Semaglutide versus placebo in people with obesity-related heart failure with preserved ejection fraction: a pooled analysis of the STEP-HFpEF and STEP-HFpEF DM randomised trials

Focused Recommendations for the Management of Metabolic Dysfunction-Associated Steatohepatitis (MASH) by Advanced Practice Providers in the United States

Metabolic dysfunction-associated steatohepatitis (MASH) has become the dominant cause of liver disease in the United States. With the growing burden of this disease in gastroenterology practices, the identification and treatment of those at risk of developing adverse outcomes (cirrhosis, hepatocellular carcinoma, or liver-related death) has become urgent. In recent years, the development of noninvasive tests (NITs) to identify "at-risk MASH" patients have provided cost-effective algorithms to identify these patients. Although treatment has historically been limited to lifestyle modification, recent FDA approval of resmetirom for noncirrhosis MASH with stages 2 and 3 fibrosis has provided a new opportunity in the United States to provide these patients with novel treatment options. Other new effective treatment regimens are on the horizon. Given that gastroenterology and hepatology practices in the United States heavily rely on advanced practice providers (APPs) to manage patients with MASLD, the APP Committee of the Global NASH/MASH Council has curated the essentials of day-to-day MASH management for our busy gastrohepatology providers and their APP colleagues. The goal of this document is to equip and mobilize more GI providers with the requisite competencies for the management of at-risk MASH, given the rapidly evolving MASH treatment landscape.

Semaglutide in obesity-related heart failure with preserved ejection fraction and type 2 diabetes across baseline HbA1c levels (STEP-HFpEF DM): a prespecified analysis of heart failure and metabolic outcomes from a randomised, placebo-controlled trial

BACKGROUND

About half of patients with heart failure with mildly reduced or preserved ejection fraction (HFpEF) have type 2 diabetes. In the STEP-HFpEF DM trial of adults with obesity-related HFpEF and type 2 diabetes, subcutaneous once weekly semaglutide 2·4 mg conferred improvements in heart failure-related symptoms and physical limitations, bodyweight, and other heart failure outcomes. We aimed to determine whether these effects of semaglutide differ according to baseline HbA1c.

METHODS

STEP-HFpEF DM, a double-blind, randomised, placebo-controlled trial conducted at 108 clinical research sites across 16 countries in Asia, Europe, and North and South America, included individuals aged 18 years or older with documented HFpEF (left ventricular ejection fraction ≥45%), type 2 diabetes, and obesity (BMI ≥30 kg/m2). Participants were randomly assigned (1:1), with a block size of four within each stratum using an interactive web response system, stratified by baseline BMI (<35 kg/m2vs ≥35 kg/m2), to receive either semaglutide 2·4 mg or placebo subcutaneously. The effects of semaglutide versus placebo on the efficacy endpoints were evaluated by HbA1c categories at baseline: low (<6·5%; <48 mmol/mol), medium (6·5% to <7·5%; 48 mmol/mol to <58 mmol/mol), and high (≥7·5%; ≥58 mmol/mol). The dual primary endpoints were change in the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS) and bodyweight percentage from baseline to 52 weeks and were assessed in all randomly assigned participants by intention to treat. Hypoglycaemia events were also analysed to assess safety in all randomly assigned participants who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, NCT04916470.

FINDINGS

Between June 27, 2021 and Sept 2, 2022, 616 participants were enrolled and randomly assigned (mean age 68·4 years [SD 8·9]; 273 [44%] were female, 343 [56%] were male, and 519 [84%] were White). The low baseline HbA1c group included 227 participants (112 assigned to semaglutide and 115 to placebo), the medium baseline HbA1c group included 226 participants (124 assigned to semaglutide and 102 to placebo), and the high baseline HbA1c group included 163 participants (74 assigned to semaglutide and 89 to placebo). The median duration of follow-up in the overall trial was 401 days (IQR 400-405). The change in KCCQ-CSS from baseline to 52 weeks was 12·4 points (95% CI 8·8 to 16·0) with semaglutide versus 5·7 points (2·1 to 9·2) with placebo (mean difference 6·7 points [1·6 to 11·8]) in the low baseline HbA1c group, 14·5 points (11·0 to 17·9) versus 8·5 points (4·8 to 12·2; 6·0 points [0·9 to 11·1]) in the medium baseline HbA1c group, and 14·5 points (10·0 to 19·0) versus 4·8 points (0·7 to 8·9; 9·6 points [3·5 to 15·7]) in the high baseline HbA1c group (pinteraction=0·64; ptrend=0·46). The change in bodyweight percentage from baseline to 52 weeks was -10·8 (95% CI -12·1 to -9·5) with semaglutide versus -3·3% (-4·6 to -2·0) with placebo (mean difference -7·5% [-9·4 to -5·6]) in the low baseline HbA1c group, -9·6% (-10·8 to -8·3) versus -3·3% (-4·7 to -1·9; -6·3 [-8·2 to -4·4]) in the medium baseline HbA1c group, and -8·6% (-10·2 to -7·0) versus -3·6% (-5·2 to -2·1; -5·0 [-7·2 to -2·7]) in the high baseline HbA1c group (pinteraction=0·22; ptrend=0·083). Hypoglycaemia events occurred in 30 (10%) of 310 participants (70 events; 22·9 events per 100 person-years) in the semaglutide group compared with 21 (7%) of 306 participants in the placebo group (90 events; 29·5 events per 100 person-years).

INTERPRETATION

Semaglutide 2·4 mg improved heart failure-related symptoms and physical limitations, and reduced bodyweight in patients with obesity-related HFpEF and type 2 diabetes, all independently of baseline HbA1c, and resulted in lower rates of hypoglycaemia than placebo, despite a well controlled baseline HbA1c and broad use of concomitant glucose-lowering medications.

FUNDING

Novo Nordisk.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2024

Rapid shifts in evidence-based medicine challenge clinicians to adapt their practices based on new information. Synthesizing relevant evidence can drive clinical advancements. To enhance knowledge of practice-changing literature, a group of six internists reviewed titles and abstracts from seven internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. In addition, collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster ACCESSSS/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to reach consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Articles pertaining to the same topic were considered together. In total,7 practice-changing articles were included.

Elevated C-reactive protein and cardiovascular risk

PURPOSE OF REVIEW

This review critically examines the evolving role of C-reactive protein (CRP) in cardiovascular disease (CVD), addressing its pathogenesis and relationship with various CVDs including coronary artery disease (CAD), heart failure, and atrial fibrillation.

RECENT FINDINGS

CRP is mechanistically implicated in endothelial dysfunction, oxidative stress, and plaque destabilization. Recent studies demonstrate that lipid-lowering agents (statins, bempedoic acid) and anti-inflammatory therapies (canakinumab, colchicine) reduce CRP levels and improve outcomes in CAD. In heart failure, elevated CRP predicts adverse events, though evidence on phenotypes varies, and novel therapies (glucagon-like peptide-1 agonists, sodium-glucose cotransporter-2 inhibitors) lower CRP independently of weight loss. For atrial fibrillation, CRP correlates with postoperative incidence and recurrence postablation, though data remain inconsistent. Guidelines offer differing opinion with the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines cautiously endorsing CRP for risk stratification in intermediate-risk individuals, while European guidelines advise against its routine use for primary prevention, reflecting unresolved questions about CRP's additive value.

SUMMARY

CRP remains a pivotal inflammation biomarker in CVD, yet its causal role and clinical applicability require clarification. While CRP-guided therapies show promise, discrepancies in guidelines highlight the need for robust trials to determine whether targeting CRP directly improves outcomes. Future research should focus on CRP's pathophysiological mechanisms and validate its utility in personalized CVD management.

Heart failure with preserved ejection fraction and metabolic dysfunction-associated steatotic liver disease: Twin challenges, one metabolic solution

Heart failure (HF) with preserved ejection fraction (HFpEF) has exceeded HF with reduced ejection fraction (HFrEF), becoming the most common type of HF. Unlike HFrEF, HFpEF is primarily a chronic low-grade inflammatory process closely associated with metabolic disorders. The coexistence of HFpEF and metabolic dysfunction-associated steatotic liver disease (MASLD) presents significant clinical challenges due to shared metabolic pathophysiology and complex interplay. Management strategies for HFpEF and MASLD remain challenging. Sodium-glucose cotransporter 2 inhibitors have shown benefits in managing both conditions. Additionally, glucagon-like peptide-1 receptor agonists are being actively investigated for their potential benefits, particularly in MASLD. A comprehensive, patient-centered approach that combines metabolic and cardiovascular care is essential for improving outcomes in patients with HFpEF and MASLD, addressing the global metabolic health challenges.

Advances in the management of obesity and heart failure: latest evidence from clinical trials

PURPOSE OF REVIEW

Obesity is an important risk factor for heart failure with preserved ejection fraction (HFpEF). In patients who already have HFpEF, obesity contributes to high symptom burden and increased risk for heart failure (HF) hospitalization. This review examines the latest clinical trials assessing the efficacy of pharmacological interventions in the treatment of obesity-related HFpEF.

RECENT FINDINGS

Recent results from randomized clinical trials (RCTs) suggest that incretin-based therapies, including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) (e.g., semaglutide) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RAs (e.g., tirzepatide), can improve quality of life, exercise tolerance, and markers of HF severity while promoting weight loss in patients with obesity and HFpEF. Some evidence also suggests that these therapies may reduce risk for HF hospitalizations. Additionally, exploratory analyses of the nonsteroidal mineralocorticoid receptor antagonist finerenone has been associated with reduced cardiovascular mortality and total worsening HF events across all body mass index (BMI) levels, with greater benefits observed in patients with higher BMIs.

SUMMARY

Antiobesity medications such as semaglutide and tirzepatide may represent important treatment options for patients with obesity-related HFpEF. Additional evidence suggests that certain other HF medications may have increased efficacy in patients with obesity.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Semaglutide ameliorates metabolic disorders in offspring via regulation of oocyte ROS of pre-pregnancy obesity mice

Pre-pregnancy obesity (PPO) seriously threatens the health of both mother and offspring. Pre-pregnancy weight management is particularly important for the prevention of metabolic diseases in offspring. Semaglutide is one of the most effective glucagon-like peptide-1 agonizts for the management of obesity and metabolic diseases, but little is known about its effect on the long-term health of offspring. In this study we investigated the effects of semaglutide administered before pregnancy on the offspring health from PPO mice. PPO mice model was established by feeding with high-fat diet for 16 weeks, and then injected with semaglutide (30 nmol/kg-1·d-1, sc.) for 22 days before pregnancy. After the treatment, the mice were mated with normal males or underwent in vitro fertilization (IVF) for offspring reproduction. We showed that the semaglutide treatment not only improved the lipid and glucose metabolic disorders and fertility of PPO mice, but also significantly reversed the overweight, impaired energy balance, adipose inflammatory state, lipid and glucose metabolic disorders and insulin resistance of their IVF offspring. By conducting RNA-seq analysis, SOD activity and malondialdehyde assays in ovaries, as well as ROS staining in oocytes, we revealed that the semaglutide treatment reduced the elevated oxidative stress in ovaries and high ROS levels in oocytes from PPO mice, possibly through activating the PI3K/AKT pathway and improving the state of SOD. Interestingly, incubation of oocytes from semaglutide-treated dams with H2O2 (100 μM) in vitro during IVF blocked the protective effects of semaglultide against the metabolic disorders in the offspring. In conclusion, semaglutide treatment before pregnancy effectively alleviates obesity-related metabolic disorders in offspring. The regulation of ROS in oocytes plays a crucial role in the protective effects of semaglutide.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Acute Heart Failure: Transitioning From Symptom-Based Care to Remission

During the past century, the characteristics of patients with heart failure (HF) and acute HF (AHF) have shifted from patients with severe pump failure due to rheumatic, hypertensive and ischemic heart disease to older and more obese patients with multiple severe comorbidities. The pathophysiology of AHF has shifted, in parallel, from that of advanced, end-stage pump failure caused by severe left ventricular dysfunction to age, obesity and comorbidity-related cardiovascular dysfunction combined with neurohormonal and inflammatory dysregulation or "inflammaging." With the advent of neurohormonal blockers leading to improved outcomes of patients with chronic HF, the focus of AHF therapy has also changed from care directed at early symptom improvement to therapies directed toward longer-term improvements in quality of life and outcomes. Studies conducted in the past 5 years suggest that the beneficial effects seen with the 4 pillars of guideline-directed medical therapy for HF, mostly comprising neurohormonal blockade, can be extended to AHF when these therapies are initiated and rapidly uptitrated during admission and after discharge. A recent pilot study, CORTAHF (Effect of Short-Term Prednisone Therapy on CRP Change in Emergency Department Patients With Acute Heart Failure and Elevated Inflammatory Markers), has suggested that these benefits can be extended by treating patients with AHF and markers of inflammatory activation with anti-inflammatory therapies. Future studies should further examine whether combined anti-inflammatory therapy and neurohormonal blockade can lead to the reversal of disrupted underlying pathophysiology and remission in patients with AHF.

Counteracting the Mechanisms of Heart Failure is the Most Effective Way to Decongest Patients while Improving Outcomes

Diuretic therapy is not associated with improved outcomes in heart failure and may cause significant side effects. Counteracting the core pathophysiological mechanisms of heart failure through neurohormonal blockade while reducing reliance on diuretics is potentially the most effective method of decongestion.

From Cardiovascular-Kidney-Metabolic Syndrome to Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Proposing an Expanded Framework

Cardiometabolic diseases represent an escalating global health crisis, slowing or even reversing earlier declines in cardiovascular disease (CVD) mortality. Traditionally, conditions such as obesity, type 2 diabetes mellitus (T2DM), atherosclerotic CVD, heart failure (HF), chronic kidney disease (CKD), and metabolic dysfunction-associated steatotic liver disease (MASLD) were managed in isolation. However, emerging evidence reveals that these disorders share overlapping pathophysiological mechanisms and treatment strategies. In 2023, the American Heart Association proposed the Cardiovascular-Kidney-Metabolic (CKM) syndrome, recognizing the interconnected roles of the heart, kidneys, and metabolic system. Yet, this model omits the liver-a critical organ impacted by metabolic dysfunction. MASLD, which can progress to metabolic dysfunction-associated steatohepatitis (MASH), is closely tied to insulin resistance and obesity, contributing directly to cardiovascular and renal impairment. Notably, MASLD is bidirectionally associated with the development and progression of CKM syndrome. As a result, we introduce an expanded framework-the Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome-to more comprehensively capture the broader inter-organ dynamics. We provide guidance for an integrated diagnostic approach aimed at halting progression to advanced stages and preventing further organ damage. In addition, we highlight advances in medical management that target shared pathophysiological pathways, offering benefits across multiple organ systems. Viewing these conditions as an integrated whole, rather than as discrete entities, and incorporating the liver into this framework fosters a more holistic management strategy and offers a promising path to addressing the cardiometabolic pandemic.

Towards a phenotype profiling of the patients with heart failure and preserved ejection fraction

The prevalence of heart failure with preserved ejection fraction (HFpEF) is increasing and prognosis remains poor, with a high risk of mortality or hospitalizations for worsening heart failure events. Apart from sodium-glucose cotransporter-2 inhibitors and diuretics, the management of HFpEF is nowadays based on the different aetiologies and cardiovascular or non-cardiovascular comorbidities. A great heterogeneity of clinical profiles has been described in HFpEF, with several recent studies focused on the identification of different HFpEF phenotypes. In this review, we summarize available evidence on phenotype profiling in HFpEF, describing the different phenotypes with the relative therapeutic implications, and reporting other specific clinical conditions relevant for HFpEF differential diagnosis.

The Impact of Obesity on Cardiac Energy Metabolism and Efficiency in Heart Failure With Preserved Ejection Fraction

The incidence and prevalence of heart failure with preserved ejection fraction (HFpEF) continues to rise, and now comprises more than half of all heart failure cases. There are many risk factors for HFpEF, including older age, hypertension, diabetes, dyslipidemia, sedentary behaviour, and obesity. The rising prevalence of obesity in society is a particularly important contributor to HFpEF development and severity. Obesity can adversely affect the heart, including inducing marked alterations in cardiac energy metabolism. This includes obesity-induced impairments in mitochondrial function, and an increase in fatty acid uptake and mitochondrial fatty acid β-oxidation. This increase in myocardial fatty acid metabolism is accompanied by an impaired myocardial insulin signaling and a marked decrease in glucose oxidation. This switch from glucose to fatty acid metabolism decreases cardiac efficiency and can contribute to severity of HFpEF. Increased myocardial fatty acid uptake in obesity is also associated with the accumulation of fatty acids, resulting in cardiac lipotoxicity. Obesity also results in dramatic changes in the release of adipokines, which can negatively impact cardiac function and energy metabolism. Obesity-induced increases in epicardial fat can also increase cardiac insulin resistance and negatively affect cardiac energy metabolism and HFpEF. However, optimizing cardiac energy metabolism in obese subjects may be one approach to preventing and treating HFpEF. This review discusses what is presently known about the effects of obesity on cardiac energy metabolism and insulin signaling in HFpEF. The clinical implications of obesity and energy metabolism on HFpEF are also discussed.

Finerenone, Obesity, and Heart Failure With Mildly Reduced/Preserved Ejection Fraction: Prespecified Analysis of FINEARTS-HF

BACKGROUND

Obesity is associated with excessive adipocyte-derived aldosterone secretion, independent of the classical renin-angiotensin-aldosterone cascade, and mineralocorticoid receptor antagonists may be more effective in patients with heart failure (HF) and obesity.

OBJECTIVES

This study sought to examine the effects of the nonsteroidal mineralocorticoid receptor antagonist finerenone compared with placebo, according to body mass index (BMI) in FINEARTS-HF (FINerenone trial to investigate Efficacy and sAfety superioR to placebo in paTientS with Heart Failure).

METHODS

A total of 6,001 patients with HF with NYHA functional class II, III, and IV, a left ventricular ejection fraction of ≥40%, evidence of structural heart disease, and elevated natriuretic peptide levels were randomized to finerenone or placebo. BMI (kg/m2) was examined using World Health Organization categories, namely, underweight/normal weight (<25.0 kg/m2; n = 1,306); overweight (25.0-29.9 kg/m2; n = 1,990); obesity class I (30.0-34.9 kg/m2; n = 1,546); obesity class II (35.0-39.9 kg/m2; n = 751); and obesity class III (≥40 kg/m2; n = 395). The primary outcome was cardiovascular death and total worsening HF events.

RESULTS

Data on baseline BMI were available for 5,988 patients (median: 29.2 kg/m2; Q1-Q3: 25.5-33.6 kg/m2). Compared with patients who were underweight/normal weight, those with obesity class II or III had a higher risk of the primary outcome (underweight/normal weight, reference; overweight, unadjusted rate ratio: 0.96 [95% CI: 0.81-1.15]; obesity class I: 1.04 [95% CI: 0.86-1.26]; obesity class II-III: 1.26 [95% CI: 1.03-1.54]). The effect of finerenone on the primary outcome did not vary by baseline BMI (underweight/normal weight, rate ratio: 0.80 [95% CI: 0.62-1.04]; overweight: 0.91 [95% CI: 0.72-1.15]; obesity class I: 0.92 [95% CI: 0.72-1.19]; obesity class II-III: 0.67 [95% CI: 0.50-0.89]; Pinteraction = 0.32). However, when BMI was examined as a continuous variable, the beneficial effect of finerenone seemed to be greater in those with a higher BMI (Pinteraction = 0.005). A similar pattern was observed for total worsening HF events. Consistent effects across baseline BMI were observed for cardiovascular and all-cause death and improvement in the Kansas City Cardiomyopathy Questionnaire scores.

CONCLUSIONS

In patients with HF with mildly reduced/preserved ejection fraction, the beneficial effects of finerenone on clinical events and symptoms were consistent, irrespective of BMI at baseline, possibly with a greater effect on the primary outcome in patients with higher BMI. (FINEARTS-HF [FINerenone trial to investigate Efficacy and sAfety superioR to placebo in paTientS with Heart Failure]; NCT04435626).

Did Finerenone Improve Health Status in the FINEARTS Trial?: A Critical Reevaluation of the Analysis of Patient-Reported Outcomes in Heart Failure

Patient-reported health status is an important assessment of patients with heart failure, but current approaches have substantial methodological and analytical limitations. Changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ) are commonly presented as a measure of the effect of drugs and devices, most often as the between-group difference in population means or as the odds of showing threshold changes of 5, 10, 15, and 20 points. However, the presentation of mean differences is based on statistical assumptions that are routinely violated in most trials. The presentation of threshold changes is based on the belief that a within-patient change in KCCQ of 5 points represents a significant treatment difference across diverse populations and trial settings, but the minimal clinically meaningful difference varies substantially depending on patient characteristics, comorbidities, and trial duration and design, with most values for minimally clinically important difference for KCCQ ranging from 10 to 20 points. Furthermore, the assessment of between-group differences is highly distorted by the assignment of a large proportion of randomized patients with very good health status as having substantially improved even if they showed no change after treatment. Any responder analysis is highly sensitive to differences in variance between the 2 treatment groups and cannot account for the stability of changes in the KCCQ score. The imposition of number-to-treat presentations onto KCCQ scores further compounds the lack of interpretability of reported changes. It is therefore not surprising that trials have reported substantial discrepancies between the effect of treatment on KCCQ and on the risk of hospitalizations for heart failure. In the FINEARTS (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure) trial, finerenone produced an 18% reduction in the risk of hospitalizations for heart failure but yielded uninterpretable and clinically questionable changes in KCCQ, with the small possibility of a modest benefit in <2% of randomized patients. Most physicians are unaware of the critically important methodological concerns summarized in the current paper, and, therefore, may make clinical decisions that hinge on unwarranted impressions of the effects of an intervention on health status.

Effect of Finerenone on the KCCQ in Patients With HFmrEF/HFpEF: A Prespecified Analysis of FINEARTS-HF

BACKGROUND

Patients with heart failure (HF) are limited by symptoms and have impaired quality of life. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a patient-reported outcome measure that enables evaluation of the effect of HF and the impact of new therapies on health status in patients with HF.

OBJECTIVES

This prespecified analysis of FINEARTS-HF (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients With Heart Failure) assessed the efficacy and safety of finerenone according to baseline KCCQ Total Symptom Score (TSS) and the effect of finerenone on KCCQ-TSS.

METHODS

FINEARTS-HF tested the efficacy of the nonsteroidal mineralocorticoid receptor antagonist (MRA) finerenone, compared with placebo, in patients with HF with mildly reduced ejection fraction/preserved ejection fraction. The primary endpoint was the composite of cardiovascular death and total worsening HF events. The KCCQ was completed by patients at randomization and at 6, 9, and 12 months after randomization. Change in KCCQ-TSS was a key secondary endpoint. Patients were stratified by KCCQ-TSS tertiles at baseline. The association between KCCQ tertile and clinical outcomes was evaluated using semiparametric proportional-rates models for total events and Cox models for time-to-first-event data, and the effects of finerenone vs placebo on the primary endpoint were assessed across tertiles of KCCQ-TSS.

RESULTS

Of the 6,001 participants in FINEARTS-HF, 5,986 (99.8%) had baseline KCCQ-TSS recorded (median score 69.8 of a possible 100; higher score = better health status). Lower (worse) KCCQ-TSS was associated with a higher risk of the primary endpoint. Finerenone, compared with placebo, reduced the risk of the primary endpoint across the range of KCCQ-TSS: tertile 1 (score 0-<57): RR: 0.82 (95% CI: 0.68-1.00); tertile 2 (57-<81): 0.88 (95% CI: 0.70-1.11); tertile 3 (81-100): 0.88 (95% CI: 0.69-1.14) (Pinteraction = 0.89). Compared with placebo, finerenone significantly improved KCCQ-TSS from baseline with a mean difference at 12 months of 1.62 points (95% CI: 0.69-2.56 points) (P < 0.001). Numerically fewer finerenone-treated patients experienced clinically meaningful deterioration, and more had improvements in KCCQ-TSS.

CONCLUSIONS

Finerenone significantly reduced HF events and improved health status in patients with HF and mildly reduced ejection fraction/preserved ejection fraction across the spectrum of KCCQ-TSS at baseline. (Study to Evaluate the Efficacy [Effect on Disease] and Safety of Finerenone on Morbidity [Events Indicating Disease Worsening] & Mortality [Death Rate] in Participants With Heart Failure and Left Ventricular Ejection Fraction [Proportion of Blood Expelled Per Heart Stroke] Greater or Equal to 40% [FINEARTS-HF], NCT04435626; Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure; EudraCT 2020-000306-29).

Initiation and sequencing of guideline-directed medical therapy for heart failure across the ejection fraction spectrum

Strong evidence supports the importance of rapid sequence or simultaneous initiation of quadruple guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) for substantially reducing risk of mortality and hospitalization. Barring absolute contraindications for each individual medication, employing the strategy of rapid sequence, simultaneous, and/or in-hospital initiation at the time of HF diagnosis best ensures patients with HFrEF have the opportunity to benefit from proven medications and achieve large absolute risk reductions for adverse clinical outcomes. However, despite guideline recommendations supporting this approach, implementation in clinical practice remains persistently low, with less than one-fifth of eligible patients being prescribed the quadruple GDMT regimen. Additionally, for heart failure with mildly reduced or preserved ejection fraction (HFpEF), sodium-glucose co-transporter 2 inhibitors (SGLT2i) and non-steroidal mineralocorticoid receptor antagonists (MRA) constitute foundational therapy for all eligible patients with significant clinical benefits within just weeks of medication initiation. Nonetheless, the burden of symptoms, functional limitations, and hospitalizations remains substantial for many of these patients, even with SGLT2i and non-steroidal MRA therapy. Additional evidence supports consideration of adjunctive therapies for HF with EF > 40% that can be tailored to the patient phenotype, including glucagon-like peptide-1 receptor agonists (GLP-1 RA) for patients with obesity, as well as angiotensin receptor-neprilysin inhibitors (ARNI) for patients with EF below normal. This article reviews the evidence-based sequencing of GDMT for HF across the spectrum of EF, emphasizing the rationale and benefits of early up-front initiation of quadruple medical therapy for HFrEF, rapid initiation of SGLT2i for HF regardless of EF, and prompt phenotype-specific tailored approach to adjunctive therapies for HF with EF > 40%.

Echocardiographic phenotypes of diabetic myocardial disorder: evolution over 15 months follow-up in the ARISE-HF trial

BACKGROUND

Diabetic myocardial disorder (DbMD, evidenced by abnormal echocardiography or cardiac biomarkers) is a form of stage B heart failure (SBHF) at high risk for progression to overt HF. SBHF is defined by abnormal LV morphology and function and/or abnormal cardiac biomarker concentrations.

OBJECTIVE

To compare the evolution of four DbMD groups based on biomarkers alone, systolic and diastolic dysfunction alone, or their combination.

METHODS

The Aldose Reductase Inhibition for Stabilization of Exercise Capacity in Heart Failure (ARISE-HF) trial was a Phase 3 randomised trial of an aldose reductase inhibitor in patients with well-controlled type 2 diabetes mellitus (T2DM). The 1858 potential participants (age 67 ± 7 years; 50% women) were screened for SBHF based on abnormal echocardiography or biomarkers (N-terminal pro-B-type natriuretic peptide ≥ 40 ng/L or high sensitivity cardiac troponin T ≥ 10 ng/L [women] and ≥ 16 ng/L [men]). Exercise capacity (peak VO2) was reduced in 669 with DbMD (age 68 ± 7, 50% women), and peak VO2 was reassessed at 15 months.

RESULTS

The 1463 (79%) participants with DbMD were allocated to four clusters; 907 (49%) showed isolated elevation of cardiac biomarkers, 301 (16%) with systolic dysfunction/hypertrophy, 162 (9%) with diastolic dysfunction and 93 (5%) comprised an overlap cluster (combined diastolic, systolic or LV geometric abnormalities). Reduced VO2 (< 75% predicted) was present in 669 (46%); 72% of those with both systolic and diastolic dysfunction, 56% of those with systolic dysfunction and LVH, 53% of those with diastolic dysfunction and 38% with biomarkers alone (p < 0.0001). In 669 patients followed over 15 months, there was a similar small decrement in VO2 in all groups.

CONCLUSIONS

Among individuals with T2DM and SBHF, reduced functional capacity is most prevalent in those with multiple physiological disturbances. However, there was no difference between phenogroups in the evolution of exercise intolerance.

TRIAL REGISTRATION

ARISE-HF, NCT04083339.

Integrated Management of Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Expanding Roles of SGLT2is, GLP-1RAs, and GIP/GLP-1RAs

Cardiovascular-Kidney-Metabolic syndrome, introduced by the American Heart Association in 2023, represents a complex and interconnected spectrum of diseases driven by shared pathophysiological mechanisms. However, this framework notably excludes the liver-an organ fundamental to metabolic regulation. Building on this concept, Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome incorporates the liver's pivotal role in this interconnected disease spectrum, particularly through its involvement via metabolic dysfunction-associated steatotic liver disease (MASLD). Despite the increasing prevalence of CRHM syndrome, unified management strategies remain insufficiently explored. This review addresses the following critical question: How can novel anti-diabetic agents, including sodium-glucose cotransporter-2 inhibitors (SGLT2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dual gastric inhibitory polypeptide (GIP)/GLP-1RA, offer an integrated approach to managing CRHM syndrome beyond the boundaries of traditional specialties? By synthesizing evidence from landmark clinical trials, we highlight the paradigm-shifting potential of these therapies. SGLT2is, such as dapagliflozin and empagliflozin, have emerged as cornerstone guideline-directed treatments for heart failure (HF) and chronic kidney disease (CKD), providing benefits that extend beyond glycemic control and are independent of diabetes status. GLP-1RAs, e.g., semaglutide, have transformed obesity management by enabling weight reductions exceeding 15% and improving outcomes in atherosclerotic cardiovascular disease (ASCVD), diabetic CKD, HF, and MASLD. Additionally, tirzepatide, a dual GIP/GLP-1RA, enables unprecedented weight loss (>20%), reduces diabetes risk by over 90%, and improves outcomes in HF with preserved ejection fraction (HFpEF), MASLD, and obstructive sleep apnea. By moving beyond the traditional organ-specific approach, we propose a unified framework that integrates these agents into holistic management strategies for CRHM syndrome. This paradigm shift moves away from fragmented, organ-centric management toward a more unified approach, fostering collaboration across specialties and marking progress in precision cardiometabolic medicine.

Dietary Interventions in Heart Failure With Preserved Ejection Fraction: A Scoping Review

Patients with heart failure with preserved ejection fraction (HFpEF) are burdened by multiple diet-sensitive comorbidities, including obesity and malnutrition. Despite this, a low percentage of patients with HFpEF have been enrolled in dietary intervention trials in heart failure and few dietary interventions have been conducted in HFpEF exclusively. This scoping review will examine available evidence regarding dietary interventions in patients with HFpEF, highlight existing gaps in knowledge, and discuss emerging dietary therapies in this population.

GLP-1 receptor agonists as promising anti-inflammatory agents in heart failure with preserved ejection fraction

Heart Failure with Preserved Ejection Fraction (HFpEF) represents a significant challenge in modern cardiovascular medicine, characterized by diastolic dysfunction and a chronic pro-inflammatory milieu. The high prevalence of comorbidities such as diabetes, visceral obesity, and aging, which contribute to systemic inflammation, plays a pivotal role in the pathogenesis and progression of HFpEF. Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs), a class of glucose-lowering drugs, have demonstrated a wide range of pleiotropic effects that extend beyond glycaemic control. These effects include the reduction of inflammation and oxidative stress, vasodilation, decreased arterial stiffness, and a reduction in myocardial fibrosis-key factors in the pathophysiology of HFpEF. Recent evidence from the STEP-HFpEF and STEP-HFpEF-DM trials provides the first robust data supporting the efficacy of GLP-1 RAs, specifically semaglutide, in improving the quality of life in obese patients with HFpEF. These trials also demonstrated a significant reduction in C-Reactive Protein (CRP) levels, reinforcing the hypothesis that suppressing the pro-inflammatory state may yield substantial clinical benefits in this patient population. These findings suggest that GLP-1 RAs could play a crucial role in the management of HFpEF, particularly in patients with obesity, by targeting the underlying inflammatory processes and contributing to better overall cardiovascular outcomes.

Beyond weight loss: the potential of glucagon-like peptide-1 receptor agonists for treating heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with various phenotypes, and obesity is one of the most common and clinically relevant phenotypes of HFpEF. Obesity contributes to HFpEF through multiple mechanisms, including sodium retention, neurohormonal dysregulation, altered energy substrate metabolism, expansion of visceral adipose tissue, and low-grade systemic inflammation. Glucagon-like peptide-1 (GLP-1) is a hormone in the incretin family. It is produced by specialized cells called neuroendocrine L cells located in the distal ileum and colon. GLP-1 reduces blood glucose levels by promoting glucose-dependent insulin secretion from pancreatic β cells, suppressing glucagon release from pancreatic α cells, and blocking hepatic gluconeogenesis. Recent evidence suggests that GLP-1 receptor agonists (GLP-1 RAs) can significantly improve physical activity limitations and exercise capacity in obese patients with HFpEF. The possible cardioprotective mechanisms of GLP-1 RAs include reducing epicardial fat tissue thickness, preventing activation of the renin-angiotensin-aldosterone system, improving myocardial energy metabolism, reducing systemic inflammation and cardiac oxidative stress, and delaying the progression of atherosclerosis. This review examines the impact of obesity on the underlying mechanisms of HFpEF, summarizes the trial data on cardiovascular outcomes of GLP-1 RAs in patients with type 2 diabetes mellitus, and highlights the potential cardioprotective mechanisms of GLP-1 RAs to give a pathophysiological and clinical rationale for using GLP-1 RAs in obese HFpEF patients.

Intravenous and oral administration of the synthetic RNA drug, TY1, reverses heart failure with preserved ejection fraction in mice

TY1, a synthetic non-coding RNA (ncRNA) bioinspired by small Y RNAs abundant in extracellular vesicles (EVs), decreases cGAS/STING activation in myocardial infarction and thereby attenuates inflammation. Motivated by the concept that heart failure with preserved ejection fraction (HFpEF) is a systemic inflammatory disease, we tested TY1 in a murine model of HFpEF. Intravenous TY1, packaged in a transfection reagent, reversed the cardiac and systemic manifestations of HFpEF in two-hit obese-hypertensive mice, without inducing weight loss. The effects of TY1 were specific, insofar as they were not reproduced by a control RNA of the same nucleotide content but in scrambled order. TY1 consistently suppressed myocardial stress-induced MAP kinase signaling, as well as downstream inflammatory, fibrotic, and hypertrophic gene pathways in heart tissue. TY1 not only prevented but actually reversed key pathological processes underlying HFpEF, with no evidence of toxicity. Most noteworthy from a practical perspective, the effects of intravenous TY1 were reproduced by feeding HFpEF mice an oral micellar formulation of TY1. As the prototype for a novel class of ncRNA drugs which target cell stress, TY1 exhibits exceptional disease-modifying bioactivity in HFpEF.

A Saudi Heart Association Position Statement on Cardiovascular Diseases and Diabetes Mellitus

Background

Cardiovascular disease (CVD) and diabetes mellitus are prominent public health concerns in Saudi Arabia owing to their increasingly high prevalence and burden. Based on this, the Saudi Heart Association (SHA) set out to develop an official position statement on CVD and diabetes mellitus, with a focus on the prevention and management of these conditions and relevant special populations in the context of Saudi Arabia.

Methods

A multidisciplinary panel of experts met under the auspices of the SHA in a series of meetings to review and discuss available evidence on the prevention and management of comorbid CVD and diabetes mellitus. Specialized subcommittees reviewed the data and offered context-specific recommendations (taking into account Saudi population characteristics, local healthcare system, available resources and medical expertise), which were later approved by the full expert panel.

Results and conclusions

The prevalence of diabetes mellitus and CVD is alarming in the Saudi Arabian population. Diabetes mellitus and CVD are interconnected on several levels, including cellular and molecular events as well as epigenetic and genetic mechanisms. Screening for CVD is a priority for patients with diabetes and concomitant risk factors. The expert panel also recommends aggressive management of high blood pressure and dyslipidemia in addition to lifestyle changes and achieving glycemic targets for the prevention of CVD in patients with diabetes. Some glucose-lowering drug classes, namely SGLT2-inhibitors and GLP-1 receptor agonists, offer significant benefits on the level of cardiovascular risk reduction and are thus a powerful addition to the clinical management armamentarium in CVD and diabetes. Special consideration is also advised for patient populations with distinct clinical presentation and needs, such as coronary artery disease, heart failure, and chronic kidney disease, among others.

Clinical phenotypes of heart failure patients with supranormal ejection fraction

AIMS

Heart failure (HF) with supranormal ejection fraction (HFsnEF) represents a distinct clinical entity characterized by limited treatment options and an unfavourable prognosis. Revealing its phenotypic diversity is crucial for understanding disease mechanism and optimizing patient management. We aim to identify phenotypic subgroups in HFsnEF using unsupervised clustering analysis.

METHODS

Consecutive hospitalized patients with a diagnosis of HF and a left ventricular ejection fraction ≥65% at baseline echocardiographic evaluations were included for analysis. We conducted unsupervised hierarchical clustering analysis on principal components (HCPC) to identify HFsnEF phenogroups using mixed data variables including demographics, HF duration, vital signs, anthropometrics, smoking/drinking status, HF aetiology, comorbid diseases, laboratory tests and echocardiographic parameters. We then employed decision tree modelling to identify parameters capable of distinguishing distinct clusters. Clinical outcomes, including all-cause death, cardiovascular (CV) death and CV readmission for different clusters, were examined.

RESULTS

Three mutually exclusive clusters were identified from the cohort of 221 HFsnEF patients. Cluster 1 (52.5%) predominantly consisted of patients with valvular heart disease, who had larger cardiac chambers and a higher prevalence of atrial fibrillation/atrial flutter. Cluster 2 (26.2%) primarily comprised older ischaemic patients with a higher prevalence of metabolic comorbidities. Cluster 3 (21.3%) were mainly hypertrophic cardiomyopathy patients. Two clinical variables were identified that could be used to group all HFsnEF patients into one of the clusters; they were HF aetiology and comorbid diabetes. During the median follow-up of 53.4 months, 46 (20.8%) all-cause deaths occurred, among them 39 of CV causes. Seventy (31.7%) patients experienced CV readmissions. Three clusters showed distinct differences in mortality outcomes, with Cluster 1 exhibiting the highest risk of all-cause mortality [Cluster 1 vs. Cluster 2: adjusted hazard ratio (aHR) = 3.32, P = 0.022; Cluster 1 vs. Cluster 3: aHR = 3.81, P = 0.036; Cluster 2 vs. Cluster 3: aHR = 1.15, P = 0.865] and CV mortality (Cluster 1 vs. Cluster 2: aHR = 3.73, P = 0.022; Cluster 1 vs. Cluster 3: aHR = 4.27, P = 0.020; Cluster 2 vs. Cluster 3: aHR = 1.15, P = 0.870). CV readmission risk was comparable among the three clusters (Cluster 1 vs. Cluster 2: aHR = 0.82, P = 0.590; Cluster 1 vs. Cluster 3: aHR = 1.04, P = 0.900; Cluster 2 vs. Cluster 3: aHR = 1.28, P = 0.580).

CONCLUSIONS

In a heterogeneous HFsnEF cohort, three clusters were identified by unsupervised HCPC with distinct clinical characteristics and outcomes.

Recent achievements and future directions of anti-obesity medications

Pharmacological management of obesity long suffered from a reputation of a 'Mission Impossible,' with inefficient weight loss and/or unacceptable tolerability. However, the tide has turned with recent progress in biochemical engineering and the development of long-acting agonists at the receptor for glucagon-like peptide-1 (GLP-1), and with unimolecular peptides that simultaneously possess activity at the receptors for GLP-1, the glucose-dependent insulinotropic polypeptide (GIP) and glucagon. Some of these novel therapeutics not only improve body weight and glycemic control in individuals with obesity and type 2 diabetes with hitherto unmet efficacy and tolerable safety, but also exhibit potential therapeutic value in diverse areas such as neurodegenerative diseases, fatty liver disease, dyslipidemia, atherosclerosis, and cardiovascular diseases. In this review, we highlight recent advances in incretin-based therapies and discuss their pharmacological potential within and beyond the treatment of obesity and diabetes, as well as their limitations in use, side effects, and underlying molecular mechanisms.

A Comprehensive Review of the Role of GLP-1 Agonists in Weight Management and Their Effect on Metabolic Parameters Such as Blood Glucose, Cholesterol, and Blood Pressure

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been developed to manage type 2 diabetes mellitus. Although, in the last 10 years, the use of GLP-1 RAs, especially semaglutide and liraglutide, has increased, its clinical implications and how it affects metabolic parameters have yet to be fully consolidated. This narrative review explores the metabolic effects of GLP-1 RAs in weight management, blood glucose, cardiovascular health, lipid profiles, and blood pressure. Data were collected by comparing GLP-1 RAs, such as semaglutide, liraglutide, tripeptide, and exenatide, as well as comparing them to a baseline treatment group. GLP-1 RAs have shown consistent results in managing blood glucose levels by lowering HbA1c with minimal hypoglycemic risk and increasing insulin production and synthesis. GLP-1 RAs have been found to improve overall cardiovascular health and reduce major adverse cardiovascular events (MACE) by improving the endothelial function of the vasculature and lowering ANP (atrial natriuretic peptide) production, leading to reduced blood pressure. In addition to the cardiovascular benefits, GLP-1 RAs have a varying effect on lipid profiles, finding statistically significant results for low-density lipoprotein cholesterol levels. In conjunction with all the effects, GLP-1 RAs have been found to lower weight and aid in weight management.

Cardiovascular, Kidney, and Safety Outcomes With GLP-1 Receptor Agonists Alone and in Combination With SGLT2 Inhibitors in Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

GLP-1 (glucagon-like peptide-1) receptor agonists and SGLT2 (sodium-glucose cotransporter 2) inhibitors both improve cardiovascular and kidney outcomes in people with type 2 diabetes. We conducted a systematic review and meta-analysis to assess the effects of GLP-1 receptor agonists on clinical outcomes with and without SGLT2 inhibitors.

METHODS

We searched MEDLINE and Embase databases from inception until July 12, 2024, for randomized, double-blind, placebo-controlled outcome trials of GLP-1 receptor agonists in type 2 diabetes that reported treatment effects by baseline use of SGLT2 inhibitors, with findings supplemented by unpublished data. We estimated treatment effects by baseline SGLT2 inhibitor use using inverse variance-weighted meta-analysis. The main cardiovascular outcomes were major adverse cardiovascular events (nonfatal myocardial infarction, stroke, or cardiovascular death) and hospitalization for heart failure. Kidney outcomes included a composite of ≥50% reduction in estimated glomerular filtration rate, kidney failure or death caused by kidney failure, and annualized rate of decline in estimated glomerular filtration rate (estimated glomerular filtration rate slope). Serious adverse events and severe hypoglycemia were also evaluated. This meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42024565765).

RESULTS

We identified 3 trials with 1743 of 17 072 (10.2%) participants with type 2 diabetes receiving an SGLT2 inhibitor at baseline. GLP-1 receptor agonists reduced the risk of major adverse cardiovascular events by 21% (hazard ratio [HR], 0.79 [95% CI, 0.71-0.87]), with consistent effects in those receiving and not receiving SGLT2 inhibitors at baseline (HR, 0.77 [95% CI, 0.54-1.09] and HR, 0.79 [95% CI, 0.71-0.87], respectively; P-heterogeneity=0.78). The effect on hospitalization for heart failure was similarly consistent regardless of SGLT2 inhibitor use (HR, 0.58 [95% CI, 0.36-0.93] and HR, 0.73 [95% CI, 0.63-0.85]; P-heterogeneity=0.26). Effects on the composite kidney outcome (risk ratio, 0.79 [95% CI, 0.66-0.95]) and estimated glomerular filtration rate slope (0.78 mL/min/1.73 m2/y [95% CI, 0.57-0.98]) also did not vary according to SGLT2 inhibitor use (P-heterogeneity=0.53 and 0.94, respectively). Serious adverse effects and severe hypoglycemia were also similar regardless of SGLT2 inhibitor use (P-heterogeneity=0.29 and 0.50, respectively).

CONCLUSIONS

In people with type 2 diabetes, the cardiovascular and kidney benefits of GLP-1 receptor agonists are consistent regardless of SGLT2 inhibitor use.

Heart failure with preserved ejection fraction management: a systematic review of clinical practice guidelines and recommendations

Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the 10 guidelines and recommendations retrieved, 7 showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced diseases. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.

Risk of Major Adverse Cardiovascular Outcomes in Families With MASLD: A Population-Based Multigenerational Cohort Study

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a risk factor for cardiovascular disease. However, whether family members of individuals with MASLD also share an increased cardiovascular risk is unknown.

METHODS

We created a nationwide multigenerational cohort study identifying all family members of Swedish adults diagnosed with biopsy-proven MASLD (1969-2017) and of matched general population comparators (by age, sex, calendar year, and county of residence). We calculated incidence rates and used Cox models to calculate adjusted hazard ratios (aHRs) and 95% CIs for incident major adverse cardiovascular events (MACE), including acute myocardial infarction, stroke, hospitalization for heart failure, or cardiovascular death. Cox models were adjusted for education, country of birth, diabetes, hypertension, obesity, dyslipidemia, chronic kidney disease, chronic obstructive pulmonary disease, and the Charlson comorbidity index.

RESULTS

We identified 22 267 MASLD first-degree relatives (FDRs; parents, siblings, and offspring) and 5687 MASLD spouses, as well as 118 056 comparator FDRs and 29 389 comparator spouses without earlier cardiovascular disease. Overall, the mean age was 41.8 years (SD, 18.0), and 51.5% were females. Over a median of 24.6 years, the incidence rate for MACE was higher in MASLD FDRs than in comparator FDRs (65.0 versus 62.5/10 000 person-years; aHR, 1.06 [95% CI, 1.01-1.11]). MASLD FDRs had higher rates of acute myocardial infarction (23.0 versus 20.9/10 000 person-years; aHR, 1.09 [95% CI, 1.01-1.18]) and cardiovascular death (aHR, 1.09 [95% CI, 1.01-1.18]). Across generations of FDRs, the risk of MACE was uniformly increased with no differences by relationship (ie, parents, siblings, and offspring; Pinteraction>0.05). MASLD spouses were also at an increased risk of MACE (117.6 versus 103.5/10 000 person-years; aHR, 1.09 [95% CI, 1.01-1.18]).

CONCLUSIONS

First-degree relatives of individuals with biopsy-proven MASLD are at slightly higher risk of incident MACE, but absolute risks do not support early screening for cardiovascular disease. Shared lifestyle factors may be the main contributors, as spouses of MASLD patients also had higher risks of MACE.

The aging heart in focus: The advanced understanding of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for 50 % of heart failure (HF) cases, making it the most common type of HF, and its prevalence continues to increase in the aging society. HFpEF is a systemic syndrome resulting from many risk factors, such as aging, metabolic syndrome, and hypertension, and its clinical features are highly heterogeneous in different populations. HFpEF syndrome involves the dysfunction of multiple organs, including the heart, lung, muscle, and vascular system. The heart shows dysfunction of various cells, including cardiomyocytes, endothelial cells, fibroblasts, adipocytes, and immune cells. The complex etiology and pathobiology limit experimental research on HFpEF in animal models, delaying a comprehensive understanding of the mechanisms and making treatment difficult. Recently, many scientists and cardiologists have attempted to improve the clinical outcomes of HFpEF. Recent advances in clinically related animal models and systemic pathology studies have improved our understanding of HFpEF, and clinical trials involving sodium-glucose cotransporter 2 inhibitors have significantly enhanced our confidence in treating HFpEF. This review provides an updated comprehensive discussion of the etiology and pathobiology, molecular and cellular mechanisms, preclinical animal models, and therapeutic trials in animals and patients to enhance our understanding of HFpEF and improve clinical outcomes.

Glucagon-like Peptide-1 Receptor Agonist Use in Hospital: A Multicentre Observational Study

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective medications for type 2 diabetes mellitus (T2DM) and obesity, yet their uptake among patients most likely to benefit has been slow.

METHODS

We conducted a cross-sectional analysis of medication exposure in adults hospitalized at 16 hospitals in Ontario, Canada, between 2015 and 2022. We estimated the proportions of those with T2DM, obesity, and cardiovascular disease. We identified the frequency of GLP-1RA use and conducted multivariable logistic regression to identify factors associated with their use.

RESULTS

Across 1,278,863 hospitalizations, 396,084 (31%) patients had T2DM and approximately 327,844 (26%) had obesity. GLP-1RA use (n=1,274) was low among those with a diagnosis of T2DM (0.3%) or obesity (0.7%), despite a high prevalence of cardiovascular disease (36%). In contrast, the use of diabetes medications lacking cardiovascular benefit was high during inpatient hospitalizations related to diabetes: 60% (n=236,612) received insulin and 14% (n=54,885) received a sulfonylurea. Apart from T2DM (odds ratio [OR]=29.6, 95% confidence interval [CI] 23.5 to 37.2), characteristics associated with greater odds of receiving a GLP-1RA were seen in those 50 to 70 years of age (OR=1.71, 95% CI 1.38 to 2.11) compared with those <50 years of age, glycated hemoglobin >9% (OR=1.83, 95% CI 1.36 to 2.47) compared with <6.5%, and highest income quintile (OR=1.73, 95% CI 1.45 to 2.07) compared with lowest income quintile.

CONCLUSION

Knowledge translation interventions are needed to address the low adoption of GLP-1RA among hospitalized patients with T2DM and obesity, who are the most likely to benefit from this treatment.

Contemporary treatment options in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) constitutes approximately half of the heart failure population, with its prevalence markedly increasing with older age and the presence of cardio-metabolic comorbidities. Although HFpEF is associated with a high symptom- and mortality burden, historically there have been few evidence-based treatment options for patients with HFpEF. Recent randomized clinical trials have expanded evidence on pharmacological treatment options, introducing new agents for managing HFpEF. Given the complex clinical phenotype with pathophysiological heterogeneity and evolving diagnostic standards, the evidence-based management of HFpEF remains challenging for clinicians. This review summarizes the latest evidence from contemporary randomized clinical trials and recent guideline recommendations to provide guidance for the treatment of patients with HFpEF.

Imaging and mechanisms of heart failure with preserved ejection fraction: a state-of-the-art review

Understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF) has advanced rapidly over the past two decades. Currently, HFpEF is recognized as a heterogeneous syndrome, and there is a growing movement towards developing personalized treatments based on phenotype-guided strategies. Left ventricular dysfunction is a fundamental pathophysiological abnormality in HFpEF; however, recent evidence also highlights significant roles for the atria, right ventricle, pericardium, and extracardiac contributors. Imaging plays a central role in characterizing these complex and highly integrated domains of pathophysiology. This review focuses on established evidence, recent insights, and the challenges that need to be addressed concerning the pathophysiology of HFpEF, with a focus on imaging-based evaluations and opportunities for further research.

Innovative Glucagon-based Therapies for Obesity

Obesity poses a significant global health challenge, with an alarming rise in prevalence rates. Traditional interventions, including lifestyle modifications, often fall short of achieving sustainable weight loss, ultimately leading to surgical interventions, which carry a significant burden and side effects. This necessitates the exploration of effective and relatively tolerable pharmacological alternatives. Among emerging therapeutic avenues, glucagon-based treatments have garnered attention for their potential to modulate metabolic pathways and regulate appetite. This paper discusses current research on the physiological mechanisms underlying obesity and the role of glucagon in energy homeostasis. Glucagon, traditionally recognized for its glycemic control functions, has emerged as a promising target for obesity management due to its multifaceted effects on metabolism, appetite regulation, and energy expenditure. This review focuses on the pharmacological landscape, encompassing single and dual agonist therapies targeting glucagon receptors (GcgRs), glucagon-like peptide-1 receptors (GLP-1Rs), glucose-dependent insulinotropic polypeptide receptors (GIPRs), amylin, triiodothyronine, fibroblast growth factor 21, and peptide tyrosine tyrosine. Moreover, novel triple-agonist therapies that simultaneously target GLP-1R, GIPR, and GcgR show promise in augmenting further metabolic benefits. This review paper tries to summarize key findings from preclinical and clinical studies, elucidating the mechanisms of action, safety profiles, and therapeutic potential of glucagon-based therapies in combating obesity and its comorbidities. Additionally, it explores ongoing research endeavors, including phase III trials, aimed at further validating the efficacy and safety of these innovative treatment modalities.

Impact of semaglutide on weight and functional outcomes among obese heart failure patients: a propensity scores matching analysis

BACKGROUND & OBJECTIVES

Obesity is a common comorbidity in heart failure, yet effective pharmacological options for weight loss in these patients are limited. Semaglutide, a glucagon-like peptide 1 receptor agonist, has shown promise for weight reduction in obese adults. This study aims to evaluate semaglutide's impact on weight loss, functional status, and clinical outcomes in obese patients with heart failure.

METHODS

A retrospective analysis was conducted on all consecutive obese (BMI > 30 kg/m²) patients with heart failure at the University Hospital Bonn outpatient clinic from July 2019 to July 2022. Propensity score matching paired patients receiving semaglutide as an add-on therapy (SEMA) with those on medical therapy alone (Control).

RESULTS

Among 1,942 patients with heart failure screened, 26 matched pairs were identified. At one year, the SEMA group exhibited significant weight loss, with a mean BMI reduction of -2.91 kg/m² (95% CI: -4.27 to -1.55; p < 0.001), while the control group showed a non-significant mean change of -0.41 kg/m² (95% CI: -1.08 to 0.26; p = 0.22). The difference in BMI between the two groups was statistically significant (mean difference: 3.42 kg/m², 95% CI: 1.43 to 5.42; p = 0.001). Improvements by at least one NYHA class were observed in 65% of the SEMA group (p < 0.001) compared to 15% of the control group (p = 0.18). The SEMA group also showed a significant increase in 6-minute walk distance (6MWD), with a mean difference of 75 m between the groups at one year (95% CI: 0.53 to 150.02; p = 0.049). NT-proBNP levels significantly decreased in the SEMA group (p < 0.001) compared to the control group (p = 0.78), with a statistically significant difference in NT-proBNP between the groups (p = 0.048). Both improvements in 6MWD and reductions in NT-proBNP were significantly correlated with BMI percentage reductions.

CONCLUSIONS

Semaglutide was associated with significant weight reduction in obese patients with heart failure, accompanied by improved NYHA classification and 6-minute walk distance. Larger, multi-center trials and prospective, randomized controlled trials are warranted. These studies should focus on assessing long-term outcomes, optimizing dosage, and exploring the potential cardiovascular benefits beyond weight reduction.

Inflammation in Obesity-Related HFpEF: The STEP-HFpEF Program

BACKGROUND

Inflammation is thought to be an important mechanism for the development and progression of obesity-related heart failure with preserved ejection fraction (HFpEF). In the STEP-HFpEF Program, once-weekly 2.4 mg semaglutide improved heart failure-related symptoms, physical limitations, and exercise function, reduced the levels of C-reactive protein (CRP), a biomarker of inflammation, and reduced body weight in participants with obesity-related HFpEF. However, neither the prevalence nor the clinical characteristics of patients who have various magnitudes of inflammation in the context of obesity-related HFpEF have been well described. Furthermore, whether the beneficial effects of semaglutide on the various HF efficacy endpoints in the STEP-HFpEF Program are modified by the baseline levels of inflammation has not been fully established. Finally, the relationship between weight reduction and changes in CRP across the STEP-HFpEF Program have not been fully defined.

OBJECTIVES

This study sought to: 1) evaluate baseline characteristics and clinical features of patients with obesity-related HFpEF that have various levels of inflammation in the STEP-HFpEF Program; 2) determine if the effects of weekly semaglutide 2.4 mg vs placebo across all key outcomes are influenced by baseline levels of inflammation assessed by CRP levels; and 3) determine the relationship between change in CRP and weight loss in the STEP-HFpEF Program.

METHODS

This was a secondary analysis of pooled data from 2 international, double-blind, placebo-controlled, randomized trials (STEP-HFpEF and STEP-HFpEF DM). The outcomes were change in the dual primary endpoints (health status [measured by the Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS)] and body weight) from baseline to 52 weeks according to baseline CRP levels. Additional efficacy endpoints included change in 6-minute walk distance (6MWD), a hierarchical composite endpoint that included death, heart failure events, and differences in the change in the KCCQ-CSS and 6MWD, and levels of CRP in semaglutide- vs placebo-treated patients. Patients were stratified into 3 categories based on baseline CRP levels (<2, ≥2 to <10, and ≥10 mg/L).

RESULTS

In total, 1,145 patients were randomized, of which 71% of patients had evidence of inflammation (CRP ≥2 mg/L). At baseline, those with higher levels of inflammation were younger, were more likely to be female, and had higher body mass index, worse health status (KCCQ-CSS), and shorter 6MWD. Semaglutide vs placebo led to reductions in HF-related symptoms and physical limitations as well as body weight, and to improvements in 6MWD and the hierarchical composite endpoint that were consistent across baseline CRP categories (all P interaction nonsignificant). Semaglutide also reduced CRP to a greater extent than placebo regardless of baseline CRP levels (P interaction = 0.32). Change in CRP from baseline to 52 weeks was similar regardless of the magnitude of weight loss (P interaction = 0.91).

CONCLUSIONS

Inflammation is highly prevalent in obesity-related HFpEF. Semaglutide consistently improved HF-related symptoms, physical limitations, and exercise function, and reduced body weight across the categories of baseline CRP. Semaglutide also reduced inflammation, regardless of either baseline CRP or magnitude of weight loss during the trials. (Research Study to Investigate How Well Semaglutide Works in People Living With Heart Failure and Obesity [STEP-HFpEF; NCT04788511]; Research Study to Look at How Well Semaglutide Works in People Living With Heart Failure, Obesity and Type 2 Diabetes [STEP HFpEF DM; NCT04916470]).