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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:S0019-4832(24)00158-5. [PMID: 39009078 DOI: 10.1016/j.ihj.2024.07.005] [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: 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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2
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein HH, Müller-Wieland D, Nauck MA, Wiesner T, Siegel E. Therapy of Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2024; 132:340-388. [PMID: 38599610 DOI: 10.1055/a-2166-6755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
| | - Jens Aberle
- Division of Endocrinology and Diabetology, University Obesity Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | | | - Baptist Gallwitz
- Department of Internal Medicine IV, Diabetology, Endocrinology, Nephrology, University Hospital Tübingen, Germany
| | - Monika Kellerer
- Department of Internal Medicine I, Marienhospital, Stuttgart, Germany
| | - Harald H Klein
- MVZ for Diagnostics and Therapy Bochum, Bergstraße 26, 44791 Bochum, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, Aachen University Hospital RWTH, Aachen, Germany
| | - Michael A Nauck
- Diabetology, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University, Bochum, Germany
| | | | - Erhard Siegel
- Department of Internal Medicine - Gastroenterology, Diabetology/Endocrinology and Nutritional Medicine, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg, Germany
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3
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Chyou JY, Qin H, Butler J, Voors AA, Lam CSP. Sex-related similarities and differences in responses to heart failure therapies. Nat Rev Cardiol 2024; 21:498-516. [PMID: 38459252 DOI: 10.1038/s41569-024-00996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Abstract
Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.
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Affiliation(s)
- Janice Y Chyou
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hailun Qin
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-NUS Medical School, Singapore, Singapore.
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4
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Abdin A, Böhm M, Shahim B, Karlström P, Kulenthiran S, Skouri H, Lund LH. Heart failure with preserved ejection fraction epidemiology, pathophysiology, diagnosis and treatment strategies. Int J Cardiol 2024; 412:132304. [PMID: 38944348 DOI: 10.1016/j.ijcard.2024.132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The prevalence of HF with preserved ejection raction (HFpEF, with EF ≥50%) is increasing across all populations with high rates of hospitalization and mortality, reaching up to 80% and 50%, respectively, within a 5-year timeframe. Comorbidity-driven systemic inflammation is thought to cause coronary microvascular dysfunction and increased epicardial adipose tissue, leading to downstream friborsis and molecular changes in the cardiomyocyte, leading to increased stiffness and diastolic dynsfunction. HFpEF poses unique challenges in terms of diagnosis due to its complex and diverse nature. The diagnosis of HFpEF relies on a combination of clinical assessment, imaging studies, and biomarkers. An additional important step in diagnosing HFpEF involves excluding certain cardiac diagnoses that may be specific underlying causes of HFpEF or may be masquerading as HFpEF and require specific alternative treatment approaches. In addition to administering sodium-glucose cotransporter 2 inhibitors to all patients, the most effective approach to enhance clinical outcomes may involve tailored therapy based on each patient's unique clinical profile. Exercise should be recommended for all patients to improve the quality of life. Glucagon-like peptide-1 1 agonists are a promising treatment option in obese HFpEF patients. Novel approaches targeting inflammation are also in early phase trials.
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Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Bahira Shahim
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Jönköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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5
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Wang M, Liu X, Ding B, Lu Q, Ma J. SGLT2 inhibitor Dapagliflozin alleviates cardiac dysfunction and fibrosis after myocardial infarction by activating PXR and promoting angiogenesis. Biomed Pharmacother 2024; 177:116994. [PMID: 38889638 DOI: 10.1016/j.biopha.2024.116994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Myocardial infarction (MI) has emerged as the primary cause of global mortality. Managing blood sugar levels could play a vital role in the treatment of MI. Dapagliflozin (DPG), a commonly used hypoglycemic drug, has demonstrated efficacy in treating heart failure. However, the impact of DPG on MI remains unclear. We aimed to investigate the effects and mechanisms of DPG in relation to MI. METHODS AND RESULTS DPG administration alleviated MI-induced cardiac dysfunction and myocardial fibrosis. We also found that DPG administration mitigated cardiomyocyte apoptosis through TUNEL staining. CD31 and α-Sma staining revealed that DPG promotes post-MI angiogenesis in mice. In vitro, using scratch assays, transwell assays, and tube formation assays, we discovered that DPG enhanced HUVEC proliferation capacity. Mechanistically, DPG promoted the expression of extracellular matrix genes and mitochondrial function-related genes. Additionally, molecular docking identified the interaction between DPG and PXR, which activated PXR and recruited it to the promoters of Pgam2 and Tcap, promoting their expressions, thus facilitating angiogenesis and post-MI heart repair. CONCLUSIONS DPG promotes angiogenesis by activating PXR, thereby alleviating cardiac dysfunction and fibrosis after myocardial infarction. This study provides new strategies and targets for the treatment of ischemic disease.
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Affiliation(s)
- Min Wang
- Department of Geriatrics, Affiliated Brain Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xiameng Liu
- Department of Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Bo Ding
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210012, China
| | - Qiulun Lu
- State Key Laboratory of Natural Medicines, Jiangsu Provincial Key Laboratory of Drug Metabolism and Pharmacokinetics, Pharmaceutical University, Nanjing 211198, China.
| | - Jianhua Ma
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210012, China.
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Song J, Liu Y, Xu Y, Hao P. Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors in Patients with Acute Coronary Syndrome. ACS Pharmacol Transl Sci 2024; 7:1847-1855. [PMID: 38898953 PMCID: PMC11184598 DOI: 10.1021/acsptsci.4c00076] [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: 02/09/2024] [Revised: 03/26/2024] [Accepted: 04/11/2024] [Indexed: 06/21/2024]
Abstract
The evidence for sodium-glucose cotransporter 2 inhibitors (SGLT2i) in the treatment of type 2 diabetes or chronic heart failure was sufficient but lacking in acute coronary syndrome (ACS). Our aim was to investigate the effects of SGLT2i on cardiovascular outcomes in ACS patients. Studies of SGLT2i selection in ACS patients were searched and pooled. Outcomes included all-cause death, adverse cardiovascular events, cardiac remodeling as measured by the left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD), cardiac function as assessed by the left ventricular ejection fraction (LVEF) and NT-proBNP, and glycemic control. Twenty-four studies with 12,413 patients were identified. Compared to the group without SGLT2i, SGLT2i showed benefits in reducing all-cause death (OR 0.72, 95% CI [0.61, 0.85]), major adverse cardiovascular events (MACE) (OR 0.44, 95% CI [0.30, 0.64]), cardiovascular death (OR 0.66, 95% CI [0.54, 0.81]), heart failure (OR 0.52, 95% CI [0.44, 0.62]), myocardial infarction (OR 0.68, 95% CI [0.56, 0.83]), angina pectoris (OR 0.37, 95% CI [0.17, 0.78]), and stroke (OR 0.48, 95% CI [0.24, 0.96]). Results favored SGLT2i for LVEDD (MD -2.03, 95% CI [-3.29, -0.77]), LVEF (MD 3.22, 95% CI [1.71, 4.72]), and NT-proBNP (MD -171.53, 95% CI [-260.98, -82.08]). Thus, SGLT2i treatment reduces the risk of all-cause death and MACE and improves cardiac remodeling and function in ACS patients.
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Affiliation(s)
- Jiawei Song
- State
Key Laboratory for Innovation and Transformation of Luobing Theory,
The Key Laboratory of Cardiovascular Remodeling and Function Research,
Chinese Ministry of Education, Chinese National Health Commission
and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, China
- Department
of Cardiology, Wuzhong People’s Hospital
Affiliated to Ningxia Medical University, Wuzhong, Ningxia 751100, China
- School
of Basic Medical Science, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Yanping Liu
- Department
of Radiology, Qilu Hospital of Shandong
University, Jinan, Shandong 250012, China
| | - Yani Xu
- State
Key Laboratory for Innovation and Transformation of Luobing Theory,
The Key Laboratory of Cardiovascular Remodeling and Function Research,
Chinese Ministry of Education, Chinese National Health Commission
and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, China
| | - Panpan Hao
- State
Key Laboratory for Innovation and Transformation of Luobing Theory,
The Key Laboratory of Cardiovascular Remodeling and Function Research,
Chinese Ministry of Education, Chinese National Health Commission
and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, China
- Department
of Cardiology, Wuzhong People’s Hospital
Affiliated to Ningxia Medical University, Wuzhong, Ningxia 751100, China
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7
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Udell JA, Petrie MC, Jones WS, Anker SD, Harrington J, Mattheus M, Seide S, Amir O, Bahit MC, Bauersachs J, Bayes-Genis A, Chen Y, Chopra VK, Figtree G, Ge J, Goodman SG, Gotcheva N, Goto S, Gasior T, Jamal W, Januzzi JL, Jeong MH, Lopatin Y, Lopes RD, Merkely B, Martinez-Traba M, Parikh PB, Parkhomenko A, Ponikowski P, Rossello X, Schou M, Simic D, Steg PG, Szachniewicz J, van der Meer P, Vinereanu D, Zieroth S, Brueckmann M, Sumin M, Bhatt DL, Hernandez AF, Butler J. Left Ventricular Function, Congestion, and Effect of Empagliflozin on Heart Failure Risk After Myocardial Infarction. J Am Coll Cardiol 2024; 83:2233-2246. [PMID: 38588929 DOI: 10.1016/j.jacc.2024.03.405] [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: 02/22/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Empagliflozin reduces the risk of heart failure (HF) hospitalizations but not all-cause mortality when started within 14 days of acute myocardial infarction (AMI). OBJECTIVES This study sought to evaluate the association of left ventricular ejection fraction (LVEF), congestion, or both, with outcomes and the impact of empagliflozin in reducing HF risk post-AMI. METHODS In the EMPACT-MI (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction) trial, patients were randomized within 14 days of an AMI complicated by either newly reduced LVEF<45%, congestion, or both, to empagliflozin (10 mg daily) or placebo and were followed up for a median of 17.9 months. RESULTS Among 6,522 patients, the mean baseline LVEF was 41 ± 9%; 2,648 patients (40.6%) presented with LVEF <45% alone, 1,483 (22.7%) presented with congestion alone, and 2,181 (33.4%) presented with both. Among patients in the placebo arm of the trial, multivariable adjusted risk for each 10-point reduction in LVEF included all-cause death or HF hospitalization (HR: 1.49; 95% CI: 1.31-1.69; P < 0.0001), first HF hospitalization (HR: 1.64; 95% CI: 1.37-1.96; P < 0.0001), and total HF hospitalizations (rate ratio [RR]: 1.89; 95% CI: 1.51-2.36; P < 0.0001). The presence of congestion was also associated with a significantly higher risk for each of these outcomes (HR: 1.52, 1.94, and RR: 2.03, respectively). Empagliflozin reduced the risk for first (HR: 0.77; 95% CI: 0.60-0.98) and total (RR: 0.67; 95% CI: 0.50-0.89) HF hospitalizations, irrespective of LVEF or congestion, or both. The safety profile of empagliflozin was consistent across baseline LVEF and irrespective of congestion status. CONCLUSIONS In patients with AMI, the severity of left ventricular dysfunction and the presence of congestion was associated with worse outcomes. Empagliflozin reduced first and total HF hospitalizations across the range of LVEF with and without congestion. (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction [EMPACT-MI]; NCT04509674).
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Affiliation(s)
- Jacob A Udell
- Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Mark C Petrie
- School of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - W Schuyler Jones
- Division of Cardiology, Duke University Department of Medicine, Durham, North Carolina, USA; Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Stefan D Anker
- Department of Cardiology, German Heart Center Charité, Charité Universitätsmedizin, Berlin, Germany; Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Josephine Harrington
- Division of Cardiology, Duke University Department of Medicine, Durham, North Carolina, USA; Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Svenja Seide
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Offer Amir
- Heart Institute, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Santa Fe, Argentina
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Department of Medicine, Universitat Autònomoa de Barcelona, Barcelona, Spain
| | - Yundai Chen
- Department of Cardiology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shaun G Goodman
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Nina Gotcheva
- Department of Cardiology, MHAT National Cardiology Hospital EAD, Sofia, Bulgaria
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Japan
| | - Tomasz Gasior
- Collegium Medicum - Faculty of Medicine, WSB University, Dabrowa Gornicza, Poland; Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA; Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Myung Ho Jeong
- Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd, Russia
| | - Renato D Lopes
- Division of Cardiology, Duke University Department of Medicine, Durham, North Carolina, USA; Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Puja B Parikh
- Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, New York, USA
| | | | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Xavier Rossello
- Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Dragan Simic
- Department of Cardiovascular Diseases, University Clinical Center, Belgrade, Serbia
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), INSERM U-1148, AP-HP, Hôpital Bichat, Paris, France
| | | | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Bucharest, Romania
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Department of Medicine, Durham, North Carolina, USA; Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
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8
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Ambery P, Greasley PJ, Menzies RI, Brynne L, Kulkarni S, Oscarsson J, Davenport AP. Targeting the endothelium by combining endothelin-1 antagonism and SGLT-2 inhibition: better together? Clin Sci (Lond) 2024; 138:687-697. [PMID: 38835256 DOI: 10.1042/cs20240605] [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: 03/28/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
Endothelin A and B receptors, together with sodium-glucose cotransporter-2 (SGLT-2) channels are important targets in improving endothelial function and intervention with inhibitors has been the subject of multiple mechanistic and clinical outcome trials over recent years. Notable successes include the treatment of pulmonary hypertension with endothelin receptor antagonists, and the treatment of heart failure and chronic kidney disease with SGLT-2 inhibitors. With distinct and complementary mechanisms, in this review, we explore the logic of combination therapy for a number of diseases which have endothelial dysfunction at their heart.
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Affiliation(s)
- Phil Ambery
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Peter J Greasley
- Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert I Menzies
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Lena Brynne
- Information Practice Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Spoorthy Kulkarni
- Department of Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB20QQ, U.K
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, U.K
| | - Jan Oscarsson
- Clinical Late Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anthony P Davenport
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, U.K
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9
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Jain P, Guha S, Kumar S, Sawhney JPS, Sharma K, Sureshkumar KP, Mehta A, Dhediya R, Gaurav K, Mittal R, Kotak B. Management of Heart Failure in a Resource-Limited Setting: Expert Opinion from India. Cardiol Ther 2024; 13:243-266. [PMID: 38687432 PMCID: PMC11093928 DOI: 10.1007/s40119-024-00367-4] [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: 10/12/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
Heart failure poses a global health challenge affecting millions of individuals, and access to guideline-directed medical therapy is often limited. This limitation is frequently attributed to factors such as drug availability, slow adoption, clinical inertia, and delayed diagnosis. Despite international recommendations promoting the use of guideline-directed medical therapy for heart failure management, personalized approaches are essential in settings with resource constraints. In India, crucial treatments like angiotensin II receptor blocker neprilysin inhibitors and sodium-glucose co-transporter 2 inhibitors are not fully utilized despite their established safety and efficacy. To address this issue, an expert consensus involving 150 specialists, including cardiologists, nephrologists, and endocrinologists, was convened. They deliberated on patient profiles, monitoring, and adverse side effects and provided tailored recommendations for guideline-directed medical therapy in heart failure management. Stressing the significance of early initiation of guideline-directed medical therapy in patients with heart failure, especially with sodium-glucose co-transporter 2 inhibitors, the consensus also explored innovative therapies like vericiguat. To improve heart failure outcomes in resource-limited settings, the experts proposed several measures, including enhanced patient education, cardiac rehabilitation, improved drug access, and reforms in healthcare policies.
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Affiliation(s)
- Peeyush Jain
- Fortis Escorts Heart Institute, New Delhi, India
| | | | | | | | - Kamal Sharma
- Apollo Hospitals, U N Mehta Institute of Cardiology, Ahmedabad, India
| | | | | | | | - Kumar Gaurav
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
| | - Rajan Mittal
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
| | - Bhavesh Kotak
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
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10
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Kodur N, Tang WHW. Non-cardiac comorbidities in heart failure: an update on diagnostic and management strategies. Minerva Med 2024; 115:337-353. [PMID: 38899946 DOI: 10.23736/s0026-4806.24.09070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Managing non-cardiac comorbidities in heart failure (HF) requires a tailored approach that addresses each patient's specific conditions and needs. Regular communication and coordination among healthcare providers is crucial to providing the best possible care for these patients. Poorly controlled hypertension contributes to left ventricular remodeling and diastolic dysfunction, emphasizing the importance of optimal blood pressure control while avoiding adverse effects. Among HF patients with diabetes, SGLT2 inhibitors and mineralocorticoid receptor antagonists have shown promise in reducing HF-related morbidity and mortality. Chronic kidney disease exacerbates HF and vice versa, forming the vicious cardiorenal syndrome, so disease-modifying therapies should be maintained in HF patients with comorbid CKD, even with transient changes in kidney function. Anemia in HF patients may be multifactorial, and there is growing evidence for the benefit of intravenous iron supplementation in HF patients with iron deficiency with or without anemia. Obesity, although a risk factor for HF, paradoxically offers a better prognosis once HF is established, though developing treatment strategies may improve symptoms and cardiac performance. In HF patients with stroke and atrial fibrillation, anticoagulation therapy is recommended. Among HF patients with sleep-disordered breathing, continuous positive airway pressure may improve sleep quality. Chronic obstructive pulmonary disease often coexists with HF, and many patients can tolerate cardioselective beta-blockers. Cancer patients with comorbid HF require careful consideration of cardiotoxicity risks associated with cancer therapies. Depression is underdiagnosed in HF patients and significantly impacts prognosis. Cognitive impairment is prevalent in HF patients and impacts their self-care and overall quality of life.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - W H Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA -
- Center for Microbiome and Human Health, Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Lin J, Liu S, Liu T, Chuang S, Huang C, Chen Y, Lee C, Chien M, Hou CJ, Yeh H, Chiang C, Hung C. ELUCIDATE Trial: A Single-Center Randomized Controlled Study. J Am Heart Assoc 2024; 13:e033832. [PMID: 38639353 PMCID: PMC11179944 DOI: 10.1161/jaha.123.033832] [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: 12/08/2023] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, is an epochal oral antidiabetic drug that improves cardiorenal outcomes. However, the effect of early dapagliflozin intervention on left ventricular (LV) remodeling in patients with type 2 diabetes free from cardiovascular disease remains unclear. METHODS AND RESULTS The ELUCIDATE trial was a prospective, open-label, randomized, active-controlled study that enrolled 76 patients with asymptomatic type 2 diabetes with LV ejection fraction ≥50%, randomized to the dapagliflozin 10 mg/day add-on or standard-of-care group. Speckle-tracking echocardiography-based measurements of the cardiac global longitudinal strain were performed at baseline and 24 weeks after treatment initiation. Patients who received dapagliflozin had a greater reduction in LV dimension (1.68 mm [95% CI, 0.53-2.84]; P=0.005), LV end-systolic volume (5.51 mL [95% CI, 0.86-10.17]; P=0.021), and LV mass index (4.25 g/m2.7 [95% CI, 2.42-6.09]; P<0.0001) compared with standard of care in absolute mean differences. Dapagliflozin add-on therapy led to a significant LV global longitudinal strain increment (0.74% [95% CI, 1.00-0.49]; P<0.0001) and improved LV systolic and early diastolic strain rates (0.27/s [95% CI, 0.17-0.60]; and 0.11/s [95% CI, 0.06-0.16], respectively; both P<0.0001) but not in global circumferential strain. No significant changes were found in insulin resistance, NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, or other biomarkers at 6 months after the dapagliflozin administration. CONCLUSIONS Dapagliflozin add-on therapy could lead to more favorable cardiac remodeling accompanied by enhanced cardiac mechanical function among patients with asymptomatic type 2 diabetes. Our findings provide evidence of the efficacy of dapagliflozin use for the primary prevention of diabetic cardiomyopathy. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03871621.
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Affiliation(s)
- Jiun‐Lu Lin
- Division of Endocrinology and Metabolism, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Sung‐Chen Liu
- Division of Endocrinology and Metabolism, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Tze‐Fan Liu
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Shih‐Ming Chuang
- Division of Endocrinology and Metabolism, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Chun‐Ta Huang
- Division of Endocrinology and Metabolism, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Ying‐Ju Chen
- Department of TelehealthMacKay Memorial HospitalTaipeiTaiwan
| | - Chun‐Chuan Lee
- Division of Endocrinology and Metabolism, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Ming‐Nan Chien
- Division of Endocrinology and Metabolism, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
| | - Charles Jia‐Yin Hou
- Division of Cardiology, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
| | - Hung‐I. Yeh
- Department of MedicineMacKay Medical CollegeNew Taipei CityTaiwan
- Division of Cardiology, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
| | - Chern‐En Chiang
- Division of Cardiology, General Clinical Research CenterTaipei Veterans General Hospital, National Yang‐Ming UniversityTaipeiTaiwan
| | - Chung‐Lieh Hung
- Department of TelehealthMacKay Memorial HospitalTaipeiTaiwan
- Division of Cardiology, Department of Internal MedicineMacKay Memorial HospitalTaipeiTaiwan
- Institute of Biomedical Science, MacKay Medical CollegeNew Taipei CityTaiwan
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12
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Bae JP, Kallenbach L, Nelson DR, Lavelle K, Winer-Jones JP, Bonafede M, Murakami M. Obesity and metabolic syndrome in patients with heart failure with preserved ejection fraction: a cross-sectional analysis of the Veradigm Cardiology Registry. BMC Endocr Disord 2024; 24:59. [PMID: 38693484 PMCID: PMC11064285 DOI: 10.1186/s12902-024-01589-2] [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: 10/24/2023] [Accepted: 04/24/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND The proportion of heart failure patients with preserved ejection fraction has been rising over the past decades and has coincided with increases in the prevalence of obesity and metabolic syndrome. The relationship between these interconnected comorbidities and heart failure with preserved ejection fraction (HFpEF) is still poorly understood. This study characterized obesity and metabolic syndrome among real-world patients with HFpEF. METHODS We identified adults with heart failure in the Veradigm Cardiology Registry, previously the PINNACLE Registry, with a left ventricular ejection fraction measurement ≥ 50% between 01/01/2016 and 12/31/2019. Patients were stratified by obesity diagnosis and presence of metabolic syndrome (≥ 3 of the following: diabetes, hypertension, hyperlipidemia, and obesity). We captured baseline demographic and clinical characteristics and used multivariable logistic regression to examine the odds of having cardiac (atrial fibrillation, coronary artery disease, coronary artery bypass surgery, myocardial infarction, and stroke/transient ischemic attack) and non-cardiac (chronic kidney disease, chronic liver disease, and peripheral artery disease) comorbidities of interest. The models adjusted for age and sex, and the main covariates of interest were obesity and metabolic burden score (0-3 based on the presence of diabetes, hypertension, and hyperlipidemia). The models were run with and without an obesity*metabolic burden score interaction term. RESULTS This study included 264,571 patients with HFpEF, of whom 55.7% had obesity, 52.5% had metabolic syndrome, 42.5% had both, and 34.3% had neither. After adjusting for age, sex, and burden of other metabolic syndrome-associated diagnoses, patients with HFpEF with obesity had lower odds of a diagnosis of other evaluated comorbidities relative to patients without obesity. The presence of metabolic syndrome in HFpEF appears to increase comorbidity burden as each additional metabolic syndrome-associated diagnosis was associated with higher odds of assessed comorbidities except atrial fibrillation. CONCLUSION Obesity was common among patients with HFpEF and not always co-occurring with metabolic syndrome. Multivariable analysis suggested that patients with obesity may develop HFpEF in the absence of other driving factors such as cardiovascular disease or metabolic syndrome.
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Affiliation(s)
- Jay P Bae
- Eli Lilly and Company, Indianapolis, USA.
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13
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Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
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Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
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14
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Garred CH, Malmborg M, Malik ME, Zahir D, Christensen DM, Arulmurugananthavadivel A, Fosbøl EL, Gislason G, McMurray JJV, Petrie MC, Andersson C, Køber L, Schou M. Age-specific mortality trends in heart failure over 25 years: a retrospective Danish nationwide cohort study. THE LANCET. HEALTHY LONGEVITY 2024; 5:e326-e335. [PMID: 38705151 DOI: 10.1016/s2666-7568(24)00029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Despite advances in heart failure care reducing mortality in clinical trials, it remains unclear whether real-life cohorts have had similar improvements in life expectancy across the age spectrum. We aimed to investigate how mortality trends changed in patients with heart failure over the past 25 years, stratified by age groups. METHODS Using Danish nationwide registries, we identified patients with new-onset heart failure aged 18-95 years. The 5-year all-cause mortality risk and the absolute risk difference of mortality between patients with heart failure and age-matched and sex-matched heart failure-free controls were assessed using Kaplan-Meier estimates and multivariable Cox regression models. Mortality trends were analysed across five calendar periods (1996-2000, 2001-05, 2006-10, 2011-15, and 2016-20) and three age groups (<65 years, 65-79 years, and ≥80 years). FINDINGS 194 997 patients with heart failure were included. Mortality significantly decreased from 1996-2000 (66% [95% CI 65·5-66·4]) to 2016-20 (43% [42·1-43·4]), with similar results shown in all age groups (<65 years: 35% [33·9-36·1] to 15% [14·6-16·3]; 65-79 years: 64% [63·1-64·5] to 39% [37·6-39·6]; and ≥80 years: 84% [83·1-84·3] to 73% [71·7-73·9]). Adjusted mortality rates supported these associations. The absolute risk difference declined notably in younger age groups (<65 years: 29·9% [28·8-31·0] to 12·7% [12·0-13·4] and 65-79 years: 41·1% [40·3-41·9] to 25·1% [24·4-25·8]), remaining relatively stable in those aged 80 years or older (30·6% [29·9-31·3] to 28% [27·2-28·8]). INTERPRETATION Over 25 years, there has been a consistent decrease in mortality among patients with heart failure across age groups, albeit less prominently in patients aged 80 years or older. Further insight is needed to identify effective strategies for improving disease burden in older patients with heart failure. FUNDING None. TRANSLATION For the Danish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
| | - Morten Malmborg
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | | | - Deewa Zahir
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | | | | | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Science, University of Copenhagen, Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Science, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- School of Cardiovascular and Metabolic Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Charlotte Andersson
- Center for Advanced Heart Disease, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Science, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Science, University of Copenhagen, Copenhagen, Denmark
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15
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Silva-Cardoso J, Santos J, Araújo I, Andrade A, Morais Sarmento P, Santos P, Moura B, Marques I, Peres M, Ferreira JP, Agostinho J, Pimenta J. conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT). Rev Port Cardiol 2024; 43:225-235. [PMID: 37689388 DOI: 10.1016/j.repc.2023.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/11/2023] [Accepted: 05/02/2023] [Indexed: 09/11/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future. METHODS A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses. RESULTS Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses. CONCLUSION This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.
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Affiliation(s)
- José Silva-Cardoso
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; RISE - Health Research Network, Portugal.
| | - Jonathan Santos
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; ARS Norte, ACES Vale Sousa Norte, USF Torrão, Portugal
| | - Inês Araújo
- Clínica de Insuficiência Cardíaca, Serviço de Medicina III, Hospital S. Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal; NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Aurora Andrade
- Serviço de Cardiologia, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Pedro Morais Sarmento
- Departamento de Medicina Interna e Hospital de Dia de Insuficiência Cardíaca do Hospital da Luz de Lisboa, Lisboa, Portugal
| | - Paulo Santos
- CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; RISE - Health Research Network, Portugal; MEDCIDS, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Brenda Moura
- Serviço de Cardiologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Irene Marques
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto (CHUPorto), Porto, Portugal; Unidade Multidisciplinar de Investigação Biomédica - Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
| | - Marisa Peres
- Serviço de Cardiologia, Hospital de Santarém, Santarém, Portugal
| | - João Pedro Ferreira
- Unic@RISE, Serviço de Cirurgia e Fisiologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Joao Agostinho
- Serviço de Cardiologia, Departamento de Coração e Vasos, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisboa, Portugal; CCUL, Centro Académico de Medicina de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Joana Pimenta
- Serviço de Medicina Interna, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; UnIC@RISE, Departamento de Medicina, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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16
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [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: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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17
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Christersson M, Gustafsson S, Lampa E, Almstedt M, Cars T, Bodegård J, Arefalk G, Sundström J. Usefulness of Heart Failure Categories Based on Left Ventricular Ejection Fraction. J Am Heart Assoc 2024; 13:e032257. [PMID: 38591322 DOI: 10.1161/jaha.123.032257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Heart failure guidelines have recently introduced a narrow category with mildly reduced left ventricular ejection fraction (LVEF) (heart failure with mildly reduced ejection fraction; LVEF 41%-49%) between the previous categories of reduced (heart failure with reduced ejection fraction; LVEF ≤40%) and preserved (heart failure with preserved ejection fraction; LVEF ≥50%) ejection fraction. Grouping of continuous measurements into narrow categories can be questioned if their variability is high. METHODS AND RESULTS We constructed a cohort of all 9716 new cases of chronic heart failure with an available LVEF in Stockholm, Sweden, from January 1, 2015, until December 31, 2020. All values of LVEF were collected over time, and patients were followed up until death, moving out of Stockholm, or end of study. Mixed models were used to quantify within-person variance in LVEF, and multistate Markov models, with death as an absorbing state, to quantify the stability of LVEF categories. LVEF values followed a normal distribution. The SD of the within-person variance in LVEF over time was 7.4%. The mean time spent in any LVEF category before transition to another category was on average <1 year for heart failure with mildly reduced ejection fraction. Probabilities of transitioning between categories during the first year were substantial; patients with heart failure with mildly reduced ejection fraction had a probability of <25% of remaining in that category 1 year later. CONCLUSIONS LVEF follows a normal distribution and has considerable variability over time, which may impose a risk for underuse of efficient treatment. The heart failure with mildly reduced ejection fraction category is especially inconstant. Assumptions of a patient's current LVEF should take this variability and the normal distribution of LVEF into account.
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Affiliation(s)
| | | | - Erik Lampa
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | | | | | - Johan Bodegård
- Cardiovascular, Renal and Metabolism, Medical Department BioPharmaceuticals, AstraZeneca Oslo Norway
| | - Gabriel Arefalk
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Johan Sundström
- Department of Medical Sciences Uppsala University Uppsala Sweden
- The George Institute for Global Health, University of New South Wales Sydney Australia
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18
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de Oliveira MT, Baptista R, Chavez-Leal SA, Bonatto MG. Heart failure management with β-blockers: can we do better? Curr Med Res Opin 2024; 40:43-54. [PMID: 38597068 DOI: 10.1080/03007995.2024.2318002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/08/2024] [Indexed: 04/11/2024]
Abstract
Heart failure (HF) is associated with disabling symptoms, poor quality of life, and a poor prognosis with substantial excess mortality in the years following diagnosis. Overactivation of the sympathetic nervous system is a key feature of the pathophysiology of HF and is an important driver of the process of adverse remodelling of the left ventricular wall that contributes to cardiac failure. Drugs which suppress the activity of the renin-angiotensin-aldosterone system, including β-blockers, are foundation therapies for the management of heart failure with reduced ejection fraction (HFrEF) and despite a lack of specific outcomes trials, are also widely used by cardiologist in patients with HF with preserved ejection fraction (HFpEF). Today, expert opinion has moved away from recommending that treatment for HF should be guided solely by the LVEF and interventions should rather address signs and symptoms of HF (e.g. oedema and tachycardia), the severity of HF, and concomitant conditions. β-blockers improve HF symptoms and functional status in HF and these agents have demonstrated improved survival, as well as a reduced risk of other important clinical outcomes such as hospitalisation for heart failure, in randomised, placebo-controlled outcomes trials. In HFpEF, β-blockers are anti-ischemic and lower blood pressure and heart rate. Moreover, β-blockers also reduce mortality in the setting of HF occurring alongside common comorbid conditions, such as diabetes, CKD (of any severity), and COPD. Higher doses of β-blockers are associated with better clinical outcomes in populations with HF, so that ensuring adequate titration of therapy to their maximal (or maximally tolerated) doses is important for ensuring optimal outcomes for people with HF. In principle, a patient with HF could have combined treatment with a β-blocker, renin-angiotensin-aldosterone system inhibitor/neprilysin inhibitor, mineralocorticoid receptor antagonist, and a SGLT2 inhibitor, according to tolerability.
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Affiliation(s)
- Mucio Tavares de Oliveira
- Heart Institute, Day Hospital and Infusion Center, University of Sao Paulo Medical School, Sao Paulo, Brazil
- Infusion Center and Day Hospital at Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Rui Baptista
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Cardiology Department, Centro Hospitalar Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | | | - Marcely Gimenes Bonatto
- Department of Heart Failure and Heart Transplant, Hospital Santa Casa de Misericórdia de, Curitiba, Brazil
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Comments on the 2023 update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:281-284. [PMID: 38048844 DOI: 10.1016/j.rec.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 12/06/2023]
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Celik A, Sahin A, Ata N, Colluoglu IT, Ural D, Kanik EA, Ayvali MO, Ulgu MM, Birinci S, Yilmaz MB. Navigating Heart Failure: Unveiling Sex Disparities in Guideline-Directed Medical Therapy Combinations. Am J Cardiol 2024; 216:27-34. [PMID: 38266795 DOI: 10.1016/j.amjcard.2024.01.017] [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: 12/17/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
Major heart failure (HF) trials remain insufficient in terms of assessing the differences in clinical characteristics, biomarkers, treatment efficacy, and safety because of the under-representation of women. The study aimed to present sex-related disparities in HF management, including differences in demographics, co-morbidities, cardiac biomarkers, prescribed medications, and treatment outcomes. The study utilized anonymized data from the Turkish Ministry of Health's National Electronic Database between January 1, 2016, and December 31, 2022. The cohort analysis included 2,501,231 adult patients with HF. Specific therapeutic combinations were analyzed using a Cox regression model to obtain relative risk reduction for all-cause death. The primary end point was all-cause mortality. In the cohort, 48.7% (n = 1,218,911) were male, whereas 51.3% (n = 1,282,320) were female. Female patients exhibited a higher median age (71 vs 68 years) and manifested higher prevalence of diabetes mellitus, anemia, atrial fibrillation, anxiety, and ischemic stroke. Male patients demonstrated higher rates of previous myocardial infarction, dyslipidemia, chronic obstructive pulmonary disease, and chronic kidney disease. Higher concentrations of natriuretic peptides were observed in female patients. Renin-angiotensin aldosterone inhibitor, β blockers, mineralocorticoid receptor antagonists, sodium/glucose cotransporter 2 inhibitor (SGLT2i), and ivabradine were more commonly prescribed in male patients, whereas loop diuretics, digoxin, and ferric carboxymaltose were more frequent in female patients. Male patients had higher rates of cardiac resynchronization therapy and implantable cardioverter defibrillator implantation rates. All-cause mortality and hospitalization rates were higher in male patients. Compared with monotherapy, all combinations, including SGLT2i, showed a beneficial effect on all-cause mortality in both female and male patients with HF. In hospitalized patients with HF, the addition of digoxin to renin-angiotensin aldosterone inhibitor, mineralocorticoid receptor antagonists, and β blockers was superior to monotherapy regarding all-cause mortality in female patients with HF compared with male patients with HF. In conclusion, this study highlights that sex-specific responses to HF medication combinations compared with monotherapy and differences in co-morbidities underscore the importance of tailored management strategies. Digoxin showed a contrasting effect on all-cause mortality between both sexes after hospitalization, whereas SGLT2i exhibited a consistent beneficial effect in both sexes when added to all combinations.
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Affiliation(s)
- Ahmet Celik
- Department of Cardiology, Faculty of Medicine, Mersin University, Mersin, Türkiye.
| | - Anil Sahin
- Department of Cardiology, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Türkiye
| | - Naim Ata
- General Directorate of Information Systems, Ministry of Health, Ankara, Türkiye
| | - Inci Tugce Colluoglu
- Department of Cardiology, Faculty of Medicine, Karabük University, Karabük, Türkiye
| | - Dilek Ural
- Department of Cardiology, Faculty of Medicine, Koç University, Istanbul, Türkiye
| | - Emine Arzu Kanik
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Türkiye
| | - Mustafa Okan Ayvali
- General Directorate of Information Systems, Ministry of Health, Ankara, Türkiye
| | - Mustafa Mahir Ulgu
- General Directorate of Information Systems, Ministry of Health, Ankara, Türkiye
| | - Suayip Birinci
- Deputy Minister of Health, Ministry of Health, Ankara, Türkiye
| | - Mehmet Birhan Yilmaz
- Department of Cardiology, Faculty of Medicine, Dokuz Eylül University, Izmir, Türkiye
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Peikert A, Bart BA, Vaduganathan M, Claggett BL, Kulac IJ, Kosiborod MN, Desai AS, Jhund PS, Lam CSP, Inzucchi SE, Martinez FA, de Boer RA, Hernandez AF, Shah SJ, Petersson M, Langkilde AM, McMurray JJV, Solomon SD, Vardeny O. Contemporary Use and Implications of Beta-Blockers in Patients With HFmrEF or HFpEF: The DELIVER Trial. JACC. HEART FAILURE 2024; 12:631-644. [PMID: 37767674 DOI: 10.1016/j.jchf.2023.09.007] [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: 07/25/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Although beta-blockers are not recommended for the treatment of heart failure with preserved ejection fraction (HFpEF) according to the latest European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines, these therapies remain commonly used for comorbidity management. There has been concern that beta-blockers may adversely influence clinical outcomes by limiting chronotropic response in HFpEF. OBJECTIVES This study sought to examine the contemporary use and implications of beta-blockers in patients with heart failure with mildly reduced ejection fraction (HFmrEF) or HFpEF. METHODS In the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trial, a total of 6,263 patients with symptomatic heart failure (HF) with a left ventricular ejection fraction (LVEF) >40% were randomized to dapagliflozin or placebo across 20 countries. In this prespecified analysis, efficacy and safety outcomes were examined according to beta-blocker use at randomization. The primary outcome was cardiovascular death or worsening HF. RESULTS Overall, beta-blockers were used in 5,177 patients (83%), with wide variation by geographic region. Beta-blocker use was associated with a lower risk of the primary outcome in covariate-adjusted models (HR: 0.70; 95% CI: 0.60-0.83). Dapagliflozin consistently reduced the risk of the primary outcome in patients taking beta-blockers (HR: 0.82; 95% CI: 0.72-0.94) and in patients not taking beta-blockers (HR: 0.79; 95% CI: 0.61-1.03; Pinteraction = 0.85), with similar findings for key secondary endpoints. Adverse events were balanced between patients randomized to dapagliflozin and placebo, regardless of background beta-blocker use. CONCLUSIONS In patients with HFmrEF or HFpEF who were enrolled in DELIVER, 4 out of 5 participants were treated with a beta-blocker. Beta-blocker use was not associated with a higher risk of worsening HF or cardiovascular death. Dapagliflozin consistently and safely reduced clinical events, irrespective of background beta-blocker use. (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bradley A Bart
- Minneapolis VA Center for Care Delivery and Outcomes Research, Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian J Kulac
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore; Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | | | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, 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 Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
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22
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Zafeiropoulos S, Farmakis IT, Milioglou I, Doundoulakis I, Gorodeski EZ, Konstantinides SV, Cooper L, Zanos S, Stavrakis S, Giamouzis G, Butler J, Giannakoulas G. Pharmacological Treatments in Heart Failure With Mildly Reduced and Preserved Ejection Fraction: Systematic Review and Network Meta-Analysis. JACC. HEART FAILURE 2024; 12:616-627. [PMID: 37656079 DOI: 10.1016/j.jchf.2023.07.014] [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: 05/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Medical treatment for heart failure with preserved ejection (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF) has weaker evidence compared with reduced ejection fraction, despite recent trials with an angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitors (SGLT2is). OBJECTIVES The authors aimed to estimate the aggregate therapeutic benefit of drugs for HFmrEF and HFpEF. METHODS The authors performed a systematic review of MEDLINE, CENTRAL, and Web of Science for randomized trials including patients with heart failure (HF) and left ventricular ejection fraction (LVEF) >40%, treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (analyzed together as renin-angiotensin system inhibitors [RASi]), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), digoxin, ARNI, and SGLT2i. An additive component network meta-analysis was performed. The primary outcome was a composite of cardiovascular (CV) death and first hospitalization for heart failure (HHF); secondary outcomes were CV death, total HHF, and all-cause mortality. RESULTS The authors identified 13 studies with a total of 29,875 patients and a mean LVEF of 56.3% ± 8.7%. ARNI, MRA, and SGLT2i separately, but not RASi, BB, or digoxin, reduced the primary composite outcome compared with placebo. The combination of ARNI, BB, MRA, and SGLT2i was the most effective (HR: 0.47 [95% CI: 0.31-0.70]); this was largely explained by the triple combination of ARNI, MRA, and SGLT2i (HR: 0.56 [95% CI 0.43-0.71]). Results were similar for CV death (HR: 0.63 [95% CI 0.43-0.91] for ARNI, MRA, and SGLT2i) or total HHF (HR: 0.49 [95% CI 0.33-0.71] for ARNI, MRA, and SGLT2i) alone. In a subgroup analysis, only SGLT2i had a consistent benefit among all LVEF subgroups, whereas the triple combination had the greatest benefit in HFmrEF, robust benefit in patients with LVEF 50% to 59%, and a statistically marginal benefit in patients with LVEF ≥60%. CONCLUSIONS In patients with HF and LVEF>40%, the quadruple combination of ARNI, BB, MRA, and SGLT2i provides the largest reduction in the risk of CV death and HHF; driven by the robust effect of the triple combination of ARNI, MRA, and SGLT2i. The benefit was more pronounced in HFmrEF patients.
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Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Ioannis Milioglou
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio, USA
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece; First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Eiran Z Gorodeski
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio, USA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupoli, Greece
| | - Lauren Cooper
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA; Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Stavros Zanos
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Grigorios Giamouzis
- Department of Cardiology, University of Thessaly, Larissa, Greece; Faculty of Medicine, School of Health Sciences, University of Thessaly, Greece
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
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Butt JH, Jhund PS, Docherty KF, Claggett BL, Vaduganathan M, Bachus E, Hernandez AF, Lam CSP, Inzucchi SE, Martinez FA, de Boer RA, Kosiborod MN, Desai AS, Køber L, Ponikowski P, Sabatine MS, Solomon SD, McMurray JJV. Dapagliflozin and Timing of Prior Heart Failure Hospitalization: A Patient-Level Meta-Analysis of DAPA-HF and DELIVER. JACC. HEART FAILURE 2024:S2213-1779(24)00149-5. [PMID: 38573262 DOI: 10.1016/j.jchf.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Patients recently hospitalized for heart failure (HF) are at a higher risk of adverse clinical outcomes, but they may experience a greater absolute and relative benefit from effective therapies than individuals who are considered more "stable." OBJECTIVES The authors examined the effects of dapagliflozin according to the timing of prior HF hospitalization in a patient-level pooled analysis of DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) and DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure). METHODS A total of 11,007 patients were randomized in DAPA-HF and DELIVER. The primary outcome was the composite of worsening HF or cardiovascular death. RESULTS In total, 12.4% were hospitalized for HF within 3 months of randomization, 14.2% between 3 and 12 months, and 16.8% more than 1 year before randomization, whereas 56.5% had not been hospitalized. The risk of the primary endpoint was inversely associated with time from prior HF hospitalization, and patients with a recent HF hospitalization had the highest risk. Compared with placebo, dapagliflozin reduced the risk of the primary outcome across HF hospitalization category (0-3 months, HR: 0.66 [95% CI: 0.55-0.81]; 3-12 months, HR: 0.73 [95% CI: 0.59-0.90]; >1 year, HR: 0.91 [95% CI: 0.74-1.12]; and no prior hospitalization, HR: 0.83 [95% CI: 0.73-0.94]; Pinteraction = 0.09). The number of patients needed to treat with dapagliflozin to prevent 1 event over the median follow-up of 22 months was 13, 20, 23, and 28, respectively. The beneficial effect was consistent across the range of LVEF regardless of HF hospitalization category. CONCLUSIONS The relative benefits of dapagliflozin were consistent across the range of LVEF regardless of the timing of the most recent HF hospitalization with a greater absolute benefit in patients with recent hospitalization.
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Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erasmus Bachus
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R and D, AstraZeneca, Gothenburg, Sweden
| | | | | | - Silvio E Inzucchi
- Duke-National University of Singapore, Singapore; Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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24
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McMurray JJV, Docherty KF, de Boer RA, Hammarstedt A, Kitzman DW, Kosiborod MN, Maria Langkilde A, Reicher B, Senni M, Shah SJ, Wilderäng U, Verma S, Solomon SD. Effect of Dapagliflozin Versus Placebo on Symptoms and 6-Minute Walk Distance in Patients With Heart Failure: The DETERMINE Randomized Clinical Trials. Circulation 2024; 149:825-838. [PMID: 38059368 DOI: 10.1161/circulationaha.123.065061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors reduce the risk of worsening heart failure (HF) and cardiovascular death in patients with HF irrespective of left ventricular ejection fraction. It is important to determine whether therapies for HF improve symptoms and functional capacity. METHODS The DETERMINE (Dapagliflozin Effect on Exercise Capacity Using a 6-Minute Walk Test in Patients With Heart Failure) double-blind, placebo-controlled, multicenter trials assessed the efficacy of the sodium-glucose cotransporter 2 inhibitor dapagliflozin on the Total Symptom Score (TSS) and Physical Limitation Scale (PLS) of the Kansas City Cardiomyopathy Questionnaire (KCCQ) and 6-minute walk distance (6MWD) in 313 patients with HF with reduced ejection fraction (DETERMINE-Reduced) and in 504 patients with HF with preserved ejection fraction (DETERMINE-Preserved) with New York Heart Association class II or III symptoms and elevated natriuretic peptide levels. The primary outcomes were changes in the KCCQ-TSS, KCCQ-PLS, and 6MWD after 16 weeks of treatment. RESULTS Among the 313 randomized patients with HF with reduced ejection fraction, the median placebo-corrected difference in KCCQ-TSS from baseline at 16 weeks was 4.2 (95% CI, 1.0, 8.2; P=0.022) in favor of dapagliflozin. The median placebo-corrected difference in KCCQ-PLS was 4.2 (95% CI, 0.0, 8.3; P=0.058). The median placebo-corrected difference in 6MWD from baseline at 16 weeks was 3.2 meters (95% CI, -6.5, 13.0; P=0.69). In the 504 patients with HF with preserved ejection fraction, the median placebo-corrected 16-week difference in KCCQ-TSS and KCCQ-PLS was 3.2 (95% CI, 0.4, 6.0; P=0.079) and 3.1 (-0.1, 5.4; P=0.23), respectively. The median 16-week difference in 6MWD was 1.6 meters (95% CI, -5.9, 9.0; P=0.67). In an exploratory post hoc analysis of both trials combined (DETERMINE-Pooled), the median placebo-corrected difference from baseline at 16 weeks was 3.7 (1.5, 5.9; P=0.005) for KCCQ-TSS, 4.0 (0.3, 4.9; P=0.036) for KCCQ-PLS, and 2.5 meters (-3.5, 8.4; P=0.50) for 6MWD. CONCLUSIONS Dapagliflozin improved the KCCQ-TSS in patients with HF with reduced ejection fraction but did not improve KCCQ-PLS or 6MWD. Dapagliflozin did not improve these outcomes in patients with HF with preserved ejection fraction. In a post hoc analysis including all patients across the full spectrum of ejection fraction, there was a beneficial effect of dapagliflozin on KCCQ-TSS and KCCQ-PLS but not 6MWD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03877237 and NCT03877224.
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Affiliation(s)
- John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., K.F.D.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., K.F.D.)
| | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands (R.A.d.B.)
| | - Ann Hammarstedt
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Dalane W Kitzman
- Sections on Cardiovascular Medicine and Geriatrics/Gerontology, Wake Forest University School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Barry Reicher
- AstraZeneca BioPharmaceuticals Research & Development, Late-Stage Development, Cardiovascular, Renal and Metabolic, Gaithersburg, MD (B.R.)
| | - Michele Senni
- Cardiovascular Department, Papa Giovanni XXIII Hospital Bergamo, Italy (M.S.)
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Ulrica Wilderäng
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada (S.V.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.)
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25
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Carrizales-Sepúlveda EF, Ordaz-Farías A, Vargas-Mendoza JA, Vera-Pineda R, Flores-Ramírez R. Initiation and Up-titration of Guideline-directed Medical Therapy for Patients with Heart Failure: Better, Faster, Stronger! Card Fail Rev 2024; 10:e03. [PMID: 38533397 PMCID: PMC10964286 DOI: 10.15420/cfr.2023.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/27/2023] [Indexed: 03/28/2024] Open
Abstract
Treatment for heart failure has experienced a major revolution in recent years, and current evidence shows that a combination of four medications (angiotensin receptor-neprilysin inhibitors + β-blockers + mineralocorticoid receptor antagonists + sodium.glucose cotransporter 2 inhibitors) offer the greatest benefit to our patients with significant reductions in cardiovascular mortality, heart failure hospitalisations and all-cause mortality. Unfortunately, despite their proven benefits, the implementation of these therapies is still low. Clinical inertia, and unfounded fear of using these drugs might contribute to this. Recently, evidence from randomised clinical trials has shown that intensive implementation of these therapies in patients with heart failure is safe and effective. In this review, we attempt to tackle some of these misconceptions/fears regarding medical therapy for heart failure and discuss the available evidence showing the best strategies for implementation of these therapies.
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Affiliation(s)
- Edgar Francisco Carrizales-Sepúlveda
- Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
- Heart Failure Unit, Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
| | - Alejandro Ordaz-Farías
- Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
- Echocardiography Laboratory, Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
| | - José Arturo Vargas-Mendoza
- Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
- Echocardiography Laboratory, Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
| | - Raymundo Vera-Pineda
- Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
| | - Ramiro Flores-Ramírez
- Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
- Heart Failure Unit, Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
- Echocardiography Laboratory, Cardiology Service, Hospital Universitario “Dr José E González”, Universidad Autónoma de Nuevo LeónMonterrey, Nuevo León, Mexico
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26
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Bhatt AS, Vaduganathan M, Claggett BL, Kulac IJ, Anand IS, Desai AS, Fang JC, Hernandez AF, Jhund PS, Kosiborod MN, Sabatine MS, Shah SJ, Vardeny O, McMurray JJV, Solomon SD, Gaziano TA. Cost Effectiveness of Dapagliflozin for Heart Failure Across the Spectrum of Ejection Fraction: An Economic Evaluation Based on Pooled, Individual Participant Data From the DELIVER and DAPA-HF Trials. J Am Heart Assoc 2024; 13:e032279. [PMID: 38390793 PMCID: PMC10944049 DOI: 10.1161/jaha.123.032279] [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: 08/18/2023] [Accepted: 11/22/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The sodium glucose cotransporter-2 inhibitors are guideline-recommended to treat heart failure across the spectrum of left ventricular ejection fraction; however, economic evaluations of adding sodium glucose cotransporter-2 inhibitors to standard of care in chronic heart failure across a broad left ventricular ejection fraction range are lacking. METHODS AND RESULTS We conducted a US-based cost-effectiveness analysis of dapagliflozin added to standard of care in a chronic heart failure population using pooled, participant data from the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) and DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trials. The 3-state Markov model used estimates of transitional probabilities, effectiveness of dapagliflozin, and utilities from the pooled trials. Costs estimates were obtained from published sources, including published rebates in dapagliflozin cost. Adding dapagliflozin to standard of care was estimated to produce an additional 0.53 quality-adjusted life years (QALYs) compared with standard of care alone. Incremental cost effectiveness ratios were $85 554/QALY when using the publicly reported full (undiscounted) Medicare cost ($515/month) and $40 081/QALY, at a published nearly 50% rebate ($263/month). The addition of dapagliflozin to standard of care would be of at least intermediate value (<$150 000/QALY) at a cost of <$872.58/month, of high value (<$50 000/QALY) at <$317.66/month, and cost saving at <$40.25/month. Dapagliflozin was of at least intermediate value in 92% of simulations when using the full (undiscounted) Medicare list cost in probabilistic sensitivity analyses. Cost effectiveness was most sensitive to the dapagliflozin cost and the effect on cardiovascular death. CONCLUSIONS The addition of dapagliflozin to standard of care in patients with heart failure across the spectrum of ejection fraction was at least of intermediate value at the undiscounted Medicare cost and may be potentially of higher value on the basis of the level of discount, rebates, and price negotiations offered. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01035255 & NCT01920711.
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Affiliation(s)
- Ankeet S. Bhatt
- Division of ResearchKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
- Division of Cardiovascular MedicineStanford University School of MedicinePalo AltoCAUSA
| | - Muthiah Vaduganathan
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - Brian L. Claggett
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - Ian J. Kulac
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | | | - Akshay S. Desai
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - James C. Fang
- University of Utah Health Sciences CenterSalt Lake CityUTUSA
| | | | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic HealthUniversity of GlasgowScotland, UK
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMOUSA
| | - Marc S. Sabatine
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - Sanjiv J. Shah
- Northwestern University Feinberg School of MedicineChicagoILUSA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes ResearchUniversity of MinnesotaMinneapolisMNUSA
| | - John J. V. McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic HealthUniversity of GlasgowScotland, UK
| | - Scott D. Solomon
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - Thomas A. Gaziano
- Division of Cardiovascular MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
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27
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Dimond MG, Ibrahim NE, Fiuzat M, McMurray JJV, Lindenfeld J, Ahmad T, Bozkurt B, Bristow MR, Butler J, Carson PE, Felker GM, Jessup M, Murillo J, Kondo T, Solomon SD, Abraham WT, O'Connor CM, Psotka MA. Left Ventricular Ejection Fraction and the Future of Heart Failure Phenotyping. JACC. HEART FAILURE 2024; 12:451-460. [PMID: 38099892 DOI: 10.1016/j.jchf.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 11/04/2023] [Indexed: 02/04/2024]
Abstract
Heart failure (HF) is a complex syndrome traditionally classified by left ventricular ejection fraction (LVEF) cutpoints. Although LVEF is prognostic for risk of events and predictive of response to some HF therapies, LVEF is a continuous variable and cutpoints are arbitrary, often based on historical clinical trial enrichment decisions rather than physiology. Holistic evaluation of the treatment effects for therapies throughout the LVEF range suggests the standard categorization paradigm for HF merits modification. The multidisciplinary Heart Failure Collaboratory reviewed data from large-scale HF clinical trials and found that many HF therapies have demonstrated therapeutic benefit across a large range of LVEF, but specific treatment effects vary across that range. Therefore, HF should practically be classified by association with an LVEF that is reduced or not reduced, while acknowledging uncertainty around the precise LVEF cutpoint, and future research should evaluate new therapies across the continuum of LVEF.
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Affiliation(s)
| | | | - Mona Fiuzat
- Duke University Medical Center, Durham, North Carolina, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - JoAnn Lindenfeld
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tariq Ahmad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Michael R Bristow
- University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | | | | | | | | | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - Christopher M O'Connor
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Duke University Medical Center, Durham, North Carolina, USA
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28
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Butt JH, Jering K, DE Boer RA, Claggett BL, Desai AS, Hernandez AF, Inzucchi SE, Jhund PS, Køber L, Kosiborod MN, Lam CSP, Martinez FA, Ponikowski P, Sabatine MS, Shah SJ, Vaduganathan M, Langkilde AM, Bengtsson O, Petersson M, Sjöstrand M, Wilderäng U, Solomon SD, McMurray JJV. Heart Failure, Investigator-Reported Sleep Apnea and Dapagliflozin: A Patient-Level Pooled Meta-Analysis of DAPA-HF and DELIVER. J Card Fail 2024; 30:436-448. [PMID: 38104937 DOI: 10.1016/j.cardfail.2023.08.027] [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: 06/08/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Sleep apnea is more common in patients with heart failure (HF) than in the general population, but little is known about its association with clinical outcomes in various HF phenotypes or how it might modify the effect of HF therapy. OBJECTIVES To examine the prevalence of sleep apnea, its association with outcomes and the effects of dapagliflozin in patients with HF with and without sleep apnea in a pooled analysis of 2 trials comparing dapagliflozin to placebo in HFrEF (DAPA-HF trial) and HFmrEF/HFpEF (DELIVER trial). METHODS A history of sleep apnea was investigator-reported. The primary outcome was a composite of worsening HF or cardiovascular death. RESULTS The prevalence of sleep apnea was 5.7% and 7.8% in patients with HFrEF and HFmrEF/HFpEF, respectively. The primary outcome occurred at a rate of 16.0 in participants with sleep apnea compared to 10.6 per 100 person-years in those without (adjusted HR 1.29 [95%CI, 1.10-1.52]). Compared with placebo, dapagliflozin reduced the risk of the primary endpoint to the same extent in patients with (HR 0.78 [95% CI, 0.59-1.03]) and without sleep apnea (HR 0.79 [0.72-0.87]) [Pinteraction = 0.93]. The beneficial effects of dapagliflozin on other clinical outcomes and symptom burden, physical function, and quality of life were consistent in participants with and without sleep apnea. CONCLUSIONS In DAPA-HF and DELIVER, the true prevalence of sleep apnea was likely underestimated. An investigator-reported history of sleep apnea was associated with higher rates of worsening HF events. The benefits of dapagliflozin on clinical outcomes were consistent in patients with and without sleep apnea. CLINICAL TRIAL REGISTRATION Unique identifiers: NCT01920711 CONDENSED ABSTRACT: In a pooled analysis of the DAPA-HF and DELIVER trials of more than 11,000 patients with heart failure (HF) across the range of ejection fractions, an investigator-reported history of sleep apnea was associated with higher rates of worsening HF events but not mortality. The beneficial effects of dapagliflozin on clinical outcomes were consistent in patients with and without sleep apnea. These findings provide further evidence for dapagliflozin as a new treatment option for patients with heart failure across the range of ejection fractions.
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Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Pardeep S Jhund
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Olof Bengtsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mikaela Sjöstrand
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrica Wilderäng
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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29
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Santas E, Llácer P, Palau P, de la Espriella R, Miñana G, Lorenzo M, Núñez-Marín G, Miró Ò, Chorro FJ, Bayés-Genís A, Sanchis J, Núñez J. Noncardiovascular morbidity and mortality across left ventricular ejection fraction categories following hospitalization for heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:206-214. [PMID: 37315921 DOI: 10.1016/j.rec.2023.05.005] [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: 02/12/2023] [Accepted: 05/16/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION AND OBJECTIVES Noncardiovascular events represent a significant proportion of the morbidity and mortality burden in patients with heart failure (HF). However, the risk of these events appears to differ by left ventricular ejection fraction (LVEF) status. In this study, we sought to evaluate the risk of noncardiovascular death and recurrent noncardiovascular readmission by LVEF status following an admission for acute HF. METHODS We retrospectively assessed a cohort of 4595 patients discharged after acute HF in a multicenter registry. We evaluated LVEF as a continuum, stratified in 4 categories (LVEF ≤ 40%, 41%-49%, 50%-59%, and ≥ 60%). Study endpoints were the risks of noncardiovascular mortality and recurrent noncardiovascular admissions during follow-up. RESULTS At a median follow-up of 2.2 [interquartile range, 0.76-4.8] years, we registered 646 noncardiovascular deaths and 4014 noncardiovascular readmissions. After multivariable adjustment including cardiovascular events as a competing event, LVEF status was associated with the risk of noncardiovascular mortality and recurrent noncardiovascular admissions. When compared with patients with LVEF ≤ 40%, those with LVEF 51%-59%, and especially those with LVEF ≥ 60%, were at higher risk of noncardiovascular mortality (HR, 1.31; 95%CI, 1.02-1,68; P=.032; and HR, 1.47; 95%CI, 1.15-1.86; P=.002; respectively), and at higher risk of recurrent noncardiovascular admissions (IRR, 1.17; 95%CI, 1.02-1.35; P=.024; and IRR, 1.26; 95%CI, 1.11-1.45; P=.001; respectively). CONCLUSIONS Following an admission for HF, LVEF status was directly associated with the risk of noncardiovascular morbidity and mortality. Patients with HFpEF were at higher risk of noncardiovascular death and total noncardiovascular readmissions, especially those with LVEF ≥ 60%.
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Affiliation(s)
- Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Pau Llácer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Miguel Lorenzo
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gonzalo Núñez-Marín
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Òscar Miró
- Servicio de Urgencias, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Francisco Javier Chorro
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Antoni Bayés-Genís
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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30
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Gori M, Giubilato S, Ceravolo R, Temporelli PL, Cornara S, Rao CM, Caretta G, Pozzi A, Binaghi G, Maloberti A, Di Nora C, Di Matteo I, Pilleri A, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Heart Failure with Preserved Ejection Fraction: How to Deal with This Chameleon. J Clin Med 2024; 13:1375. [PMID: 38592244 PMCID: PMC10933980 DOI: 10.3390/jcm13051375] [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: 12/13/2023] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by a notable heterogeneity in both phenotypic and pathophysiological features, with a growing incidence due to the increase in median age and comorbidities such as obesity, arterial hypertension, and cardiometabolic disease. In recent decades, the development of new pharmacological and non-pharmacological options has significantly impacted outcomes, improving clinical status and reducing mortality. Moreover, a more personalized and accurate therapeutic management has been demonstrated to enhance the quality of life, diminish hospitalizations, and improve overall survival. Therefore, assessing the peculiarities of patients with HFpEF is crucial in order to obtain a better understanding of this disorder. Importantly, comorbidities have been shown to influence symptoms and prognosis, and, consequently, they should be carefully addressed. In this sense, it is mandatory to join forces with a multidisciplinary team in order to achieve high-quality care. However, HFpEF remains largely under-recognized and under-treated in clinical practice, and the diagnostic and therapeutic management of these patients remains challenging. The aim of this paper is to articulate a pragmatic approach for patients with HFpEF focusing on the etiology, diagnosis, and treatment of HFpEF.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | | | | | - Mauro Gori
- Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Simona Giubilato
- Cardiology Department, Ospedale Lamezia Terme, 88046 Catanzaro, Italy
| | - Roberto Ceravolo
- Cardiac Rehabilitation Unitof Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | | | - Giorgio Caretta
- Levante Ligure Sant’Andrea Hospital, ASL 5 Liguria, 19121 La Spezia, Italy
| | - Andrea Pozzi
- Cardiology Division, Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09134 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria UniversitariaIntegrata di Udine, 33100 Udine, Italy
| | - Irene Di Matteo
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | - Anna Pilleri
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09134 Cagliari, Italy
| | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy
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31
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Greene SJ, Butler J, Kosiborod MN. Chapter 3: Clinical Trials of Sodium-Glucose Co-Transporter-2 Inhibitors for Treatment of Heart Failure. Am J Med 2024; 137:S25-S34. [PMID: 38184323 DOI: 10.1016/j.amjmed.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/18/2023] [Indexed: 01/08/2024]
Abstract
Cardiovascular outcomes trials of sodium-glucose co-transporter-2 (SGLT2) inhibitors have demonstrated consistent signals of benefit in terms of both prevention and treatment of heart failure (HF), in patients with and without type 2 diabetes (T2D). In response to growing evidence of the benefits of SGLT2 inhibitors, including increased survival, reduced hospitalizations and improved patient-reported symptoms, functional status, and quality of life, the treatment landscape for HF has evolved. Importantly, these agents have also demonstrated safety and tolerability in individuals with HF across the spectrum of left ventricular ejection fraction, with improvements in clinical and patient-reported outcomes occurring as early as days to weeks after treatment initiation. For patients with heart failure with reduced ejection fraction (HFrEF), SGLT2 inhibitors are now increasingly recognized as foundational disease-modifying therapy. An updated joint guideline from the American College of Cardiology and American Heart Association now recommends including SGLT2 inhibitors for patients with HF across the spectrum of ejection fraction, irrespective of the presence of diabetes, and regardless of background therapy (Class 1 recommendation for HFrEF, Class 2a recommendation for HF with mildly reduced ejection fraction [HFmrEF] and HF with preserved ejection fraction [HFpEF]). The European Society of Cardiology also include a Class I recommendation to use SGLT2 inhibitors for patients with HFrEF to reduce the risk of hospitalization for HF and CV death, irrespective of T2D status. This chapter reviews published clinical trial data about the efficacy and safety of SGLT2 inhibitors among patients with HFrEF, HFpEF, and patients hospitalized for HF.
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Affiliation(s)
- Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, MS.
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Mo; University of Missouri-Kansas City, Kansas City, Mo
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32
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James S, Erlinge D, Storey RF, McGuire DK, de Belder M, Eriksson N, Andersen K, Austin D, Arefalk G, Carrick D, Hofmann R, Hoole SP, Jones DA, Lee K, Tygesen H, Johansson PA, Langkilde AM, Ridderstråle W, Parvaresh Rizi E, Deanfield J, Oldgren J. Dapagliflozin in Myocardial Infarction without Diabetes or Heart Failure. NEJM EVIDENCE 2024; 3:EVIDoa2300286. [PMID: 38320489 DOI: 10.1056/evidoa2300286] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: In patients with acute myocardial infarction (MI), therapies that could further reduce the risk of adverse cardiovascular and metabolic outcomes are needed. METHODS: In this international registry-based, randomized, double-blind trial, patients without prior diabetes or chronic heart failure, presenting with acute MI and impaired left ventricular systolic function, were randomly assigned 10 mg of dapagliflozin or placebo, given once daily. The primary outcome was the hierarchical composite of death, hospitalization for heart failure, nonfatal MI, atrial fibrillation/flutter, type 2 diabetes mellitus, New York Heart Association Functional Classification at the last visit, and body weight decrease of 5% or greater at the last visit using the win ratio analysis method. The key secondary outcome was the same hierarchical composite excluding the body weight component. RESULTS: We enrolled 4017 patients of whom 2019 were assigned to dapagliflozin and 1998 to placebo. The analysis of the primary hierarchical composite outcome resulted in significantly more wins for dapagliflozin than for placebo (win ratio, 1.34; 95% confidence interval [CI], 1.20 to 1.50; P<0.001). The win ratio outcome, which was adopted in a change of analysis during trial performance because of low event accrual, was mainly driven by the added cardiometabolic outcomes. The composite of time to cardiovascular death/hospitalization for heart failure occurred in 50/2019 (2.5%) patients assigned to dapagliflozin and 52/1998 (2.6%) patients assigned to placebo (hazard ratio, 0.95; 95% CI, 0.64 to 1.40). The rates of other cardiovascular events were low, with differences between the groups not reaching nominal statistical significance. No safety concerns were identified. CONCLUSIONS: In patients with acute MI as noted above, after approximately 1 year of treatment with dapagliflozin there were significant benefits with regard to improvement in cardiometabolic outcomes but no impact on the composite of cardiovascular death or hospitalization for heart failure compared with placebo. (Funded by AstraZeneca; ClinicalTrial.gov number, NCT04564742.)
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Affiliation(s)
- Stefan James
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
- Division of Cardiology, Parkland Health and Hospital System, Dallas
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research (NICOR), NHS Arden & GEM Commissioning Support Unit, Leicester, United Kingdom
| | - Niclas Eriksson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Kasper Andersen
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| | - David Austin
- Academic Cardiovascular Unit, The James Cook University Hospital, South Tees NHS FT, Middlesbrough, United Kingdom
- Population Health Science Institute, Newcastle University, Newcastle, United Kingdom
| | - Gabriel Arefalk
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
- Thoracic Center, Blekinge Hospital, Karlskrona, Sweden
| | - David Carrick
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, University Hospital Hairmyres, East Kilbride, United Kingdom
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm
| | - Stephen P Hoole
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Daniel A Jones
- William Harvey Research Institute, Barts & The London Faculty of Medicine & Dentistry, Queen Mary University of London, London
- Department of Cardiology, St. Bartholomew's Hospital, West Smithfield, London
| | - Kelvin Lee
- Lincolnshire Heart Centre, United Lincolnshire Hospitals NHS Trust, Lincoln, United Kingdom
- School of Life Sciences, University of Lincoln, Lincoln, United Kingdom
| | - Hans Tygesen
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Peter A Johansson
- 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
| | - Wilhelm Ridderstråle
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Ehsan Parvaresh Rizi
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - John Deanfield
- Institute of Cardiovascular Sciences, University College London, London
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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Naito A, Nagatomo Y, Kawai A, Yukino-Iwashita M, Nakazawa R, Taruoka A, Takefuji A, Yasuda R, Toya T, Ikegami Y, Masaki N, Ido Y, Adachi T. The Safety and Efficacy of Sodium-Glucose Cotransporter-2 Inhibitors for Patients with Sarcopenia or Frailty: Double Edged Sword? J Pers Med 2024; 14:141. [PMID: 38392575 PMCID: PMC10890336 DOI: 10.3390/jpm14020141] [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: 12/29/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) show cardiovascular protective effects, regardless of the patient's history of diabetes mellitus (DM). SGLT2is suppressed cardiovascular adverse events in patients with type 2 DM, and furthermore, SGLT-2is reduced the risk of worsening heart failure (HF) events or cardiovascular death in patients with HF. Along with these research findings, SGLT-2is are recommended for patients with HF in the latest guidelines. Despite these benefits, the concern surrounding the increasing risk of body weight loss and other adverse events has not yet been resolved, especially for patients with sarcopenia or frailty. The DAPA-HF and DELIVER trials consistently showed the efficacy and safety of SGLT-2i for HF patients with frailty. However, the Rockwood frailty index that derived from a cumulative deficit model was employed for frailty assessment in these trials, which might not be suitable for the evaluation of physical frailty or sarcopenia alone. There is no fixed consensus on which evaluation tool to use or its cutoff value for the diagnosis and assessment of frailty in HF patients, or which patients can receive SGLT-2i safely. In this review, we summarize the methodology of frailty assessment and discuss the efficacy and safety of SGLT-2i for HF patients with sarcopenia or frailty.
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Affiliation(s)
- Ayami Naito
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | | | - Ryota Nakazawa
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akira Taruoka
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Asako Takefuji
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Risako Yasuda
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Nobuyuki Masaki
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yasuo Ido
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
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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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Stoicescu L, Crişan D, Morgovan C, Avram L, Ghibu S. Heart Failure with Preserved Ejection Fraction: The Pathophysiological Mechanisms behind the Clinical Phenotypes and the Therapeutic Approach. Int J Mol Sci 2024; 25:794. [PMID: 38255869 PMCID: PMC10815792 DOI: 10.3390/ijms25020794] [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: 11/26/2023] [Revised: 12/27/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is an increasingly frequent form and is estimated to be the dominant form of HF. On the other hand, HFpEF is a syndrome with systemic involvement, and it is characterized by multiple cardiac and extracardiac pathophysiological alterations. The increasing prevalence is currently reaching epidemic levels, thereby making HFpEF one of the greatest challenges facing cardiovascular medicine today. Compared to HF with reduced ejection fraction (HFrEF), the medical attitude in the case of HFpEF was a relaxed one towards the disease, despite the fact that it is much more complex, with many problems related to the identification of physiopathogenetic mechanisms and optimal methods of treatment. The current medical challenge is to develop effective therapeutic strategies, because patients suffering from HFpEF have symptoms and quality of life comparable to those with reduced ejection fraction, but the specific medication for HFrEF is ineffective in this situation; for this, we must first understand the pathological mechanisms in detail and correlate them with the clinical presentation. Another important aspect of HFpEF is the diversity of patients that can be identified under the umbrella of this syndrome. Thus, before being able to test and develop effective therapies, we must succeed in grouping patients into several categories, called phenotypes, depending on the pathological pathways and clinical features. This narrative review critiques issues related to the definition, etiology, clinical features, and pathophysiology of HFpEF. We tried to describe in as much detail as possible the clinical and biological phenotypes recognized in the literature in order to better understand the current therapeutic approach and the reason for the limited effectiveness. We have also highlighted possible pathological pathways that can be targeted by the latest research in this field.
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Affiliation(s)
- Laurențiu Stoicescu
- Internal Medicine Department, Faculty of Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (L.S.); or (D.C.); or (L.A.)
- Cardiology Department, Clinical Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Dana Crişan
- Internal Medicine Department, Faculty of Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (L.S.); or (D.C.); or (L.A.)
- Internal Medicine Department, Clinical Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Claudiu Morgovan
- Preclinical Department, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania
| | - Lucreţia Avram
- Internal Medicine Department, Faculty of Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (L.S.); or (D.C.); or (L.A.)
- Internal Medicine Department, Clinical Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Steliana Ghibu
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
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Savarese G, Gatti P, Benson L, Adamo M, Chioncel O, Crespo-Leiro MG, Anker SD, Coats AJS, Filippatos G, Lainscak M, McDonagh T, Mebazaa A, Metra M, Piepoli MF, Rosano GMC, Ruschitzka F, Seferovic P, Volterrani M, Maggioni AP, Lund LH. Left ventricular ejection fraction digit bias and reclassification of heart failure with mildly reduced vs reduced ejection fraction based on the 2021 definition and classification of heart failure. Am Heart J 2024; 267:52-61. [PMID: 37972677 DOI: 10.1016/j.ahj.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
AIMS Aims were to evaluate (1) reclassification of patients from heart failure with mildly reduced (HFmrEF) to reduced (HFrEF) ejection fraction when an EF = 40% was considered as HFrEF, (2) role of EF digit bias, ie, EF reporting favouring 5% increments; (3) outcomes in relation to missing and biased EF reports, in a large multinational HF registry. METHODS AND RESULTS Of 25,154 patients in the European Society of Cardiology (ESC) HF Long-Term registry, 17% had missing EF and of those with available EF, 24% had HFpEF (EF≥50%), 21% HFmrEF (40%-49%) and 55% HFrEF (<40%) according to the 2016 ESC guidelines´ classification. EF was "exactly" 40% in 7%, leading to reclassifying 34% of the HFmrEF population defined as EF = 40% to 49% to HFrEF when applying the 2021 ESC Guidelines classification (14% had HFmrEF as EF = 41% to 49% and 62% had HFrEF as EF≤40%). EF was reported as a value ending with 0 or 5 in ∼37% of the population. Such potential digit bias was associated with more missing values for other characteristics and higher risk of all-cause death and HF hospitalization. Patients with missing EF had higher risk of all-cause and CV mortality, and HF hospitalization compared to those with recorded EF. CONCLUSIONS Many patients had reported EF = 40%. This led to substantial reclassification of EF from old HFmrEF (40%-49%) to new HFrEF (≤40%). There was considerable digit bias in EF reporting and missing EF reporting, which appeared to occur not at random and may reflect less rigorous overall care and worse outcomes.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Paolo Gatti
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, University Hospital Attikon, National and Kapodistrian Univeristy of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Alexandre Mebazaa
- UMR 942 Inserm - MASCOT; University of Paris, Paris, France; Department of Anesthesia-Burn-Critical Care, APHP Saint Louis Lariboisière University Hospitals, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Massimo F Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | | | | | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade, Serbia
| | | | - Aldo P Maggioni
- ANMCO Research Center, He 1 art Care Foundation, Firenze, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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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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Albani S, Zilio F, Scicchitano P, Musella F, Ceriello L, Marini M, Gori M, Khoury G, D'Andrea A, Campana M, Iannopollo G, Fortuni F, Ciliberti G, Gabrielli D, Oliva F, Colivicchi F. Comprehensive diagnostic workup in patients with suspected heart failure and preserved ejection fraction. Hellenic J Cardiol 2024; 75:60-73. [PMID: 37743019 DOI: 10.1016/j.hjc.2023.09.013] [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: 06/18/2023] [Revised: 08/30/2023] [Accepted: 09/19/2023] [Indexed: 09/26/2023] Open
Abstract
Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging and it could require different tests, some of which are affected by limited availability. Nowadays, considering that new therapies are available for HFpEF and related conditions, a prompt and correct diagnosis is relevant. However, the diagnostic role of biomarker level, imaging tools, score-based algorithms and invasive evaluation, should be based on the strengths and weaknesses of each test. The aim of this review is to help the clinician in diagnosing HFpEF, overcoming the diagnostic uncertainty and disentangling among the different underlying causes, in order to properly treat this kind of patient.
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Affiliation(s)
- Stefano Albani
- Division of Cardiology, U. Parini Hospital, Aosta, Italy; Cardiovascular Institute Paris Sud, Massy, France
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento, Italy.
| | | | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Cardiology Department, Santa Maria Delle Grazie Hospital, Naples, Italy
| | - Laura Ceriello
- Cardiology Department, Ospedale Civile G. Mazzini, Teramo, Italy
| | - Marco Marini
- Cardiology and Coronary Care Unit, Marche University Hospital, Ancona, Italy
| | - Mauro Gori
- Division of Cardiology, Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Antonello D'Andrea
- Department of Cardiology, Umberto I Hospital, Nocera Inferiore, Salerno and Luigi Vanvitelli University, Italy
| | | | - Gianmarco Iannopollo
- Department of Cardiology, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Domenico Gabrielli
- Cardio-Toraco-Vascular Department, San Camillo-Forlanini Hospital, Rome, Italy; Heart Care Foundation, Florence, Italy
| | - Fabrizio Oliva
- Cardiologia 1, A. De Gasperis Cardicocenter, ASST Niguarda, Milan, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, Rome, Italy
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McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Skibelund AK. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2024; 26:5-17. [PMID: 38169072 DOI: 10.1002/ejhf.3024] [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] [Indexed: 01/05/2024] Open
Abstract
Document Reviewers: Rudolf A. de Boer (CPG Review Co-ordinator) (Netherlands), P. Christian Schulze (CPG Review Co-ordinator) (Germany), Elena Arbelo (Spain), Jozef Bartunek (Belgium), Johann Bauersachs (Germany), Michael A. Borger (Germany), Sergio Buccheri (Sweden), Elisabetta Cerbai (Italy), Erwan Donal (France), Frank Edelmann (Germany), Gloria Färber (Germany), Bettina Heidecker (Germany), Borja Ibanez (Spain), Stefan James (Sweden), Lars Køber (Denmark), Konstantinos C. Koskinas (Switzerland), Josep Masip (Spain), John William McEvoy (Ireland), Robert Mentz (United States of America), Borislava Mihaylova (United Kingdom), Jacob Eifer Møller (Denmark), Wilfried Mullens (Belgium), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Agnes A. Pasquet (Belgium), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Bianca Rocca (Italy), Xavier Rossello (Spain), Leyla Elif Sade (United States of America/Türkiye), Hannah Schaubroeck (Belgium), Elena Tessitore (Switzerland), Mariya Tokmakova (Bulgaria), Peter van der Meer (Netherlands), Isabelle C. Van Gelder (Netherlands), Mattias Van Heetvelde (Belgium), Christiaan Vrints (Belgium), Matthias Wilhelm (Switzerland), Adam Witkowski (Poland), and Katja Zeppenfeld (Netherlands) All experts involved in the development of this Focused Update have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the Focused Update. The report is also available on the ESC website www.escardio.org/guidelines See the European Heart Journal online for supplementary documents that include evidence tables.
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40
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Chan JC, Siddiqui A. Pharmacological Treatment of Heart Failure: Recent Advances. Curr Cardiol Rev 2024; 20:29-38. [PMID: 38284706 PMCID: PMC11107472 DOI: 10.2174/011573403x270178231228061314] [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: 07/22/2023] [Revised: 11/15/2023] [Accepted: 11/29/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Heart failure is a clinical condition with high mortality and morbidity that occurs when the heart is unable to pump enough blood to meet the metabolic demands of the body. The pharmacological management of heart failure has been revolutionized over the past decade with novel treatments. OBJECTIVE The aim of the review is to highlight the recent pharmacological advances in the management of heart failure. RESULTS Sodium-glucose cotransporter-2 inhibitor (SGLT2i), iron carboxymaltose, finerenone, omecamtiv mecarbil, and vericiguat have been shown to reduce hospitalization for heart failure. However, only SGLT2i, vericiguat, and omecamtiv mecarbil have been shown to reduce cardiovascular death. Finerenone has been shown to reduce cardiovascular events and renal adverse outcomes in patients with diabetes and kidney disease. Currently, only SGLT2i has been studied in patients beyond the heart failure with reduced ejection fraction population. CONCLUSION The current quadruple therapy in the treatment of heart failure has demonstrated a reduction in the hospitalization of patients and a decrease in mortality associated with the condition. Individualized heart failure therapy research have shown some benefit in select heart failure patients. Further research on novel therapies will help improve heart failure patient outcomes.
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Affiliation(s)
- Jonathan C.H. Chan
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Areeb Siddiqui
- College of Medicine and Veterinary Medicine, Edinburgh Medical School, Edinburgh, Scotland
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41
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Taheri S. Heterogeneity in cardiorenal protection by Sodium glucose cotransporter 2 inhibitors in heart failure across the ejection fraction strata: Systematic review and meta-analysis. World J Nephrol 2023; 12:182-200. [PMID: 38230296 PMCID: PMC10789083 DOI: 10.5527/wjn.v12.i5.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND Gliflozins or Sodium glucose cotransporter 2 inhibitors (SGLT2i) are relatively novel antidiabetic medications that have recently been shown to represent favorable effects on patients' cardiorenal outcomes. However, there is shortage of data on potential disparities in this therapeutic effect across different patient subpopulations. AIM To investigate differential effects of SGLT2i on the cardiorenal outcomes of heart failure patients across left ventricular ejection fraction (LVEF) levels. METHODS Literature was searched systematically for the large randomized double-blind controlled trials with long enough follow up periods reporting cardiovascular and renal outcomes in their patients regarding heart failure status and LVEF levels. Data were then meta-analyzed after stratification of the pooled data across the LVEF strata and New York Heart Associations (NYHA) classifications for heart failure using Stata software version 17.0. RESULTS The literature search returned 13 Large clinical trials and 13 post hoc analysis reports. Meta-analysis of the effects of gliflozins on the primary composite outcome showed no significant difference in efficacy across the heart failure subtypes, but higher efficacy were detected in patient groups at lower NYHA classifications (I2 = 46%, P = 0.02). Meta-analyses across the LVEF stratums revealed that a baseline LVEF lower than 30% was associated with enhanced improvement in the primary composite outcome compared to patients with higher LVEF levels at the borderline statistical significance (HR: 0.70, 95%CI: 0.60 to 0.79 vs 0.81, 95%CI: 0.75 to 0.87; respectively, P = 0.06). Composite renal outcome was improved significantly higher in patients with no heart failure than in heart failure patients with preserved ejection fraction (HFpEF) (HR: 0.60, 95%CI: 0.49 to 0.72 vs 0.94, 95%CI: 0.74 to 1.13; P = 0.04). Acute renal injury occurred significantly less frequently in heart failure patients with reduced ejection fraction who received gliflozins than in HFpEF (HR: 0.67, 95%CI: 51 to 0.82 vs 0.94, 95%CI: 0.82 to 1.06; P = 0.01). Volume depletion was consistently increased in response to SGLT2i in all the subgroups. CONCLUSION Heart failure patients with lower LVEF and lower NYHA sub-classifications were found to be generally more likely to benefit from therapy with gliflozins. Further research are required to identify patient subgroups representing the highest benefits or adverse events in response to SGLT2i.
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Affiliation(s)
- Saeed Taheri
- Department of Medicine, New Lahijan Scientific Foundation, Lahijan 4415813166, Iran
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42
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Pandey A, Kolkailah AA, Cosentino F, Cannon CP, Frederich RC, Cherney DZI, Dagogo-Jack S, Pratley RE, Cater NB, Gantz I, Mancuso JP, McGuire DK. Ertugliflozin and hospitalization for heart failure across the spectrum of pre-trial ejection fraction: post-hoc analyses of the VERTIS CV trial. Eur Heart J 2023; 44:5163-5166. [PMID: 37864578 PMCID: PMC10733716 DOI: 10.1093/eurheartj/ehad639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 07/06/2023] [Accepted: 09/11/2023] [Indexed: 10/23/2023] Open
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047, USA
- Parkland Health and Hospital System, 5200 Harry Hines Blvd, Dallas, TX 75235, USA
| | - Ahmed A Kolkailah
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047, USA
- Parkland Health and Hospital System, 5200 Harry Hines Blvd, Dallas, TX 75235, USA
| | - Francesco Cosentino
- Unit of Cardiology, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - David Z I Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047, USA
- Parkland Health and Hospital System, 5200 Harry Hines Blvd, Dallas, TX 75235, USA
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Smetana GW, Ho JE, Orkaby AR, Reynolds EE. How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:1656-1665. [PMID: 38079640 DOI: 10.7326/m23-2384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.
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Affiliation(s)
- Gerald W Smetana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
| | - Jennifer E Ho
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
| | - Ariela R Orkaby
- VA Boston Healthcare System and Brigham & Women's Hospital, Boston, Massachusetts (A.R.O.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
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James S, Erlinge D, Storey RF, McGuire DK, de Belder M, Björkgren I, Johansson PA, Langkilde AM, Ridderstråle W, Parvaresh Rizi E, Deanfield J, Oldgren J. Rationale and design of the DAPA-MI trial: Dapagliflozin in patients without diabetes mellitus with acute myocardial infarction. Am Heart J 2023; 266:188-197. [PMID: 37648579 DOI: 10.1016/j.ahj.2023.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Therapies that could further prevent the development of heart failure (HF) and other cardiovascular and metabolic events in patients with recent myocardial infarction (MI) represent a large and unmet medical need. METHODS DAPA-MI is a multicenter, parallel-group, registry-based, randomized, double-blind, placebo-controlled phase 3 trial in patients without known diabetes or established HF, presenting with MI and impaired left ventricular systolic function or Q-wave MI. The trial evaluated the effect of dapagliflozin 10 mg vs placebo, given once daily in addition to standard of care therapy, on death, hospitalization for HF (HHF), and other cardiometabolic outcomes. The primary objective of the trial was to determine, using the win-ratio method, if dapagliflozin is superior to placebo by comparing the hierarchical composite outcome of death, HHF, nonfatal MI, atrial fibrillation/flutter, new onset of type 2 diabetes mellitus, HF symptoms as measured by New York Heart Association Functional Classification at last visit, and body weight decrease ≥5% at last visit. Assuming a true win-ratio of 1.20 between dapagliflozin and placebo, 4,000 patients provide a statistical power of 80% for the test of the primary composite outcome. A registry-based randomized controlled trial framework allowed for recruitment, randomization, blinding, and pragmatic data collection of baseline demographics, medications, and clinical outcomes using existing national clinical registries (in Sweden and the UK) integrated with the trial database. CONCLUSIONS The trial explores opportunities to improve further the outcome of patients with impaired LV function after MI. The innovative trial design of DAPA-MI, incorporating national clinical registry data, has facilitated efficient patient recruitment as well as outcome ascertainment. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04564742.
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Affiliation(s)
- Stefan James
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK; NIHR Sheffield Biomedical Research Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Division of Cardiology, Parkland Health and Hospital System, Dallas, TX
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research (NICOR), NHS Arden & GEM Commissioning Support Unit, Leicester, UK
| | - Ida Björkgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Peter A Johansson
- 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
| | - Wilhelm Ridderstråle
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Ehsan Parvaresh Rizi
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - John Deanfield
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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Kasiakogias A, Ragavan A, Halliday BP. Your Heart Function Has Normalized-What Next After TRED-HF? Curr Heart Fail Rep 2023; 20:542-554. [PMID: 37999902 PMCID: PMC10746577 DOI: 10.1007/s11897-023-00636-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW With the widespread implementation of contemporary disease-modifying heart failure therapy, the rates of normalization of ejection fraction are continuously increasing. The TRED-HF trial confirmed that heart failure remission rather than complete recovery is typical in patients with dilated cardiomyopathy who respond to therapy. The present review outlines key points related to the management and knowledge gaps of this growing patient group, focusing on patients with non-ischaemic dilated cardiomyopathy. RECENT FINDINGS There is substantial heterogeneity among patients with normalized ejection fraction. The specific etiology is likely to affect the outcome, although a multiple-hit phenotype is frequent and may not be identified without comprehensive characterization. A monogenic or polygenic genetic susceptibility is common. Ongoing pathophysiological processes may be unraveled with advanced cardiac imaging, biomarkers, multi-omics, and machine learning technologies. There are limited studies that have investigated the withdrawal of specific heart failure therapies in these patients. Diuretics may be safely withdrawn if there is no evidence of congestion, while continued therapy with at least some disease-modifying therapy is likely to be required to reduce myocardial workload and sustain remission for the vast majority. Understanding the underlying disease mechanisms of patients with normalized ejection fraction is crucial in identifying markers of myocardial relapse and guiding individualized therapy in the future. Ongoing clinical trials should inform personalized approaches to therapy.
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Affiliation(s)
- Alexandros Kasiakogias
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aaraby Ragavan
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Brian P Halliday
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK.
- National Heart and Lung Institute, Imperial College London, London, UK.
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46
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Ndumele CE, Neeland IJ, Tuttle KR, Chow SL, Mathew RO, Khan SS, Coresh J, Baker-Smith CM, Carnethon MR, Després JP, Ho JE, Joseph JJ, Kernan WN, Khera A, Kosiborod MN, Lekavich CL, Lewis EF, Lo KB, Ozkan B, Palaniappan LP, Patel SS, Pencina MJ, Powell-Wiley TM, Sperling LS, Virani SS, Wright JT, Rajgopal Singh R, Elkind MSV, Rangaswami J. A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1636-1664. [PMID: 37807920 DOI: 10.1161/cir.0000000000001186] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.
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Nedogoda SV, Tereshchenko SN, Zhirov IV, Salasyuk AS, Barykina IN, Lutova VO, Popova EA. [A clinical and economic analysis of the use of dapagliflozin in patients with chronic heart failure in the entire spectrum of left ventricular ejection fraction in the Russian Federation]. TERAPEVT ARKH 2023; 95:782-788. [PMID: 38158921 DOI: 10.26442/00403660.2023.09.202369] [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: 11/04/2023] [Accepted: 11/04/2023] [Indexed: 01/03/2024]
Abstract
AIM To estimate the cost-effectiveness of dapagliflozin across the range of ejection fraction in patients with heart failure (HF) in Russian Federation. MATERIALS AND METHODS Cost-effectiveness model was developed for estimate the use of dapagliflozin as part of standard therapy in patients with HF regardless of ejection fraction is unknown. The calculation of costs was carried out in a mathematical model adapted to the conditions of Russian healthcare system by using Russian costs inputs and patient population characteristics. RESULTS In the model, dapagliflozin therapy yielded a mean of 0.209 additional life-years compared with standard of care in 10 years horizon. The incremental cost of 1 additional life-year was 665,715 RUB, which does not exceed the threshold of willingness to pay 2,235,202 RUB. CONCLUSION Thus, the intensification of chronic HF therapy with dapagliflozin is cost effective. The use of dapagliflozin in a cohort of 1000 target patients over 10 years will avoid 146 hospitalizations and 39 emergency visits due to HF, as well as prevent 32 deaths from cardiovascular diseases.
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Affiliation(s)
| | - S N Tereshchenko
- Chazov National Medical Research Center of Cardiology
- Russian Medical Academy of Continuous Professional Education
| | - I V Zhirov
- Chazov National Medical Research Center of Cardiology
- Russian Medical Academy of Continuous Professional Education
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48
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Kondo T, Gasparyan SB, Jhund PS, Bengtsson O, Claggett BL, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Køber L, Lam CSP, Langkilde AM, Martinez FA, Petersson M, Ponikowski P, Sabatine MS, Shah SJ, Sjostrand M, Wilderang U, Vaduganathan M, Solomon SD, McMurray JJV. Use of Win Statistics to Analyze Outcomes in the DAPA-HF and DELIVER Trials. NEJM EVIDENCE 2023; 2:EVIDoa2300042. [PMID: 38320525 DOI: 10.1056/evidoa2300042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: The primary end point in most heart failure (HF) trials is a composite of time to a first worsening HF event or cardiovascular death. Prevention of recurrent events and improvements in symptoms/quality of life are also important for patients but are usually analyzed separately. Win statistics can integrate all these outcomes into a single composite end point, which is analyzed in hierarchical order, reflecting the clinical importance of each component. METHODS: The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF, n=4744) and Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure (DELIVER, n=6263) trials enrolled patients with New York Heart Association class II, III, or IV HF, elevated natriuretic peptides, and either an ejection fraction of 40% or less (DAPA-HF) or greater than 40% and left atrial enlargement/left ventricular hypertrophy (DELIVER). We examined the effects of dapagliflozin compared with placebo on a hierarchical composite outcome, including cardiovascular death, total (first and recurrent) HF hospitalizations, total urgent HF visits, and improvement/deterioration in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ-TSS; range from 0 to 100, with a higher score indicating fewer symptoms and physical limitations) at 8 months. RESULTS: For this composite outcome, the win ratio was 1.30 (95% confidence interval [CI], 1.23 to 1.36) in the pooled cohort, 1.33 (95% CI, 1.23 to 1.43) in the DAPA-HF trial, and 1.27 (95% CI, 1.18 to 1.36) in the DELIVER trial. Win odds and net benefit in overall patients were 1.19 (95% CI, 1.14 to 1.24) and 8.7% (95% CI, 6.6 to 10.9%), respectively. In the overall pooled cohort, the majority of wins and losses were accounted for by KCCQ-TSS; 52.4% were settled by the KCCQ-TSS tier in the pooled cohort. CONCLUSIONS: In both the DAPA-HF and DELIVER trials, dapagliflozin led to a significant improvement in composite outcomes that incorporated patient-reported outcomes along with total HF events, as well as cardiovascular deaths. These analyses provided a comprehensive presentation of win statistics and illustrated the utility and flexibility of win statistics in describing the effects of dapagliflozin in two recent clinical trials in patients with HF. (Funded by British Heart Foundation Centre of Research Excellence and others; clinical trial registration numbers, NCT03036124 and NCT03619213.)
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Samvel B Gasparyan
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Olof Bengtsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | | | | | | | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago
| | - Mikaela Sjostrand
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrica Wilderang
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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Heusch G, Andreadou I, Bell R, Bertero E, Botker HE, Davidson SM, Downey J, Eaton P, Ferdinandy P, Gersh BJ, Giacca M, Hausenloy DJ, Ibanez B, Krieg T, Maack C, Schulz R, Sellke F, Shah AM, Thiele H, Yellon DM, Di Lisa F. Health position paper and redox perspectives on reactive oxygen species as signals and targets of cardioprotection. Redox Biol 2023; 67:102894. [PMID: 37839355 PMCID: PMC10590874 DOI: 10.1016/j.redox.2023.102894] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
The present review summarizes the beneficial and detrimental roles of reactive oxygen species in myocardial ischemia/reperfusion injury and cardioprotection. In the first part, the continued need for cardioprotection beyond that by rapid reperfusion of acute myocardial infarction is emphasized. Then, pathomechanisms of myocardial ischemia/reperfusion to the myocardium and the coronary circulation and the different modes of cell death in myocardial infarction are characterized. Different mechanical and pharmacological interventions to protect the ischemic/reperfused myocardium in elective percutaneous coronary interventions and coronary artery bypass grafting, in acute myocardial infarction and in cardiotoxicity from cancer therapy are detailed. The second part keeps the focus on ROS providing a comprehensive overview of molecular and cellular mechanisms involved in ischemia/reperfusion injury. Starting from mitochondria as the main sources and targets of ROS in ischemic/reperfused myocardium, a complex network of cellular and extracellular processes is discussed, including relationships with Ca2+ homeostasis, thiol group redox balance, hydrogen sulfide modulation, cross-talk with NAPDH oxidases, exosomes, cytokines and growth factors. While mechanistic insights are needed to improve our current therapeutic approaches, advancements in knowledge of ROS-mediated processes indicate that detrimental facets of oxidative stress are opposed by ROS requirement for physiological and protective reactions. This inevitable contrast is likely to underlie unsuccessful clinical trials and limits the development of novel cardioprotective interventions simply based upon ROS removal.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Robert Bell
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Edoardo Bertero
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Hans-Erik Botker
- Department of Cardiology, Institute for Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - James Downey
- Department of Physiology, University of South Alabama, Mobile, AL, USA
| | - Philip Eaton
- William Harvey Research Institute, Queen Mary University of London, Heart Centre, Charterhouse Square, London, United Kingdom
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; Pharmahungary Group, Szeged, Hungary
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mauro Giacca
- School of Cardiovascular and Metabolic Medicine & Sciences, King's College, London, United Kingdom
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom; Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, National Heart Research Institute Singapore, National Heart Centre, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), IIS-Fundación Jiménez Díaz University Hospital, and CIBERCV, Madrid, Spain
| | - Thomas Krieg
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Rainer Schulz
- Institute for Physiology, Justus-Liebig -Universität, Giessen, Germany
| | - Frank Sellke
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Ajay M Shah
- King's College London British Heart Foundation Centre of Excellence, London, United Kingdom
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Fabio Di Lisa
- Dipartimento di Scienze Biomediche, Università degli studi di Padova, Padova, Italy.
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50
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Escobar C, Pascual-Figal D, Manzano L, Nuñez J, Camafort M. Current Role of SLGT2 Inhibitors in the Management of the Whole Spectrum of Heart Failure: Focus on Dapagliflozin. J Clin Med 2023; 12:6798. [PMID: 37959263 PMCID: PMC10649290 DOI: 10.3390/jcm12216798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Heart failure (HF) is associated with a high morbidity and mortality burden. In light of more recent evidence, SGLT2 inhibitors are currently recommended as first-line therapy in managing patients with HF, regardless of ejection fraction, to reduce HF burden. The DAPA-HF and DELIVER trials, and particularly, the pooled analysis of both studies, have shown that dapagliflozin significantly reduces the risk of cardiovascular death, all-cause death, total HF hospitalizations, and MACE in the whole spectrum of HF, with sustained benefits over time. Recent data have shown that the full implementation of dapagliflozin in clinical practice would translate into a robust reduction in hospitalizations for HF and death in real-life populations. Many pathophysiological mechanisms have been involved in these benefits, particularly the positive effects of dapagliflozin on reversing cardiac (atrial and ventricular) remodeling, reducing cardiac fibrosis and inflammation, and improving endothelial dysfunction. In this manuscript, we reviewed from a practical point of view the role of dapagliflozin in the management of the whole spectrum of patients with HF.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, University Hospital La Paz, 28046 Madrid, Spain
| | - Domingo Pascual-Figal
- Cardiology Department, Hospital Clinico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
- Spanish National Cardiovascular Research Centre (CNIC), 28029 Madrid, Spain
- Department of Medicine, Universidad de Murcia, 30100 Murcia, Spain
| | - Luis Manzano
- Internal Medicine Department, University Hospital Ramon y Cajal, Alcala de Henares University, 28034 Madrid, Spain;
| | - Julio Nuñez
- Cardiology Department, University Hospital Clínico of Valencia, Instituto de Investigación Sanitaria (INCLIVA), 46010 Valencia, Spain;
- CIBER Cardiovascular, 28029 Madrid, Spain
| | - Miguel Camafort
- Internal Medicine Department, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
- CIBER OBN, ISCIII (Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III), 28222 Madrid, Spain
- Working Group of Cardiovascular Risk, Nutrition, and Aging, IDIBAPS (Instituto de Investigaciones Biomédicas August Pi i Sunyer), 08036 Barcelona, Spain
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