L.); (S.H.); (L.T.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, Fujian Normal University, Fuzhou 350117, China
- Provincial University Key Laboratory of Cellular Stress Response and Metabolic Regulation, Fujian Normal University, Fuzhou 350117, China
| | - Yingsheng Luo
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, Fujian Normal University, Fuzhou 350117, China; (J.S.); (Y.L.); (S.H.); (L.T.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, Fujian Normal University, Fuzhou 350117, China
- Provincial University Key Laboratory of Cellular Stress Response and Metabolic Regulation, Fujian Normal University, Fuzhou 350117, China
| | - Shan Hu
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, Fujian Normal University, Fuzhou 350117, China; (J.S.); (Y.L.); (S.H.); (L.T.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, Fujian Normal University, Fuzhou 350117, China
- Provincial University Key Laboratory of Cellular Stress Response and Metabolic Regulation, Fujian Normal University, Fuzhou 350117, China
| | - Lu Tang
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, Fujian Normal University, Fuzhou 350117, China; (J.S.); (Y.L.); (S.H.); (L.T.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, Fujian Normal University, Fuzhou 350117, China
- Provincial University Key Laboratory of Cellular Stress Response and Metabolic Regulation, Fujian Normal University, Fuzhou 350117, China
| | - Songying Ouyang
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, Fujian Normal University, Fuzhou 350117, China; (J.S.); (Y.L.); (S.H.); (L.T.)
- Provincial University Key Laboratory of Microbial Pathogenesis and Interventions, Fujian Normal University, Fuzhou 350117, China
- Provincial University Key Laboratory of Cellular Stress Response and Metabolic Regulation, Fujian Normal University, Fuzhou 350117, China
- Key Laboratory of OptoElectronic Science and Technology for Medicine of the Ministry of Education, College of Life Sciences, Fujian Normal University, Fuzhou 350117, China
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35
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Chatur S, Vaduganathan M, Claggett B, Vardeny O, Desai AS, Jhund PS, de Boer RA, Lam CSP, Kosiborod MN, Shah SJ, Martinez F, Inzucchi SE, Hernandez AF, Haddad T, Mitter SS, Miao ZM, Petersson M, Maria Langkilde A, McMurray JJV, Solomon SD. Dapagliflozin and diuretic utilization in heart failure with mildly reduced or preserved ejection fraction: the DELIVER trial. Eur Heart J 2023; 44:2930-2943. [PMID: 37220093 PMCID: PMC10484057 DOI: 10.1093/eurheartj/ehad283] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 05/25/2023] Open
Abstract
AIMS Dapagliflozin reduced the combined risk of worsening heart failure or cardiovascular death among patients with heart failure with mildly reduced or preserved ejection fraction. In this study, the safety and efficacy of dapagliflozin according to background diuretic therapy and the influence of dapagliflozin on longitudinal diuretic use were evaluated. METHODS AND RESULTS In this pre-specified analysis of the Dapagliflozin Evaluation to Improve the LIVEs of Patients With Preserved Ejection Fraction Heart Failure (DELIVER) trial, the effects of dapagliflozin vs. placebo were assessed in the following subgroups: no diuretic, non-loop diuretic, and loop diuretic furosemide equivalent doses of <40, 40, and >40 mg, respectively. Of the 6263 randomized patients, 683 (10.9%) were on no diuretic, 769 (12.3%) were on a non-loop diuretic, and 4811 (76.8%) were on a loop diuretic at baseline. Treatment benefits of dapagliflozin on the primary composite outcome were consistent by diuretic use categories (Pinteraction = 0.64) or loop diuretic dose (Pinteraction = 0.57). Serious adverse events were similar between dapagliflozin and placebo arms, irrespective of diuretic use or dosing. Dapagliflozin reduced new initiation of loop diuretics by 32% [hazard ratio (HR) 0.68; 95% confidence interval (CI): 0.55-0.84, P < 0.001] but did not influence discontinuations/disruptions (HR 0.98; 95% CI: 0.86-1.13, P = 0.83) in follow-up. First sustained loop diuretic dose increases were less frequent, and sustained dose decreases were more frequent in patients treated with dapagliflozin: net difference of -6.5% (95% CI: -9.4 to -3.6; P < 0.001). The mean dose of loop diuretic increased over time in the placebo arm, a longitudinal increase that was significantly attenuated with treatment with dapagliflozin (placebo-corrected treatment effect of -2.5 mg/year; 95% CI: -1.5, -3.7, P < 0.001). CONCLUSION In patients with heart failure with mildly reduced or preserved ejection fraction, the clinical benefits of dapagliflozin relative to placebo were consistent across a wide range of diuretic categories and doses with a similar safety profile. Treatment with dapagliflozin significantly reduced new loop diuretic requirement over time.
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, MN, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore
| | - Mikhail N Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Tariq Haddad
- Department of Cardiology, Virginia Heart, Falls Church, VA, USA
| | | | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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36
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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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37
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Docherty KF, McDowell K, Welsh P, Osmanska J, Anand I, de Boer RA, Køber L, Kosiborod MN, Martinez FA, O'Meara E, Ponikowski P, Schou M, Berg DD, Sabatine MS, Morrow DA, Jarolim P, Hammarstedt A, Sjöstrand M, Langkilde AM, Solomon SD, Sattar N, Jhund PS, McMurray JJV. Association of Carbohydrate Antigen 125 on the Response to Dapagliflozin in Patients With Heart Failure. J Am Coll Cardiol 2023; 82:142-157. [PMID: 37407113 DOI: 10.1016/j.jacc.2023.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/17/2023] [Accepted: 05/02/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Elevated circulating carbohydrate antigen 125 (CA125) is a marker of congestion and a predictor of outcomes in acute heart failure (HF). Less is known about CA125 in chronic ambulatory HF with reduced ejection fraction. OBJECTIVES This study examined the association between baseline CA125 (and changes in CA125) and outcomes in patients with HF with reduced ejection fraction in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure; NCT03036124) trial and its relationship with the effect of dapagliflozin. METHODS The primary outcome was a composite of a first episode of worsening HF or cardiovascular death. CA125 was measured at baseline and 12 months following randomization. RESULTS Median baseline CA125 was 13.04 U/mL (IQR: 8.78-21.13 U/mL) in 3,123 of 4,774 patients with available data. Compared with CA125 ≤35 U/mL (upper limit of normal), patients with CA125 >35 U/mL were at a higher risk of the primary outcome (adjusted HR: 1.59; 95% CI: 1.29-1.96). The adjusted risks of the primary outcome relative to quartile 1 (Q1) (≤8.78 U/mL) were as follow: Q2, 8.79-13.04 U/mL (HR: 0.94; 95% CI: 0.71-1.24); Q3, 13.05-21.13 U/mL (HR: 1.22; 95% CI: 0.94-1.59); Q4, ≥21.14 U/mL (HR: 1.63; 95% CI: 1.28-2.09). The beneficial effect of dapagliflozin compared with placebo on the primary outcome was consistent whether CA125 was analyzed in quartiles (interaction P = 0.13) or as a continuous variable (interaction P = 0.75). The placebo-corrected relative change in CA125 at 12 months was -5.2% (95% CI: -10.6% to 0.5%; P = 0.07). CONCLUSIONS In DAPA-HF, elevated CA125 levels were an independent predictor of the risk of worsening HF or cardiovascular death. Dapagliflozin reduced the risk of worsening HF or cardiovascular death regardless of baseline CA125.
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Affiliation(s)
- Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Kirsty McDowell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Paul Welsh
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Joanna Osmanska
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom. https://twitter.com/Kieranfdocherty
| | - Inder Anand
- Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Rudolf A de Boer
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands. https://twitter.com/UoGHeartFailure
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Felipe A Martinez
- Instituto Docencia Asistencia Médica e Investigación Clinica, Cordoba National University, Cordoba, Argentina
| | - Eileen O'Meara
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | | | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - David D Berg
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; TIMI Study Group, Boston, Massachusetts, USA
| | - Marc S Sabatine
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; TIMI Study Group, Boston, Massachusetts, USA
| | - David A Morrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; TIMI Study Group, Boston, Massachusetts, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ann Hammarstedt
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Mikaela Sjöstrand
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Naveed Sattar
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom.
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Forzano I, Wilson S, Lombardi A, Jankauskas SS, Kansakar U, Mone P, Varzideh F, Santulli G. SGLT2 inhibitors: an evidence-based update on cardiovascular implications. Expert Opin Investig Drugs 2023; 32:839-847. [PMID: 37740906 PMCID: PMC10591907 DOI: 10.1080/13543784.2023.2263354] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/22/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Sodium Glucose co-Transporter 2 (SGLT2) inhibitors (also known as 'gliflozins') represent a cornerstone to treat diabetes mellitus. Moreover, recent randomized clinical trials have demonstrated important cardioprotective effects of gliflozins, independent of the presence of diabetes. Herein, we summarize the recent therapeutic progress in the cardiovascular field obtained with SGLT2 inhibitors. AREA COVERED We critically examine the rationale and results of recent clinical studies examining the effects of SGLT2 inhibitors on cardiovascular outcomes, along with a brief overview of the main ongoing trials that have been designed in order to answer the many pending questions in the field of gliflozins and cardiovascular disease. EXPERT OPINION The favorable results of several clinical trials have broadened the therapeutic scenario for SGLT2 inhibitors, opening, at the same time, new challenges. Additionally, recent preclinical findings have evidenced off-target effects of SGLT2 inhibitors.
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Affiliation(s)
| | - Scott Wilson
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Angela Lombardi
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | | | - Urna Kansakar
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Pasquale Mone
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Fahimeh Varzideh
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Gaetano Santulli
- University of Naples “Federico II”
- Department of Medicine, Albert Einstein College of Medicine, New York City, NY, USA
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Aziri B, Begic E, Jankovic S, Mladenovic Z, Stanetic B, Kovacevic‐Preradovic T, Iglica A, Mujakovic A. Systematic review of sodium-glucose cotransporter 2 inhibitors: a hopeful prospect in tackling heart failure-related events. ESC Heart Fail 2023; 10:1499-1530. [PMID: 36967133 PMCID: PMC10192234 DOI: 10.1002/ehf2.14355] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/13/2023] [Accepted: 02/16/2023] [Indexed: 03/28/2023] Open
Abstract
In modern cardiology, sodium-glucose cotransporter 2 (SGLT2) inhibitors are critical components of heart failure (HF) treatment algorithms and exert their effects primarily by preventing glucose reabsorption and facilitating its urinary excretion. The objective was to systematically review randomized controlled trials (RCTs) assessing the effects of SGLT2 inhibitors, particularly canagliflozin, empagliflozin, dapagliflozin, ertugliflozin, sotagliflozin (dual SGLT inhibitor), and their use in HF. Systematic searches of PubMed/Medline, The Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases were performed. There were no restrictions imposed on the date and status of publication; however, there were restrictions on language for the searched studies. A total of 1139 records were identified in the bibliographic searches from both databases and the register of choice for this systematic review. Following duplicate removal, screening for titles and abstracts, and thorough assessment of full-text articles, 12 RCTs met the inclusion criteria. Altogether, 83 878 patients were included in this review. Among the included studies, two RCTs, with six respective reports, investigated canagliflozin, four RCTs with 13 derived reports investigated dapagliflozin, three RCTs with 12 separate reports studied the effects of empagliflozin, one RCT and its three respective reports assessed ertugliflozin's effects, and two RCTs with one added report investigated the dual inhibitor sotagliflozin. Pooled meta-analytic effects of SGLT2 inhibitors were as follows: on atrial fibrillation odds ratio (OR) = 0.83, 95% confidence interval (CI): 0.68-1.01, prediction interval (PI): 0.57-1.19; on HF hospitalization OR = 0.69, 95% CI: 0.60-0.78, PI: 0.60-0.78; on cardiovascular death OR = 0.82, 95% CI: 0.58-1.15, PI: 0.42-1.60; and on major adverse cardiovascular events OR = 0.90, 95% CI: 0.77-1.06, PI: 0.71-1.15. SGLT2 inhibitors significantly improve the quality of life in HF patients. Their beneficial effects on HF, especially in left ventricular dysfunction, have made their use possible irrespective of diabetes mellitus or atrial fibrillation status.
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Affiliation(s)
- Buena Aziri
- Sarajevo Medical SchoolSarajevo School of Science and TechnologySarajevoBosnia and Herzegovina
| | - Edin Begic
- Sarajevo Medical SchoolSarajevo School of Science and TechnologySarajevoBosnia and Herzegovina
- General Hospital “Prim. Dr. Abdulah Nakas”SarajevoBosnia and Herzegovina
| | | | | | - Bojan Stanetic
- Faculty of MedicineUniversity of Banja Luka, University Clinical Centre of the Republic of SrpskaBanja LukaRepublic of SrpskaBosnia and Herzegovina
| | - Tamara Kovacevic‐Preradovic
- Faculty of MedicineUniversity of Banja Luka, University Clinical Centre of the Republic of SrpskaBanja LukaRepublic of SrpskaBosnia and Herzegovina
| | - Amer Iglica
- Clinic for Heart, Blood Vessel and Rheumatic DiseasesClinical Center University of SarajevoSarajevoBosnia and Herzegovina
| | - Aida Mujakovic
- General Hospital “Prim. Dr. Abdulah Nakas”SarajevoBosnia and Herzegovina
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Malik ME, Falkentoft AC, Jensen J, Zahir D, Parveen S, Alhakak A, Andersson C, Petrie MC, Sattar N, McMurray JJ, Køber L, Schou M. Discontinuation and reinitiation of SGLT-2 inhibitors and GLP-1R agonists in patients with type 2 diabetes: a nationwide study from 2013 to 2021. Lancet Reg Health Eur 2023. [DOI: 10.1016/j.lanepe.2023.100617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
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Reis T, Ronco F, Ostermann M. Diuretics and Ultrafiltration in Heart Failure. Cardiorenal Med 2023; 13:56-65. [PMID: 36630939 DOI: 10.1159/000529068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023] Open
Abstract
Fluid overload is a risk factor for increased morbidity and mortality, especially in patients with heart disease. The treatment options are limited to diuretics and mechanical fluid removal using ultrafiltration or renal replacement therapy. This paper provides an overview of the challenges of managing fluid overload, outlines the risks and benefits of different pharmacological options and extracorporeal techniques, and provides guidance for clinical practice.
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Affiliation(s)
- Thiago Reis
- Division of Kidney Transplantation, D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Asa Norte, Campus Darcy Ribeiro, Brasília, Brazil
| | - Federico Ronco
- Interventional Cardiology, Ospedale dell'Angelo, Mestre, Venezia, Italy
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
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42
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Gitto M, Villaschi A, Federici M, Condorelli G, Stefanini GG. The Emerging Role of Sodium-glucose Cotransporter 2 Inhibitors in Heart Failure. Curr Pharm Des 2023; 29:481-493. [PMID: 36799420 DOI: 10.2174/1381612829666230217143324] [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: 07/21/2022] [Revised: 12/24/2022] [Accepted: 12/30/2022] [Indexed: 02/18/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively novel drug class that most cardiologists are becoming familiar with. By contrasting glucose reabsorption in the proximal convoluted tubule of the nephron, SGLT2 inhibition results in glycosuria with improved glycemic control. Although originally introduced as anti-diabetic medications, the cardiovascular effects of SGLT2i have progressively emerged, leading them to become one of the four pillars for the treatment of heart failure with reduced ejection fraction (HFrEF) according to the 2021 guidelines from the European Society of Cardiology. Also, two recent randomized trials have demonstrated SGLT2i as the first compounds with proven prognostic impact in heart failure with preserved ejection fraction (HFpEF), setting a milestone in the treatment for this condition. While the exact pathogenic mechanisms mediating the substantial reduction in cardiovascular death and heart failure (HF) hospitalizations are still controversial, there is growing clinical evidence on the efficacy and safety of SGLT2i in various subsets of patients with HF. As known, heart failure is a complex and heterogeneous clinical syndrome with a magnitude of phenotypes and a variety of underlying hemodynamic and physiological aspects which cannot be fully incorporated into the traditional left ventricular ejection fraction based classification adopted in clinical trials. The aim of this review is to provide an overview of the cardiovascular benefits and indications of SGLT2i across different HF patterns and to highlight current gaps in knowledge that should be addressed by future research.
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Affiliation(s)
- Mauro Gitto
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Center for Atherosclerosis, Policlinico Tor Vergata, Rome, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
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Golubovskaya DP, Karetnikova VN, Oleinik IR, Barbarash OL. A New Chapter in the Treatment of Patients with Heart Failure. The Role of Sodium-Glucose Co-transporter Type 2 Inhibitors. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-10-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Heart failure (HF) remains one of the major social and medical public health problems worldwide. Despite new advances in the treatment of patients with HF, the prognosis is still poor. According to the European Cardiology Society guidelines for the diagnosis and treatment of acute and chronic heart failure (CHF) 2021, a new class of drugs related to hypoglycemic has been confirmed to be effective in influencing the survival of patients with heart failure with low ejection fraction (HFpEF), regardless of the presence of disorders of carbohydrate metabolism. We are talking about inhibitors of the sodium-glucose co-transporter type 2 (iSGLT-2) or gliflozins. The article presents the results of the latest large clinical trials on the effective use of SGLT-2 in patients with HF, not only with low, but also with intact ejection fraction (HFpEF), for which there is no evidence base at the present stage. The review article presents the results of experimental studies that explored the potential mechanisms of action of gliflozins with an emphasis on new ones that are of fundamental importance for patients with heart failure, and also describes controversial and little-studied issues. Currently, there is no therapy that improves outcomes in patients with acute heart failure. The article presents the results of small analyzes of the use of iSGLT-2 in this category of patients, which are the basis for the hypothesis of their potentially effective and safe use in the case of acute decompensation of CHF, however, the role of gliflozins in this category of patients requires further in-depth study.
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Affiliation(s)
| | - V. N. Karetnikova
- Kemerovo State Medical University;
Research Institute for Complex Problems of Cardiovascular Diseases
| | - I. R. Oleinik
- Research Institute for Complex Problems of Cardiovascular Diseases
| | - O. L. Barbarash
- Kemerovo State Medical University;
Research Institute for Complex Problems of Cardiovascular Diseases
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44
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Pipilas A, Martyn T, Lindenfeld J. Heart Failure Medical Therapy: A Review for Structural/Interventional Cardiologists. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100082. [PMID: 37288122 PMCID: PMC10242575 DOI: 10.1016/j.shj.2022.100082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/11/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022]
Abstract
Medical therapy for heart failure (HF) has expanded rapidly in the last decade contributing to improved morbidity and mortality for patients living with HF. The indicated treatments have been traditionally stratified based on left ventricular ejection fraction. The optimization of HF medical therapy is important for interventional and structural cardiologists as HF remains among the most common causes of periprocedural hospitalization and death. Additionally, optimization of medical therapy for HF prior to the utilization of device-based therapies as well as enrollment in clinical trials is crucial. This review will serve to highlight medical therapy indicated across the left ventricular ejection fraction strata.
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Affiliation(s)
- Alexandra Pipilas
- Department of Cardiovascular Medicine, Boston University, Boston, Massachusetts, USA
| | - Trejeeve Martyn
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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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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Zannad F, Ferreira JP, Gregson J, Kraus BJ, Mattheus M, Hauske SJ, Butler J, Filippatos G, Wanner C, Anker SD, Pocock SJ, Packer M. Early changes in estimated glomerular filtration rate post-initiation of empagliflozin in EMPEROR-Reduced. Eur J Heart Fail 2022; 24:1829-1839. [PMID: 35711093 DOI: 10.1002/ejhf.2578] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/18/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) may induce an early post-initiation decrease of estimated glomerular filtration rate (eGFR), which does not impact the SGLT2i benefits. The occurrence, characteristics, determinants, and clinical significance of an initial eGFR change among patients with heart failure with reduced ejection fraction require further study. In this study we aimed to describe eGFR change from randomization to week 4 (as percent of change relative to randomization) and assess its impact in EMPEROR-Reduced. METHODS AND RESULTS Landmark analyses (week 4) were performed. eGFR change was available in 3547 patients out of 3730 (95%). The tertiles of post-initiation % eGFR change for empagliflozin were: tertile 1 (T1) ≤-11.4%; T2 ≥-11.4% to ≤-1.0% and T3 ≥0.0%. The placebo group tertiles were: T1 ≤-6.5%; T2 ≥-6.4% to ≤+3.6%; and T3 ≥+3.6%. On average, empagliflozin induced a leftward distributional shift of initial eGFR changes of -2.5 ml/min/1.73 m2 versus placebo. In the empagliflozin group, after covariate adjustment, the risk of cardiovascular and renal outcomes did not differ between patients in whom early post-treatment initiation eGFR decreased (T1) and patients in whom it increased (T3). However, in the placebo group, patients in whom early post-treatment initiation eGFR decreased (T1) had a higher risk of sustained worsening kidney function and all-cause mortality compared to patients in whom eGFR increased (T3) (hazard ratio [HR] 2.38, 95% confidence interval [CI] 1.25-4.55 and HR 1.37, 95% CI 1.01-1.85, respectively). CONCLUSION A mild eGFR decrease may be expected after the initiation of empagliflozin, and it is not associated with untoward heart failure, mortality, or kidney safety events. Clinicians should not be concerned with early eGFR changes post-initiation of empagliflozin.
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Affiliation(s)
- Faiez Zannad
- Université de Lorraine, Inserm, Center d'Investigations Cliniques, - Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Center d'Investigations Cliniques, - Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Bettina Johanna Kraus
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Würzburg University Clinic, Würzburg, Germany
| | - Michaela Mattheus
- Biostatistics, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Sibylle Jenny Hauske
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, TX and University of Mississippi, Jackson, MS, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
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Zhan Q, Peng W, Wang S, Gao J. Heart Failure with Preserved Ejection Fraction: Pathogenesis, Diagnosis, Exercise, and Medical Therapies. J Cardiovasc Transl Res 2022; 16:310-326. [PMID: 36171526 DOI: 10.1007/s12265-022-10324-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for more than one-half of total heart failure cases, with a high prevalence and poor prognosis, especially in older and female patients. Patients with HFpEF are characterized by hypertension, left ventricular hypertrophy, and diastolic dysfunction, and the main symptoms are dyspnea and exercise intolerance. HFpEF is currently poorly studied, and pharmacological treatment for HFpEF is still underexplored. Accumulating clinical trials have shown that exercise could exert benefits on diastolic dysfunction and quality of life in patients with HFpEF. However, there is a high limitation for applying exercise therapy due to exercise intolerance in patients with HFpEF. Key effectors of exercise-protection could be novel therapeutic targets for developing drugs to prevent and treat HFpEF. In this review article, we provide an overview of the pathogenic factors, diagnostic methods, research animal models, the mechanisms of exercise-mediated cardiac protection, and current treatments for HFpEF.
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Affiliation(s)
- Qingyi Zhan
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, 200444, China
| | - Wenjing Peng
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, 200444, China
| | - Siqi Wang
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, 200444, China
| | - Juan Gao
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, 200444, China. .,Shanghai Engineering Research Center of Organ Repair, School of Medicine, Shanghai University, Shanghai, 200444, China.
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48
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Li J, Zhou L, Gong H. New insights and advances of sodium-glucose cotransporter 2 inhibitors in heart failure. Front Cardiovasc Med 2022; 9:903902. [PMID: 36186974 PMCID: PMC9520058 DOI: 10.3389/fcvm.2022.903902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are newly emerging insulin-independent anti-hyperglycemic agents that work independently of β-cells. Quite a few large-scale clinical trials have proven the cardiovascular protective function of SGLT2is in both diabetic and non-diabetic patients. By searching all relevant terms related to our topics over the previous 3 years, including all the names of agents and their brands in PubMed, here we review the mechanisms underlying the improvement of heart failure. We also discuss the interaction of various mechanisms proposed by diverse works of literature, including corresponding and opposing viewpoints to support each subtopic. The regulation of diuresis, sodium excretion, weight loss, better blood pressure control, stimulation of hematocrit and erythropoietin, metabolism remodeling, protection from structural dysregulation, and other potential mechanisms of SGLT2i contributing to heart failure improvement have all been discussed in this manuscript. Although some remain debatable or even contradictory, those newly emerging agents hold great promise for the future in cardiology-related therapies, and more research needs to be conducted to confirm their functionality, particularly in metabolism, Na+-H+ exchange protein, and myeloid angiogenic cells.
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Affiliation(s)
- Juexing Li
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
- Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
- Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hui Gong
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
- Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China
- *Correspondence: Hui Gong
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Marfella R, Scisciola L, D'Onofrio N, Maiello C, Trotta MC, Sardu C, Panarese I, Ferraraccio F, Capuano A, Barbieri M, Balestrieri ML, Napoli C, Paolisso G. Sodium-glucose cotransporter-2 (SGLT2) expression in diabetic and non-diabetic failing human cardiomyocytes. Pharmacol Res 2022; 184:106448. [PMID: 36096423 DOI: 10.1016/j.phrs.2022.106448] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 12/13/2022]
Abstract
This study aimed at investigating the SGLT2 expression in human cardiomyocytes. Human studies evaluating cardiomyocyte SGLT2s expression are limited. To better clarify this issue, SGLT2 protein expression was assessed in human hearts of diabetic and non-diabetic patients, and in AC16 human cardiomyocyte cell line. A prospective study with a follow-up of patients who underwent their first heart transplant (HTX) was performed. Explanted heart, basal (1 week after HTX), and final (48 weeks after HTX) endomyocardial biopsies (EMBs) from patients were evaluated for SGLT2 occurrence in cardiomyocyte with immunohistochemistry, immunofluorescence and SGLT2 quantization with both real-time reverse transcription-polymerase chain reaction and Western blot analysis. The immunofluorescence co-localization of SGLT2 in cardiomyocyte evidenced that an increased expression in the explanted heart from diabetic patients compared to non-diabetic (p < 0.001). In all final EMBs from diabetic patients, the expression of SGLT2 in cardiomyocyte was increased compared to non-diabetic (p < 0.01). This evidence was confirmed by Western blot analysis of SGLT2 protein. In addition, PCR analysis revealed very low mRNA levels in basal EMBs from diabetic and non-diabetic patients (p = NS), whereas final EMBs from diabetic patients showed higher SGLT2 mRNA levels in diabetic compared to non-diabetic patients (p < 0.05). Cultured human cardiomyocytes exposed to high-glucose showed increased expression of SGLT2 protein compared to cells exposed to normal glucose (p < 0.05). The presence of SGLT2 in cardiomyocytes supports the hypothesis of SGLT2i-mediated impact on metabolic pathways within cardiomyocytes. Moreover, metabolic disorders linked to diabetes may lead promptly to upregulation of SGLT2 levels in human cardiomyocytes.
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Affiliation(s)
- Raffaele Marfella
- Department of Advanced Clinical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Lucia Scisciola
- Department of Advanced Clinical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| | - Nunzia D'Onofrio
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Italy
| | - Ciro Maiello
- Unit of Cardiac Surgery and Transplants, AORN Ospedali dei Colli-Monaldi Hospital, Naples, Italy
| | - Maria Consiglia Trotta
- Department of Experimental Medicine, Division of Pharmacology, University of Campania "Luigi Vanvitelli", Italy
| | - Celestino Sardu
- Department of Advanced Clinical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| | - Iacopo Panarese
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università della Campania 'Luigi Vanvitelli,', Naples, Italy
| | - Franca Ferraraccio
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università della Campania 'Luigi Vanvitelli,', Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Division of Pharmacology, University of Campania "Luigi Vanvitelli", Italy
| | - Michelangela Barbieri
- Department of Advanced Clinical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| | | | - Claudio Napoli
- Department of Advanced Clinical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| | - Giuseppe Paolisso
- Department of Advanced Clinical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy; Mediterranea Cardiocentro, Naples, Italy.
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Scisciola L, Cataldo V, Taktaz F, Fontanella RA, Pesapane A, Ghosh P, Franzese M, Puocci A, De Angelis A, Sportiello L, Marfella R, Barbieri M. Anti-inflammatory role of SGLT2 inhibitors as part of their anti-atherosclerotic activity: Data from basic science and clinical trials. Front Cardiovasc Med 2022; 9:1008922. [PMID: 36148061 PMCID: PMC9485634 DOI: 10.3389/fcvm.2022.1008922] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/16/2022] [Indexed: 01/10/2023] Open
Abstract
Atherosclerosis is a progressive inflammatory disease leading to mortality and morbidity in the civilized world. Atherosclerosis manifests as an accumulation of plaques in the intimal layer of the arterial wall that, by its subsequent erosion or rupture, triggers cardiovascular diseases. Diabetes mellitus is a well-known risk factor for atherosclerosis. Indeed, Type 2 diabetes mellitus patients have an increased risk of atherosclerosis and its associated-cardiovascular complications than non-diabetic patients. Sodium-glucose co-transport 2 inhibitors (SGLT2i), a novel anti-diabetic drugs, have a surprising advantage in cardiovascular effects, such as reducing cardiovascular death in a patient with or without diabetes. Numerous studies have shown that atherosclerosis is due to a significant inflammatory burden and that SGLT2i may play a role in inflammation. In fact, several experiment results have demonstrated that SGLT2i, with suppression of inflammatory mechanism, slows the progression of atherosclerosis. Therefore, SGLT2i may have a double benefit in terms of glycemic control and control of the atherosclerotic process at a myocardial and vascular level. This review elaborates on the anti-inflammatory effects of sodium-glucose co-transporter 2 inhibitors on atherosclerosis.
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Affiliation(s)
- Lucia Scisciola
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
- *Correspondence: Lucia Scisciola
| | - Vittoria Cataldo
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Fatemeh Taktaz
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Rosaria Anna Fontanella
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Ada Pesapane
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Puja Ghosh
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Martina Franzese
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Armando Puocci
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonella De Angelis
- Department of Experimental Medicine, Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Liberata Sportiello
- Department of Experimental Medicine, Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
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