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Connelly KA, Mazer CD, Puar P, Teoh H, Wang CH, Mason T, Akhavein F, Chang CW, Liu MH, Yang NI, Chen WS, Juan YH, Opingari E, Salyani Y, Barbour W, Pasricha A, Ahmed S, Kosmopoulos A, Verma R, Moroney M, Bakbak E, Krishnaraj A, Bhatt DL, Butler J, Kosiborod MN, Lam CSP, Hess DA, Rizzi Coelho-Filho O, Lafreniere-Roula M, Thorpe KE, Quan A, Leiter LA, Yan AT, Verma S. Empagliflozin and Left Ventricular Remodeling in People Without Diabetes: Primary Results of the EMPA-HEART 2 CardioLink-7 Randomized Clinical Trial. Circulation 2023; 147:284-295. [PMID: 36335517 DOI: 10.1161/circulationaha.122.062769] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors have been demonstrated to promote reverse cardiac remodeling in people with diabetes or heart failure. Although it has been theorized that sodium-glucose cotransporter 2 inhibitors might afford similar benefits in people without diabetes or prevalent heart failure, this has not been evaluated. We sought to determine whether sodium-glucose cotransporter 2 inhibition with empagliflozin leads to a decrease in left ventricular (LV) mass in people without type 2 diabetes or significant heart failure. METHODS Between April 2021 and January 2022, 169 individuals, 40 to 80 years of age, without diabetes but with risk factors for adverse cardiac remodeling were randomly assigned to empagliflozin (10 mg/d; n=85) or placebo (n=84) for 6 months. The primary outcome was the 6-month change in LV mass indexed (LVMi) to baseline body surface area as measured by cardiac magnetic resonance imaging. Other measures included 6-month changes in LV end-diastolic and LV end-systolic volumes indexed to baseline body surface area and LV ejection fraction. RESULTS Among the 169 participants (141 men [83%]; mean age, 59.3±10.5 years), baseline LVMi was 63.2±17.9 g/m2 and 63.8±14.0 g/m2 for the empagliflozin- and placebo-assigned groups, respectively. The difference (95% CI) in LVMi at 6 months in the empagliflozin group versus placebo group adjusted for baseline LVMi was -0.30 g/m2 (-2.1 to 1.5 g/m2; P=0.74). Median baseline (interquartile range) NT-proBNP (N-terminal-pro B-type natriuretic peptide) was 51 pg/mL (20-105 pg/mL) and 55 pg/mL (21-132 pg/mL) for the empagliflozin- and placebo-assigned groups, respectively. The 6-month treatment effect of empagliflozin versus placebo (95% CI) on blood pressure and NT-proBNP (adjusted for baseline values) were -1.3 mm Hg (-5.2 to 2.6 mm Hg; P=0.52), 0.69 mm Hg (-1.9 to 3.3 mm Hg; P=0.60), and -6.1 pg/mL (-37.0 to 24.8 pg/mL; P=0.70) for systolic blood pressure, diastolic blood pressure, and NT-proBNP, respectively. No clinically meaningful between-group differences in LV volumes (diastolic and systolic indexed to baseline body surface area) or ejection fraction were observed. No difference in adverse events was noted between the groups. CONCLUSIONS Among people with neither diabetes nor significant heart failure but with risk factors for adverse cardiac remodeling, sodium-glucose cotransporter 2 inhibition with empagliflozin did not result in a meaningful reduction in LVMi after 6 months. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04461041.
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Affiliation(s)
- Kim A Connelly
- Division of Cardiology (K.A.C., F.A., A.T.Y.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Medicine (K.A.C., L.A.L., A.T.Y.), University of Toronto, ON, Canada.,Department of Physiology (K.A.C., C.D.M.), University of Toronto, ON, Canada
| | - C David Mazer
- Department of Anesthesia (C.D.M.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Physiology (K.A.C., C.D.M.), University of Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine (C.D.M.), University of Toronto, ON, Canada
| | - Pankaj Puar
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, Canada (P.P., S.A.)
| | - Hwee Teoh
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Division of Endocrinology and Metabolism (H.T., L.A.L.), St. Michael's Hospital of Unity Health Toronto, ON, Canada
| | - Chao-Hung Wang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine (C.-H.W., C.-W.C., M.-H.L., N.-I.Y., W.-S.C.), Keelung Chang Gung Memorial Hospital, Taiwan.,School of Medicine (C.-H.W., C.-W.C., N.-I.Y., Y.-H.J.), Chang Gung University, Taoyuan, Taiwan
| | - Tamique Mason
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada
| | - Farhad Akhavein
- Division of Cardiology (K.A.C., F.A., A.T.Y.), St. Michael's Hospital of Unity Health Toronto, ON, Canada
| | - Ching-Wen Chang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine (C.-H.W., C.-W.C., M.-H.L., N.-I.Y., W.-S.C.), Keelung Chang Gung Memorial Hospital, Taiwan.,Department of Diagnostic Radiology (C.-W.C.), Keelung Chang Gung Memorial Hospital, Taiwan.,School of Medicine (C.-H.W., C.-W.C., N.-I.Y., Y.-H.J.), Chang Gung University, Taoyuan, Taiwan
| | - Min-Hui Liu
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine (C.-H.W., C.-W.C., M.-H.L., N.-I.Y., W.-S.C.), Keelung Chang Gung Memorial Hospital, Taiwan.,Department of Nursing, Ching Kuo Institute of Management and Health, Keelung, Taiwan (M.-H.L.)
| | - Ning-I Yang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine (C.-H.W., C.-W.C., M.-H.L., N.-I.Y., W.-S.C.), Keelung Chang Gung Memorial Hospital, Taiwan.,School of Medicine (C.-H.W., C.-W.C., N.-I.Y., Y.-H.J.), Chang Gung University, Taoyuan, Taiwan
| | - Wei-Siang Chen
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine (C.-H.W., C.-W.C., M.-H.L., N.-I.Y., W.-S.C.), Keelung Chang Gung Memorial Hospital, Taiwan.,Intensive Care Unit, Division of Cardiology, Department of Internal Medicine (W.-S.C.), Keelung Chang Gung Memorial Hospital, Taiwan
| | - Yu-Hsiang Juan
- School of Medicine (C.-H.W., C.-W.C., N.-I.Y., Y.-H.J.), Chang Gung University, Taoyuan, Taiwan.,Institute for Radiological Research (Y.-H.J.), Chang Gung University, Taoyuan, Taiwan.,Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan (Y.-H.J.)
| | - Erika Opingari
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Temerty Faculty of Medicine (E.O., A. Kosmopoulos), University of Toronto, ON, Canada
| | - Yaseen Salyani
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,School of Medicine, Royal College of Surgeons in Ireland, Dublin (Y.S., R.V., M.M.)
| | - William Barbour
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Physiology and Pharmacology, Western University, London, ON, Canada (W.B., D.A.H.)
| | - Aryan Pasricha
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Health & Exercise Science, Wake Forest University, Winston-Salem, NC (A.P.)
| | - Shamon Ahmed
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, Canada (P.P., S.A.)
| | - Andrew Kosmopoulos
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Temerty Faculty of Medicine (E.O., A. Kosmopoulos), University of Toronto, ON, Canada
| | - Raj Verma
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,School of Medicine, Royal College of Surgeons in Ireland, Dublin (Y.S., R.V., M.M.)
| | - Michael Moroney
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,School of Medicine, Royal College of Surgeons in Ireland, Dublin (Y.S., R.V., M.M.)
| | - Ehab Bakbak
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Pharmacology and Toxicology (E.B., A. Krishnaraj, D.A.H., S.V.), University of Toronto, ON, Canada
| | - Aishwarya Krishnaraj
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Pharmacology and Toxicology (E.B., A. Krishnaraj, D.A.H., S.V.), University of Toronto, ON, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.).,Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.N.K.)
| | - Carolyn S P Lam
- National Heart Centre Singapore (C.S.P.L.).,Division of Cardiology, Duke-National University of Singapore (C.S.P.L.).,Division of Cardiology, Department of Medicine, State University of Campinas (UNICAMP), São Paulo, Brazil (C.S.P.L.)
| | - David A Hess
- Division of Vascular Surgery (D.A.H.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Pharmacology and Toxicology (E.B., A. Krishnaraj, D.A.H., S.V.), University of Toronto, ON, Canada.,Department of Physiology and Pharmacology, Western University, London, ON, Canada (W.B., D.A.H.).,Molecular Medicine Research Laboratories, Robarts Research Institute, London, ON, Canada (D.A.H.)
| | | | - Myriam Lafreniere-Roula
- Applied Health Research Centre (M.L.-R., K.E.T.), St. Michael's Hospital of Unity Health Toronto, ON, Canada
| | - Kevin E Thorpe
- Applied Health Research Centre (M.L.-R., K.E.T.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Dana Lana School of Public Health (K.E.T.), University of Toronto, ON, Canada
| | - Adrian Quan
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada
| | - Lawrence A Leiter
- Division of Endocrinology and Metabolism (H.T., L.A.L.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Medicine (K.A.C., L.A.L., A.T.Y.), University of Toronto, ON, Canada.,Department of Nutritional Sciences (L.A.L.), University of Toronto, ON, Canada
| | - Andrew T Yan
- Division of Cardiology (K.A.C., F.A., A.T.Y.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Medicine (K.A.C., L.A.L., A.T.Y.), University of Toronto, ON, Canada
| | - Subodh Verma
- Division of Cardiac Surgery (P.P., H.T., T.M., E.O., Y.S., W.B., A.P., S.A., A. Kosmopoulos, R.V., M.M., E.B., A. Krishnaraj, A.Q., S.V.), St. Michael's Hospital of Unity Health Toronto, ON, Canada.,Department of Pharmacology and Toxicology (E.B., A. Krishnaraj, D.A.H., S.V.), University of Toronto, ON, Canada.,Department of Surgery (S.V.), University of Toronto, ON, Canada
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