1
|
Gagnon LR, Hazra D, Perera K, Wang K, Kashyap N, Sadasivan C, Youngson E, Chu L, Dover DC, Kaul P, Simpson S, Bello A, McAlister FA, Oudit GY. Uptake of SGLT2i and Outcomes in Patients with Diabetes and Heart Failure: A Population-Based Cohort and a Specialized Clinic Cohort. Am Heart J 2024; 274:11-22. [PMID: 38670300 DOI: 10.1016/j.ahj.2024.04.007] [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: 01/06/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors are effective in adults with diabetes mellitus (DM) and heart failure (HF) based on randomized clinical trials. We compared SGLT2 inhibitor uptake and outcomes in two cohorts: a population-based cohort of all adults with DM and HF in Alberta, Canada and a specialized heart function clinic (HFC) cohort. METHODS The population-based cohort was derived from linked provincial healthcare datasets. The specialized clinic cohort was created by chart review of consecutive patients prospectively enrolled in the HFC between February 2018 and August 2022. We examined the association between SGLT2 inhibitor use (modeled as a time-varying covariate) and all-cause mortality or deaths/cardiovascular hospitalizations. RESULTS Of the 4,885 individuals from the population-based cohort, 64.2% met the eligibility criteria of the trials proving the effectiveness of SGLT2 inhibitors. Utilization of SGLT2 inhibitors increased from 1.2% in 2017 to 26.4% by January 2022. In comparison, of the 530 patients followed in the HFC, SGLT2 inhibitor use increased from 9.8% in 2019 to 49.1 % by March 2022. SGLT2 inhibitor use in the population-based cohort was associated with fewer all-cause mortality (aHR 0.51, 95%CI 0.41-0.63) and deaths/cardiovascular hospitalizations (aHR 0.65, 95%CI 0.54-0.77). However, SGLT2 inhibitor usage rates were far lower in HF patients without DM (3.5% by March 2022 in the HFC cohort). CONCLUSIONS Despite robust randomized trial evidence of clinical benefit, the uptake of SGLT2 inhibitors in patients with HF and DM remains low, even in the specialized HFC. Clinical care strategies are needed to enhance the use of SGLT2 inhibitors and improve implementation.
Collapse
Affiliation(s)
- Luke R Gagnon
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Deepan Hazra
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Perera
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kaiming Wang
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Niharika Kashyap
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Chandu Sadasivan
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- The Alberta Strategy for Patient Oriented Research Support Unit (AbSPORU), Alberta, Canada; Provincial Research Data Services, Alberta Health Services, College Plaza 1702, 8215 112 St NW Edmonton, AB T6G 2C8, Canada
| | - Luan Chu
- The Alberta Strategy for Patient Oriented Research Support Unit (AbSPORU), Alberta, Canada; Provincial Research Data Services, Alberta Health Services, College Plaza 1702, 8215 112 St NW Edmonton, AB T6G 2C8, Canada
| | - Douglas C Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Scot Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 2-35 Medical Sciences Building, Edmonton, AB T6G 2H1, Canada
| | - Aminu Bello
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; The Alberta Strategy for Patient Oriented Research Support Unit (AbSPORU), Alberta, Canada
| | - Gavin Y Oudit
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
2
|
Zhou Z, Zheng M, Zuo Z, Wu T. Comparison of cardiovascular outcomes of new antihyperglycemic agents in Type 2 Diabetes Mellitus: a meta-analysis. ESC Heart Fail 2024; 11:1647-1656. [PMID: 38419382 PMCID: PMC11098653 DOI: 10.1002/ehf2.14726] [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: 11/03/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
AIMS The study aims to provide comprehensive evidence for the selection of agents in type 2 diabetes mellitus (T2DM) patients with cardiovascular risk and summarize the lasted evidence for the cardiovascular effects of sodium glucose cotransporter-2 inhibitor (SGLT2i) in patients with heart failure (HF). METHODS AND RESULTS Several online databases were searched. All studies that explored the cardiovascular effects of SGLT2i or glucagon-like peptide 1 receptor agonist (GLP1-RA) were screened and reviewed. A total of 38 studies were included. Compared with GLP1-RA, the use of SGLT2i significantly reduced the risk of cardiovascular death [risk ratio (RR) = 0.59; 95% confidence interval (CI), 0.44-0.58], hospitalization of heart failure (HHF) (RR = 0.77; 95% CI, 0.74-0.80), death from any cause (RR = 0.64; 95% CI, 0.60-0.68), and myocardial infarction (MI) (RR = 0.81; 95% CI, 0.76-0.87). However, SGLT2i significantly increased the risk of stroke (RR = 1.10; 95% CI, 1.04-1.17). Compared with the control group, SGLT2i treatment reduced the risk of cardiovascular death by 14% (RR = 0.86; 95% CI, 0.79-0.94), HHF by 25%, and death from any cause by 9% in patients with HF, regardless of diabetes status. CONCLUSIONS SGLT2i is associated with a lower risk of cardiovascular death, HHF, death from any cause, and MI in patients with T2DM compared with GLP1-RA. In addition, SGLT2i brought more benefits with respect to the effects of cardiovascular death, HHF, and death from any cause in patients with HF, regardless of diabetes status.
Collapse
Affiliation(s)
- Zijing Zhou
- Department of Cardiovascular MedicineXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Min Zheng
- Department of Cardiovascular MedicineXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Zhihong Zuo
- Department of Critical Care MedicineXiangya Hospital, Central South UniversityChangshaHunanChina
| | - Ting Wu
- Department of Cardiovascular MedicineXiangya Hospital, Central South UniversityChangshaHunanChina
| |
Collapse
|
3
|
Natale P, Tunnicliffe DJ, Toyama T, Palmer SC, Saglimbene VM, Ruospo M, Gargano L, Stallone G, Gesualdo L, Strippoli GF. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors for people with chronic kidney disease and diabetes. Cochrane Database Syst Rev 2024; 5:CD015588. [PMID: 38770818 PMCID: PMC11106805 DOI: 10.1002/14651858.cd015588.pub2] [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: 05/22/2024]
Abstract
BACKGROUND Diabetes is associated with high risks of premature chronic kidney disease (CKD), cardiovascular diseases, cardiovascular death and impaired quality of life. People with diabetes are more likely to develop kidney impairment, and approximately one in three adults with diabetes have CKD. People with CKD and diabetes experience a substantially higher risk of cardiovascular outcomes. Sodium-glucose co-transporter protein 2 (SGLT2) inhibitors have shown potential effects in preventing kidney and cardiovascular outcomes in people with CKD and diabetes. However, new trials are emerging rapidly, and evidence synthesis is essential to summarising cumulative evidence. OBJECTIVES This review aimed to assess the benefits and harms of SGLT2 inhibitors for people with CKD and diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2023 using a search strategy designed by an Information Specialist. Studies in the Register are continually identified through regular searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled studies were eligible if they evaluated SGLT2 inhibitors versus placebo, standard care or other glucose-lowering agents in people with CKD and diabetes. CKD includes all stages (from 1 to 5), including dialysis patients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the study risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The primary review outcomes were all-cause death, 3-point and 4-point major adverse cardiovascular events (MACE), fatal or nonfatal myocardial infarction (MI), fatal or nonfatal stroke, and kidney failure. MAIN RESULTS Fifty-three studies randomising 65,241 people with CKD and diabetes were included. SGLT2 inhibitors with or without other background treatments were compared to placebo, standard care, sulfonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, or insulin. In the majority of domains, the risks of bias in the included studies were low or unclear. No studies evaluated the treatment in children or in people treated with dialysis. No studies compared SGLT2 inhibitors with glucagon-like peptide-1 receptor agonists or tirzepatide. Compared to placebo, SGLT2 inhibitors decreased the risk of all-cause death (20 studies, 44,397 participants: RR 0.85, 95% CI 0.78 to 0.94; I2 = 0%; high certainty) and cardiovascular death (16 studies, 43,792 participants: RR 0.83, 95% CI 0.74 to 0.93; I2 = 29%; high certainty). Compared to placebo, SGLT2 inhibitors probably make little or no difference to the risk of fatal or nonfatal MI (2 studies, 13,726 participants: RR 0.95, 95% CI 0.80 to 1.14; I2 = 24%; moderate certainty), and fatal or nonfatal stroke (2 studies, 13,726 participants: RR 1.07, 95% CI 0.88 to 1.30; I2 = 0%; moderate certainty). Compared to placebo, SGLT2 inhibitors probably decrease 3-point MACE (7 studies, 38,320 participants: RR 0.89, 95% CI 0.81 to 0.98; I2 = 46%; moderate certainty), and 4-point MACE (4 studies, 23,539 participants: RR 0.82, 95% CI 0.70 to 0.96; I2 = 77%; moderate certainty), and decrease hospital admission due to heart failure (6 studies, 28,339 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 17%; high certainty). Compared to placebo, SGLT2 inhibitors may decrease creatinine clearance (1 study, 132 participants: MD -2.63 mL/min, 95% CI -5.19 to -0.07; low certainty) and probably decrease the doubling of serum creatinine (2 studies, 12,647 participants: RR 0.70, 95% CI 0.56 to 0.89; I2 = 53%; moderate certainty). SGLT2 inhibitors decrease the risk of kidney failure (6 studies, 11,232 participants: RR 0.70, 95% CI 0.62 to 0.79; I2 = 0%; high certainty), and kidney composite outcomes (generally reported as kidney failure, kidney death with or without ≥ 40% decrease in estimated glomerular filtration rate (eGFR)) (7 studies, 36,380 participants: RR 0.68, 95% CI 0.59 to 0.78; I2 = 25%; high certainty) compared to placebo. Compared to placebo, SGLT2 inhibitors incur less hypoglycaemia (16 studies, 28,322 participants: RR 0.93, 95% CI 0.89 to 0.98; I2 = 0%; high certainty), and hypoglycaemia requiring third-party assistance (14 studies, 26,478 participants: RR 0.75, 95% CI 0.65 to 0.88; I2 = 0%; high certainty), and probably decrease the withdrawal from treatment due to adverse events (15 studies, 16,622 participants: RR 0.94, 95% CI 0.82 to 1.08; I2 = 16%; moderate certainty). The effects of SGLT2 inhibitors on eGFR, amputation and fracture were uncertain. No studies evaluated the effects of treatment on fatigue, life participation, or lactic acidosis. The effects of SGLT2 inhibitors compared to standard care alone, sulfonylurea, DPP-4 inhibitors, or insulin were uncertain. AUTHORS' CONCLUSIONS SGLT2 inhibitors alone or added to standard care decrease all-cause death, cardiovascular death, and kidney failure and probably decrease major cardiovascular events while incurring less hypoglycaemia compared to placebo in people with CKD and diabetes.
Collapse
Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Tadashi Toyama
- Department of Nephrology, Kanazawa University, Kanazawa, Japan
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Marinella Ruospo
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Letizia Gargano
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| |
Collapse
|
4
|
Usman MS, Bhatt DL, Hameed I, Anker SD, Cheng AYY, Hernandez AF, Jones WS, Khan MS, Petrie MC, Udell JA, Friede T, Butler J. Effect of SGLT2 inhibitors on heart failure outcomes and cardiovascular death across the cardiometabolic disease spectrum: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2024:S2213-8587(24)00102-5. [PMID: 38768620 DOI: 10.1016/s2213-8587(24)00102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors have been studied in patients with heart failure, type 2 diabetes, chronic kidney disease, atherosclerotic cardiovascular disease, and acute myocardial infarction. Individual trials were powered to study composite outcomes in one disease state. We aimed to evaluate the treatment effect of SGLT2 inhibitors on specific clinical endpoints across multiple demographic and disease subgroups. METHODS In this systematic review and meta-analysis, we queried online databases (PubMed, Cochrane CENTRAL, and SCOPUS) up to Feb 10, 2024, for primary and secondary analyses of large trials (n>1000) of SGLT2 inhibitors in patients with heart failure, type 2 diabetes, chronic kidney disease, and atherosclerotic cardiovascular disease (including acute myocardial infarction). Outcomes studied included composite of first hospitalisation for heart failure or cardiovascular death, first hospitalisation for heart failure, cardiovascular death, total (first and recurrent) hospitalisation for heart failure, and all-cause mortality. Effect sizes were pooled using random-effects models. This study is registered with PROSPERO, CRD42024513836. FINDINGS We included 15 trials (N=100 952). Compared with placebo, SGLT2 inhibitors reduced the risk of first hospitalisation for heart failure by 29% in patients with heart failure (hazard ratio [HR] 0·71 [95% CI 0·67-0·77]), 28% in patients with type 2 diabetes (0·72 [0·67-0·77]), 32% in patients with chronic kidney disease (0·68 [0·61-0·77]), and 28% in patients with atherosclerotic cardiovascular disease (0·72 [0·66-0·79]). SGLT2 inhibitors reduced cardiovascular death by 14% in patients with heart failure (HR 0·86 [95% CI 0·79-0·93]), 15% in patients with type 2 diabetes (0·85 [0·79-0·91]), 11% in patients with chronic kidney disease (0·89 [0·82-0·96]), and 13% in patients with atherosclerotic cardiovascular disease (0·87 [0·78-0·97]). The benefit of SGLT2 inhibitors on both first hospitalisation for heart failure and cardiovascular death was consistent across the majority of the 51 subgroups studied. Notable exceptions included acute myocardial infarction (22% reduction in first hospitalisation for heart failure; no effect on cardiovascular death) and heart failure with preserved ejection fraction (26% reduction in first hospitalisation for heart failure; no effect on cardiovascular death). INTERPRETATION SGLT2 inhibitors reduced heart failure events and cardiovascular death in patients with heart failure, type 2 diabetes, chronic kidney disease, and atherosclerotic cardiovascular disease. These effects were consistent across a wide range of subgroups within these populations. This supports the eligibility of a large population with cardiorenal-metabolic diseases for treatment with SGLT2 inhibitors. FUNDING None.
Collapse
Affiliation(s)
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ishaque Hameed
- Department of Medicine, Medstar Health, Baltimore, MD, USA
| | - Stefan D Anker
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, German Heart Center Charité, Charité-University Medicine Berlin, Corporate Member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; BIH Center for Regenerative Therapies (BCRT), Charité-University Medicine Berlin, Corporate Member of Free University Berlin and Humboldt-University Berlin, Berlin, Germany
| | - Alice Y Y Cheng
- Department of Medicine, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - William Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor Scott and White Health, Dallas, TX, USA; Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
| |
Collapse
|
5
|
Zhang C, Shi Y, Liu C, Sudesh SM, Hu Z, Li P, Liu Q, Ma Y, Shi A, Cai H. Therapeutic strategies targeting mechanisms of macrophages in diabetic heart disease. Cardiovasc Diabetol 2024; 23:169. [PMID: 38750502 PMCID: PMC11097480 DOI: 10.1186/s12933-024-02273-4] [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: 10/12/2023] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
Diabetic heart disease (DHD) is a serious complication in patients with diabetes. Despite numerous studies on the pathogenic mechanisms and therapeutic targets of DHD, effective means of prevention and treatment are still lacking. The pathogenic mechanisms of DHD include cardiac inflammation, insulin resistance, myocardial fibrosis, and oxidative stress. Macrophages, the primary cells of the human innate immune system, contribute significantly to these pathological processes, playing an important role in human disease and health. Therefore, drugs targeting macrophages hold great promise for the treatment of DHD. In this review, we examine how macrophages contribute to the development of DHD and which drugs could potentially be used to target macrophages in the treatment of DHD.
Collapse
Affiliation(s)
- Chaoyue Zhang
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yunke Shi
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Changzhi Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shivon Mirza Sudesh
- Faculty of Medicine, St. George University of London, London, UK
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Zhao Hu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Qi Liu
- Wafic Said Molecular Cardiology Research Laboratory, The Texas Heart Institute, Houston, TX, USA
| | - Yiming Ma
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ao Shi
- Faculty of Medicine, St. George University of London, London, UK.
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.
| | - Hongyan Cai
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China.
| |
Collapse
|
6
|
Yankah RK, Anku EK, Eligar V. Sodium-Glucose Cotransporter-2 Inhibitors and Cardiovascular Protection Among Patients With Type 2 Diabetes Mellitus: A Systematic Review. J Diabetes Res 2024; 2024:9985836. [PMID: 38766320 PMCID: PMC11102109 DOI: 10.1155/2024/9985836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/13/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Background: Accumulating evidence has demonstrated the positive effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors in managing patients with type 2 diabetes mellitus (T2DM). SGLT2 inhibitors protect patients with T2DM from cardiovascular complications and are generally safe. Aim: The aim of this study is to assess the cardiovascular effects of SGLT2 inhibitors in patients with T2DM. Methods: A systematic review was conducted using published English literature in PubMed and Google Scholar databases. Results: Most of the studies showed significant positive cardiovascular effects of SGLT2 inhibitors in patients with and without established cardiovascular disease (CVD). Empagliflozin reduced the risk of cardiovascular death, hospitalization for heart failure (HHF), cardiovascular death or heart failure, and major adverse cardiovascular events (MACE) such as nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death regardless of the number of cardiovascular risk factors. The effects of empagliflozin on cardiovascular events and mortality in patients with coronary artery bypass graft (CABG) were assessed. Further, the efficacy of empagliflozin in three different phenotypic groups, namely, younger patients with shorter duration of T2DM and highest glomerular filtration rate, women without coronary artery disease, and older adults with advanced coronary artery disease plus several comorbidities, was also assessed. The effects of canagliflozin were evaluated in patients with and without a history of CVD and with different body weights, and in those with and without prior heart failure. Treatment with canagliflozin based on multivariable-predicted cardiovascular risk factors prevented heart failure events more than treatment based on glycated hemoglobin and albuminuria alone. The efficacy of dapagliflozin was evaluated in patients with or at risk of atherosclerotic cardiovascular disease (ASCVD), heart failure status, and left ventricular ejection fraction (LVEF), as well as the elderly population. A reduction in HHF or cardiovascular death and insignificant reduction in MACE were noted. Furthermore, significant reduction in the risk of cardiovascular death and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF) was also observed. Sotagliflozin was studied for its cardiovascular outcomes in patients with chronic kidney disease with or without albuminuria and resulted in a reduction in cardiovascular-related deaths and HHF. Conclusion: SGLT2 inhibitors have beneficial cardiovascular effects in patients with T2DM and should be incorporated into their management.
Collapse
Affiliation(s)
- Richard K. Yankah
- Diabetes Specialist Clinic, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Eric K. Anku
- Dietherapy and Nutrition Unit, Cape Coast Teaching Hospital, P. O. Box CC 1363, Cape Coast, Ghana
| | - Vinay Eligar
- Department of Diabetes and Endocrinology, Imperial College London Diabetes Centre, Abu Dhabi, UAE
| |
Collapse
|
7
|
He J, Li X, Yan M, Chen X, Sun C, Tan J, Song Y, Xu H, Wu L, Yang Z. Inulin Reduces Kidney Damage in Type 2 Diabetic Mice by Decreasing Inflammation and Serum Metabolomics. J Diabetes Res 2024; 2024:1222395. [PMID: 38725443 PMCID: PMC11081752 DOI: 10.1155/2024/1222395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 05/12/2024] Open
Abstract
This study is aimed at assessing the impact of soluble dietary fiber inulin on the treatment of diabetes-related chronic inflammation and kidney injury in mice with type 2 diabetes (T2DM). The T2DM model was created by feeding the Institute of Cancer Research (ICR) mice a high-fat diet and intraperitoneally injecting them with streptozotocin (50 mg/kg for 5 consecutive days). The thirty-six ICR mice were divided into three dietary groups: the normal control (NC) group, the T2DM (DM) group, and the DM + inulin diet (INU) group. The INU group mice were given inulin at the dose of 500 mg/kg gavage daily until the end of the 12th week. After 12 weeks, the administration of inulin resulted in decreased serum levels of fasting blood glucose (FBG), low-density lipoprotein cholesterol (LDL-C), blood urea nitrogen (BUN), and creatinine (CRE). The administration of inulin not only ameliorated renal injury but also resulted in a reduction in the mRNA expressions of inflammatory factors in the spleen and serum oxidative stress levels, when compared to the DM group. Additionally, inulin treatment in mice with a T2DM model led to a significant increase in the concentrations of three primary short-chain fatty acids (SCFAs) (acetic acid, propionic acid, and butyric acid), while the concentration of advanced glycation end products (AGEs), a prominent inflammatory factor in diabetes, exhibited a significant decrease. The results of untargeted metabolomics indicate that inulin has the potential to alleviate inflammatory response and kidney damage in diabetic mice. This beneficial effect is attributed to its impact on various metabolic pathways, including glycerophospholipid metabolism, taurine and hypotaurine metabolism, arginine biosynthesis, and tryptophan metabolism. Consequently, oral inulin emerges as a promising treatment option for diabetes and kidney injury.
Collapse
Affiliation(s)
- Jiayuan He
- Health Testing Center, Zhenjiang Center for Disease Control and Prevention, Zhenjiang 212002, China
| | - Xiang Li
- Medical Laboratory Department, Huai'an Second People's Hospital, Huai'an 223022, China
| | - Man Yan
- Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang 212013, China
| | - Xinsheng Chen
- Hospital Infection-Disease Control Department, Zhenjiang First People's Hospital, Zhenjiang 212002, China
| | - Chang Sun
- Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang 212013, China
| | - Jiajun Tan
- Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang 212013, China
| | - Yinsheng Song
- Health Testing Center, Zhenjiang Center for Disease Control and Prevention, Zhenjiang 212002, China
| | - Hong Xu
- Health Testing Center, Zhenjiang Center for Disease Control and Prevention, Zhenjiang 212002, China
| | - Liang Wu
- Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang 212013, China
| | - Zhengnan Yang
- Department of Clinical Laboratory, Yizheng Hospital, Nanjing Drum Tower Hospital Group, Yizheng 210008, China
| |
Collapse
|
8
|
Desai N, Olewinska E, Famulska A, Remuzat C, Francois C, Folkerts K. Heart failure with mildly reduced and preserved ejection fraction: A review of disease burden and remaining unmet medical needs within a new treatment landscape. Heart Fail Rev 2024; 29:631-662. [PMID: 38411769 PMCID: PMC11035416 DOI: 10.1007/s10741-024-10385-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/28/2024]
Abstract
This review provides a comprehensive overview of heart failure with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF), including its definition, diagnosis, and epidemiology; clinical, humanistic, and economic burdens; current pharmacologic landscape in key pharmaceutical markets; and unmet needs to identify key knowledge gaps. We conducted a targeted literature review in electronic databases and prioritized articles with valuable insights into HFmrEF/HFpEF. Overall, 27 randomized controlled trials (RCTs), 66 real-world evidence studies, 18 clinical practice guidelines, and 25 additional publications were included. Although recent heart failure (HF) guidelines set left ventricular ejection fraction thresholds to differentiate categories, characterization and diagnosis criteria vary because of the incomplete disease understanding. Recent epidemiological data are limited and diverse. Approximately 50% of symptomatic HF patients have HFpEF, more common than HFmrEF. Prevalence varies with country because of differing definitions and study characteristics, making prevalence interpretation challenging. HFmrEF/HFpEF has considerable mortality risk, and the mortality rate varies with study and patient characteristics and treatments. HFmrEF/HFpEF is associated with considerable morbidity, poor patient outcomes, and common comorbidities. Patients require frequent hospitalizations; therefore, early intervention is crucial to prevent disease burden. Recent RCTs show promising results like risk reduction of composite cardiovascular death or HF hospitalization. Costs data are scarce, but the economic burden is increasing. Despite new drugs, unmet medical needs requiring new treatments remain. Thus, HFmrEF/HFpEF is a growing global healthcare concern. With improving yet incomplete understanding of this disease and its promising treatments, further research is required for better patient outcomes.
Collapse
Affiliation(s)
- Nihar Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | | | | | | | | | | |
Collapse
|
9
|
Luo J, Shi L, Liu J, Li G, Tu L, Hu S. SGLT2 inhibition, plasma proteins, and heart failure: a proteome-wide Mendelian Randomization and colocalization study. Front Cardiovasc Med 2024; 11:1371513. [PMID: 38725835 PMCID: PMC11079590 DOI: 10.3389/fcvm.2024.1371513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
Objective To investigate the causal contributions of Sodium-glucose cotransporter 2 (SGLT2) inhibition on Heart Failure (HF) and identify the circulating proteins that mediate SGLT2 inhibition's effects on HF. Methods Applying a two-sample, two-step Mendelian Randomization (MR) analysis, we aimed to estimate: (1) the causal impact of SGLT2 inhibition on HF; (2) the causal correlation of SGLT2 inhibition on 4,907 circulating proteins; (3) the causal association of SGLT2 inhibition-driven plasma proteins on HF. Genetic variants linked to SGLT2 inhibition derived from the previous studies. The 4,907 circulating proteins were derived from the deCODE study. Genetic links to HF were obtained through the Heart Failure Molecular Epidemiology for Therapeutic Targets (HERMES) consortium. Results SGLT2 inhibition demonstrated a lower risk of HF (odds ratio [OR] = 0.44, 95% CI [0.26, 0.76], P = 0.003). Among 4,907 circulating proteins, we identified leucine rich repeat transmembrane protein 2 (LRRTM2), which was related to both SGLT2 inhibition and HF. Mediation analysis revealed that the impact of SGLT2 inhibition on HF operates indirectly through LRRTM2 [β = -0.20, 95% CI (-0.39, -0.06), P = 0.02] with a mediation proportion of 24.6%. Colocalization analysis provided support for the connections between LRRTM2 and HF. Conclusion The study indicated a causative link between SGLT2 inhibition and HF, with plasma LRRTM2 potentially serving as a mediator.
Collapse
Affiliation(s)
- Jinlan Luo
- Department of Geriatric Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
| | - Lili Shi
- Department of Geriatric Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
| | - Jingrui Liu
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gen Li
- Department of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Tu
- Department of Geriatric Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
| | - Shuiqing Hu
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
10
|
Cortesi PA, Antonazzo IC, Palladino P, Gnesi M, Mele S, D'Amelio M, Zanzottera Ferrari E, Mazzaglia G, Mantovani LG. Health and economic impact of dapagliflozin for type 2 diabetes patients who had or were at risk for atherosclerotic cardiovascular disease in the Italian general practitioners setting: a budget impact analysis. Acta Diabetol 2024:10.1007/s00592-024-02276-3. [PMID: 38634912 DOI: 10.1007/s00592-024-02276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024]
Abstract
AIM In 2022, in Italy, general practitioners (GPs) have been allowed to prescribe SGLT2i in Type 2 Diabetes (T2D) under National Health Service (NHS) reimbursement. In the pivotal clinical trial named DECLARE-TIMI 58, dapagliflozin reduced the risk of hospitalization for heart failure, CV death and kidney disease progression compared to placebo in a population of T2D patients. This study evaluated the health and economic impact of dapagliflozin for T2D patients who had or were at risk for atherosclerotic cardiovascular disease in the Italian GPs setting. METHODS A budget impact model was developed to assess the health and economic impact of introducing dapagliflozin in GPs setting. The analysis was conducted by adopting the Italian NHS perspective and a 3-year time horizon. The model estimated and compared the health outcomes and direct medical costs associated with a scenario with dapagliflozin and other antidiabetic therapies available for GPs prescription (scenario B) and a scenario where only other antidiabetic therapies are available (scenario A). Rates of occurrence of cardiovascular and renal complications as well as adverse events were captured from DECLARE-TIMI 58 trial and the literature, while cost data were retrieved from the Italian tariff and the literature. One-way sensitivity analyses were conducted to test the impact of model parameters on the budget impact. RESULTS The model estimated around 442.000 patients eligible for the treatment with dapagliflozin in the GPs setting for each simulated year. The scenario B compared to scenario A was associated with a reduction in the occurrence of cardiovascular and renal complication (-1.83%) over the 3 years simulated. Furthermore, the scenario A allowed for an overall cost saving of 102,692,305€: 14,521,464€ in the first year, 33,007,064€ in the second and 55,163,777€ in the third. The cost of cost of drug acquisition, the probability of cardiovascular events and the percentage of patients potentially eligible to the treatment were the factor with largest impact on the results. CONCLUSIONS The use of dapagliflozin in GPs setting reduce the number of CVD events, kidney disease progression and healthcare costs in Italy. These data should be considered to optimize the value produced for the T2D patients who had or were at risk for atherosclerotic cardiovascular disease.
Collapse
Affiliation(s)
- Paolo Angelo Cortesi
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy
- Istituto Auxologico Italiano-IRCCS, Milan, Italy
| | - Ippazio Cosimo Antonazzo
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy.
- Istituto Auxologico Italiano-IRCCS, Milan, Italy.
| | | | - Marco Gnesi
- Medical Evidence, Biopharmaceuticals Medical, AstraZeneca, Milan, Italy
| | | | | | | | - Giampiero Mazzaglia
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy
| | - Lorenzo Giovanni Mantovani
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy
- Istituto Auxologico Italiano-IRCCS, Milan, Italy
| |
Collapse
|
11
|
Lin L, Ning K, Xiang L, Peng L, Li X. SGLT2 inhibition and three urological cancers: Up-to-date results. Diabetes Metab Res Rev 2024; 40:e3797. [PMID: 38523292 DOI: 10.1002/dmrr.3797] [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: 03/15/2023] [Revised: 01/23/2024] [Accepted: 02/22/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE To identify the causal role of sodium-glucose cotransporter 2 (SGLT2) inhibition on three urological cancers. METHODS Six single nucleotide polymorphisms associated with the expression level of SLC5A2, a proxy for SGLT2 inhibition, from a recent publication were extracted. Three common urological cancers, including bladder cancer, prostate cancer and kidney cancer, were analysed. The main cohort of bladder cancer was derived from UK Biobank (1279 cases and 372,016 controls). The prostate cancer cohort was from the Prostate Cancer Association Group to Investigate Cancer Associated Alterations in the Genome (PRACTICAL) consortium (79,148 cases and 61,106 controls). The kidney cancer phenotype was from the UK Biobank cohort of 463,010 individuals (1114 cases and 461,896 controls). Primary and sensitivity analysis were performed to validate the results. In vitro analysis was also incorporated to validate the Mendelian randomisation results. RESULTS In primary analysis, SGLT2 inhibition was associated with reduced risk of bladder cancer (OR: 0.98, 95% CI: 0.97-0.99) per unit lowering of HbA1c level. A protective association was also observed for prostate cancer with odds ratio = 0.31 (95% CI = 0.21-0.47). However, we did not discover a causal relationship between SGLT2 inhibition and kidney cancer (OR: 1.00, 95% CI: 0.99-1.00). Sensitivity analysis and in vitro validation did not support the causal role of SGLT2 inhibition in increasing cancer risk. CONCLUSIONS We did not find any evidence that SGLT2 inhibition could increase the risk of the three cancers. Even in some analysis, SGLT2 inhibition tended to show protective effects on the three urological cancers.
Collapse
Affiliation(s)
- Lede Lin
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kang Ning
- Department of Head and Neck Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Liyuan Xiang
- Department of Clinical Research Management, West China Hospital, Chengdu, Sichuan, China
| | - Liao Peng
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiang Li
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
12
|
Sreenivasan J, Malik A, Khan MS, Lloji A, Hooda U, Aronow WS, Lanier GM, Pan S, Greene SJ, Murad MH, Michos ED, Cooper HA, Gass A, Gupta R, Desai NR, Mentz RJ, Frishman WH, Panza JA. Pharmacotherapies in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Network Meta-Analysis. Cardiol Rev 2024; 32:114-123. [PMID: 36576372 DOI: 10.1097/crd.0000000000000484] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Various pharmacotherapies exist for heart failure with preserved ejection fraction (HFpEF), but with unclear comparative efficacy. We searched EMBASE, Medline, and Cochrane Library from inception through August 2021 for all randomized clinical trials in HFpEF (EF >40%) that evaluated beta-blockers, mineralocorticoid receptor antagonist (MRA), angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Outcomes assessed were cardiovascular mortality, all-cause mortality, and HF hospitalization. A frequentist network meta-analysis was performed with a random-effects model. We included 22 randomized clinical trials (30,673 participants; mean age = 71.7 ± 4.2 years; females = 49.3 ± 7.7%; median follow-up = 24.4 ± 11.1 months). Compared with placebo, there was no statistically significant difference in cardiovascular mortality [beta-blockers; odds ratio (OR) 0.79 (0.46-1.34), MRA; OR 0.90 (0.70-1.14), ACE OR 0.95 (0.59-1.53), ARB; OR 1.02 (0.87-1.19), ARNI; OR 0.97 (0.74-1.26) and SGLT2i; OR 1.00 (0.84-1.18)] or all-cause mortality [beta blockers; OR 0.75 (0.54-1.04), MRA; OR 0.90 (0.75-1.08) ACE; OR 1.05 (0.71-1.54), ARB; OR 1.03 (0.91-1.15), ARNI; OR 0.99 (0.82-1.20) and SGLT2i; OR 1.00 (0.89-1.13)]. The certainty in these estimates was low or very low. There was a significantly reduction in HF hospitalization with the use of SGLT2i [OR 0.71 (0.62-0.82), moderate certainty], ARNI [OR 0.77 (0.63-0.94), low certainty], and MRA [OR 0.81 (0.66-0.98), moderate certainty]; with corresponding P scores of 0.84, 0.68, and 0.58, respectively. In HFpEF, the use of beta-blockers, MRA, ACE/ARB/ARNI, or SGLT2i was not associated with improved cardiovascular or all-cause mortality. SGLT2i, ARNI, and MRA reduced the risk of HF hospitalizations.
Collapse
Affiliation(s)
- Jayakumar Sreenivasan
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Aaqib Malik
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Muhammad Shahzeb Khan
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Amanda Lloji
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Urvashi Hooda
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen Pan
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - M Hassan Murad
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Howard A Cooper
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Alan Gass
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Rahul Gupta
- Division of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | - Julio A Panza
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| |
Collapse
|
13
|
Târtea G, Popa-Wagner A, Sfredel V, Mitran SI, Dan AO, Țucă AM, Preda AN, Raicea V, Țieranu E, Cozma D, Vătășescu R. Chitosan Versus Dapagliflozin in a Diabetic Cardiomyopathy Mouse Model. Int J Mol Sci 2024; 25:2118. [PMID: 38396795 PMCID: PMC10888683 DOI: 10.3390/ijms25042118] [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: 01/09/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Diabetes mellitus is a metabolic disorder with global economic implications that can lead to complications such as diabetic cardiomyopathy. The aim of this study was to compare the effects of chitosan versus dapagliflozin in mouse diabetic cardiomyopathy. We used 32 C57Bl/6 male mice aged between 8 and 10 weeks, which were randomly divided into Control-without diabetes mellitus (DM), type 1 DM (T1DM), T1DM + Chitosan, and T1DM + Dapapgliflozin groups. We induced diabetes with streptozotocin and treated the animals for 12 weeks. The analysis showed a reduction in intramyocardial fibrosis in the T1DM + Dapapgliflozin compared to T1DM animals. In T1DM + CHIT, a reduction in intramyocardial fibrosis was observed although, accordingly, there was also no significant decrease in blood glucose. The level of oxidative stress was reduced in the groups of treated animals compared to T1DM. All these observed changes in the structure and function of hearts were highlighted in the echocardiographic examination. In the treated groups, there was delayed appearance of left ventricular (LV) hypertrophy, a slight decrease in the ejection fraction of the LV, and an improved diastolic profile. The results demonstrate that chitosan has promising effects on diabetic cardiomyopathy that are comparable to the beneficial effects of dapagliflozin.
Collapse
Affiliation(s)
- Georgică Târtea
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (G.T.); (V.S.); (S.I.M.); (A.O.D.); (A.-M.Ț.)
| | - Aurel Popa-Wagner
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Veronica Sfredel
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (G.T.); (V.S.); (S.I.M.); (A.O.D.); (A.-M.Ț.)
| | - Smaranda Ioana Mitran
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (G.T.); (V.S.); (S.I.M.); (A.O.D.); (A.-M.Ț.)
| | - Alexandra Oltea Dan
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (G.T.); (V.S.); (S.I.M.); (A.O.D.); (A.-M.Ț.)
| | - Anca-Maria Țucă
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (G.T.); (V.S.); (S.I.M.); (A.O.D.); (A.-M.Ț.)
| | - Alexandra Nicoleta Preda
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (G.T.); (V.S.); (S.I.M.); (A.O.D.); (A.-M.Ț.)
| | - Victor Raicea
- Department of Cardiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (V.R.); (E.Ț.)
| | - Eugen Țieranu
- Department of Cardiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (V.R.); (E.Ț.)
| | - Dragoș Cozma
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania;
| | - Radu Vătășescu
- Cardio-Thoracic Pathology Department, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Blin P, Joubert M, Jourdain P, Zaoui P, Guiard E, Sakr D, Dureau-Pournin C, Bernard MA, Lassalle R, Thomas-Delecourt F, Bineau S, Moore N, Droz-Perroteau C. Cardiovascular and renal diseases in type 2 diabetes patients: 5-year cumulative incidence of the first occurred manifestation and hospitalization cost: a cohort within the French SNDS nationwide claims database. Cardiovasc Diabetol 2024; 23:22. [PMID: 38195491 PMCID: PMC10777660 DOI: 10.1186/s12933-023-02101-1] [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: 10/03/2023] [Accepted: 12/22/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Myocardial infarction (MI), stroke, peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD) are common cardiovascular renal diseases (CVRD) manifestations for type 2 diabetes. The objective was to estimate the incidence of the first occurring CVRD manifestation and cumulative hospitalization costs of each CVRD manifestation for type 2 diabetes without CVRD history. METHODS A cohort study of all type 2 diabetes free of CVRD as of January 1st 2014, was identified and followed-up for 5 years within the French SNDS nationwide claims database. The cumulative incidence of the first occurring CVRD manifestation was estimated using the cumulative incidence function, with death as a competing risk. Cumulative hospitalization costs of each CVRD manifestations were estimated from the perspective of all payers. RESULTS From 2,079,089 type 2 diabetes without cancer or transplantation, 76.5% were free of CVRD at baseline with a mean age of 65 years, 52% of women and 7% with microvascular complications history. The cumulative incidence of a first CVRD manifestation was 15.3% after 5 years of follow-up with a constant linear increase over time for all CVRD manifestations: The most frequent was CKD representing 40.6% of first occurred CVRD manifestation, followed by HF (23.0%), then PAD (13.5%), stroke (13.2%) and MI (9.7%). HF and CKD together reached about one patient out of ten after 5 years and represented 63.6% of first CVRD manifestations. The 5-year global cost of all CVRD hospitalizations was 3.9 billion euros (B€), i.e. 2,450€ per patient of the whole cohort, with an exponential increase over time for each specific CVRD manifestation. The costliest was CKD (2.0 B€), followed by HF (1.2 B€), then PAD (0.7 B€), stroke (0.6 B€) and MI (0.3 B€). CONCLUSIONS/INTERPRETATION While MI, stroke and PAD remain classic major risks of complications for CVRD-free type 2 diabetes, HF and CKD nowadays represent individually a higher risk and cost than each of these classic manifestations, and jointly represents a risk and a cost twice as high as these three classic manifestations all together. This should encourage the development of specific HF and CKD preventive strategies.
Collapse
Affiliation(s)
- Patrick Blin
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France.
| | - Michael Joubert
- Diabetes Care Unit, Caen University Hospital, UNICAEN, Caen, 14033, France
| | | | | | - Estelle Guiard
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| | - Dunia Sakr
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| | - Caroline Dureau-Pournin
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| | - Marie-Agnès Bernard
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| | - Régis Lassalle
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| | | | | | - Nicholas Moore
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| | - Cécile Droz-Perroteau
- Univ. Bordeaux, INSERM CIC-P 1401, Bordeaux PharmacoEpi, 146 rue Léo Saignat, Bordeaux, 33000, 33076, France
| |
Collapse
|
16
|
Aldafas R, Crabtree T, Alkharaiji M, Vinogradova Y, Idris I. Sodium-glucose cotransporter-2 inhibitors (SGLT2) in frail or older people with type 2 diabetes and heart failure: a systematic review and meta-analysis. Age Ageing 2024; 53:afad254. [PMID: 38287703 PMCID: PMC10825241 DOI: 10.1093/ageing/afad254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/09/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) reduce cardio-metabolic and renal outcomes in patients with type 2 diabetes (T2D) but their efficacy and safety in older or frail individuals remains unclear. METHODS We searched PubMed, Scopus, Web of Science, Cochrane CENTRA and Google Scholar and selected randomised controlled trials and observational studies comparing SGLT2Is versus placebo/other glucose-lowering agent for people with frailty or older individuals (>65 years) with T2D and heart failure (HF). Extracted data on the change in HbA1c % and safety outcomes were pooled in a random-effects meta-analysis model. RESULTS We included data from 20 studies (22 reports; N = 77,083 patients). SGLT2Is did not significantly reduce HbA1c level (mean difference -0.13, 95%CI: -0.41 to 0.14). SGLT2Is were associated with a significant reduction in the risk of all-cause mortality (risk ratio (RR) 0.81, 95%CI: -0.69 to 0.95), cardiac death (RR 0.80, 95%CI: -0.94 to 0.69) and hospitalisation for heart failure (HHF) (RR 0.69, 95%CI: 0.59-0.81). However, SGLT2Is did not demonstrate significant effect in reducing in the risk of macrovascular events (acute coronary syndrome or cerebral vascular occlusion), renal progression/composite renal endpoint, acute kidney injury, worsening HF, atrial fibrillation or diabetic ketoacidosis. CONCLUSIONS In older or frail patients with T2D and HF, SGLT2Is are consistently linked with a decrease in total mortality and the overall burden of cardiovascular (CV) events, including HHF events and cardiac death, but not protective for macrovascular death or renal events. Adverse events were more difficult to quantify but the risk of diabetic ketoacidosis or acute kidney injury was not significantly increase.
Collapse
Affiliation(s)
- Rami Aldafas
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Tomas Crabtree
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
| | - Mohammed Alkharaiji
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham NG2 7RD, UK
| | - Iskandar Idris
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, NIHR, Nottingham BRC, University of Nottingham, Derby, UK
| |
Collapse
|
17
|
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.
Collapse
Affiliation(s)
- Saeed Taheri
- Department of Medicine, New Lahijan Scientific Foundation, Lahijan 4415813166, Iran
| |
Collapse
|
18
|
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
| |
Collapse
|
19
|
Kongmalai T, Hadnorntun P, Leelahavarong P, Kongmalai P, Srinonprasert V, Chirakarnjanakorn S, Chaikledkaew U, McKay G, Attia J, Thakkinstian A. Comparative cardiovascular benefits of individual SGLT2 inhibitors in type 2 diabetes and heart failure: a systematic review and network meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2023; 14:1216160. [PMID: 38179304 PMCID: PMC10765518 DOI: 10.3389/fendo.2023.1216160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/17/2023] [Indexed: 01/06/2024] Open
Abstract
Background In patients with type 2 diabetes (T2D) and a history of heart failure (HF), sodium-glucose cotransporter-2 inhibitors (SGLT2is) have demonstrated cardiovascular (CV) benefits. However, the comparative efficacy of individual SGLT2is remains uncertain. This network meta-analysis (NMA) compared the efficacy and safety of five SGLT2is (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and sotagliflozin) on CV outcomes in these patients. Materials and methods PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to September 23, 2022, to identify all randomized controlled trials (RCTs) comparing SGLT2is to placebo in T2D patients with HF. The main outcomes included composite CV death/heart failure hospitalization (HFH), HFH, CV death, all-cause mortality, and adverse events. Pairwise and NMA approaches were applied. Results Our analysis included 11 RCTs with a total of 20,438 patients with T2D and HF. All SGLT2is significantly reduced HFH compared to standard of care (SoC) alone. "Add-on" SGLT2is, except ertugliflozin, significantly reduced composite CV death/HFH relative to SoC alone. Moreover, canagliflozin had lower composite CV death/HFH compared to dapagliflozin. Based on the surface under the cumulative ranking curve (SUCRA), the top-ranked SGLT2is for reducing HFH were canagliflozin (95.5%), sotagliflozin (66.0%), and empagliflozin (57.2%). Head-to-head comparisons found no significant differences between individual SGLT2is in reducing CV death. "Add-on" SGLT2is reduced all-cause mortality compared with SoC alone, although only dapagliflozin was statistically significant. No SGLT2is were significantly associated with serious adverse events. A sensitivity analysis focusing on HF-specific trials found that dapagliflozin, empagliflozin, and sotagliflozin significantly reduced composite CV death/HFH, consistent with the main analysis. However, no significant differences were identified from their head-to-head comparisons in the NMA. The SUCRA indicated that sotagliflozin had the highest probability of reducing composite CV death/HFH (97.6%), followed by empagliflozin (58.4%) and dapagliflozin (44.0%). Conclusion SGLT2is significantly reduce the composite CV death/HFH outcome. Among them, canagliflozin may be considered the preferred treatment for patients with diabetes and a history of heart failure, but it may also be associated with an increased risk of any adverse events compared to other SGLT2is. However, a sensitivity analysis focusing on HF-specific trials identified sotagliflozin as the most likely agent to reduce CV death/HFH, followed by empagliflozin and dapagliflozin. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022353754.
Collapse
Affiliation(s)
- Tanawan Kongmalai
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phorntida Hadnorntun
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pattara Leelahavarong
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pinkawas Kongmalai
- Department of Orthopedics, Faculty of Medicine, Kasetsart University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Srisakul Chirakarnjanakorn
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Gareth McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
20
|
Ye Q, Zha K. SGLT2i‑treated heart failure patients with a reduced ejection fraction: A meta‑analysis. Exp Ther Med 2023; 26:548. [PMID: 37928504 PMCID: PMC10623217 DOI: 10.3892/etm.2023.12248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 09/15/2023] [Indexed: 11/07/2023] Open
Abstract
The aim of this study was to investigate the effects of SGLT2 inhibitors (SGLT2i) on patients with heart failure (HF) and reduced ejection fraction, with or without diabetes. A systematic review of randomized controlled trials (RCTs) was conducted, comparing SGLT2i to a placebo for HF patients. Relevant studies from PubMed, Web of Science, and EMBASE were searched from inception to July 2021, without any language restrictions. The pooled effect was estimated using the odds ratio (OR) and 95% confidence interval (CI). Depending on the heterogeneity test results, either random effects or fixed effects models were selected to estimate the pooled effects. Sensitivity analysis was conducted by gradually removing each study to evaluate the results' stability. A total of 5 RCT studies were included in the analysis. The fixed-effects model demonstrated that the patients in the SGLT2i group had a lower risk of hospitalization for HF/cardiovascular death (OR=0.72; 95% CI, 0.67-0.78), P<0.0001; I2=0.0%, P=0.966), cardiovascular death (OR=0.84, 95% CI (0.77, 0.93), P<0.0001; I2=0.0%, P=0.633), hospitalization for HF (OR=0.69, 95% CI (0.63, 0.75), P<0.0001; I2=0.0%, P=0.933), and all-cause mortality (OR=0.79, 95% CI (0.71, 0.89), P<0.0001; I2=3.3%, P=0.376) compared to the placebo group. Sensitivity analysis showed that the pooled effect value remained stable within the corresponding range, even after each study was gradually removed. In conclusion, SGLT2i can reduce the risk of HF hospitalization, cardiovascular death, and all-cause mortality in patients with HF and a reduced ejection fraction, regardless of the presence or absence of diabetes.
Collapse
Affiliation(s)
- Qiang Ye
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Kelan Zha
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| |
Collapse
|
21
|
Stampouloglou PK, Anastasiou A, Bletsa E, Lygkoni S, Chouzouri F, Xenou M, Katsarou O, Theofilis P, Zisimos K, Tousoulis D, Vavuranakis M, Siasos G, Oikonomou E. Diabetes Mellitus in Acute Coronary Syndrome. Life (Basel) 2023; 13:2226. [PMID: 38004366 PMCID: PMC10671950 DOI: 10.3390/life13112226] [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: 10/14/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
The global prevalence of diabetes mellitus (DM) has led to a pandemic, with significant microvascular and macrovascular complications including coronary artery disease (CAD), which worsen clinical outcomes and cardiovascular prognosis. Patients with both acute coronary syndrome (ACS) and DM have worse prognosis and several pathophysiologic mechanisms have been implicated including, insulin resistance, hyperglycemia, endothelial dysfunction, platelet activation and aggregations as well as plaque characteristics and extent of coronary lesions. Therefore, regarding reperfusion strategies in the more complex anatomies coronary artery bypass surgery may be the preferred therapeutic strategy over percutaneous coronary intervention while both hyperglycemia and hypoglycemia should be avoided with closed monitoring of glycemic status during the acute phase of myocardial infraction. However, the best treatment strategy remains undefined. Non-insulin therapies, due to the low risk of hypoglycemia concurrently with the multifactorial CV protective effects, may be proved to be the best treatment option in the future. Nevertheless, evidence for the beneficial effects of glucagon like peptide-1 receptor agonists, dipeptidyl-peptidase 4 inhibitors and sodium glycose cotransporter 2 inhibitors, despite accumulating, is not robust and future randomized control trials may provide more definitive data.
Collapse
Affiliation(s)
- Panagiota K. Stampouloglou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Artemis Anastasiou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Evanthia Bletsa
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Stavroula Lygkoni
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Flora Chouzouri
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Maria Xenou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Ourania Katsarou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Panagiotis Theofilis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (D.T.)
| | - Konstantinos Zisimos
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Dimitris Tousoulis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (D.T.)
| | - Manolis Vavuranakis
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.S.); (A.A.); (E.B.); (S.L.); (F.C.); (M.X.); (K.Z.); (M.V.); (G.S.)
| |
Collapse
|
22
|
Shi Y, Bhalla V. Kidney single-cell transcriptomes uncover SGLT2i-induced metabolic reprogramming via restoring glycolysis and fatty acid oxidation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.10.31.564836. [PMID: 37961186 PMCID: PMC10634955 DOI: 10.1101/2023.10.31.564836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Approximately 40% of individuals with chronic kidney disease have type 2 diabetes mellitus, and diabetic kidney disease is the leading cause of end-stage kidney disease worldwide. Inhibitors of sodium-glucose cotransporter 2 (SGLT2) have been demonstrated to be effective in glucose control, improving cardiovascular outcomes and the progression of kidney disease. However, the protective role of SGLT2 inhibition on kidney metabolism is not fully understood. To explore these mechanisms further, we conducted analysis of publicly available single-cell RNA sequencing data of db/db mice treated with an SGLT2 inhibitor(dapagliflozin) and accompanying controls. We found that proximal tubule cells exhibited impaired glycolysis and high fatty acid oxidation in diabetes compared with control mice. SGLT2 inhibition reversed this metabolic dysfunction by reducing glycolysis and its substrate accumulation. SGLT2 inhibition also upregulates high fatty oxidation without increasing the uptake of fatty acids and elongation, along with low lipotoxicity. Surprisingly, both SGLT2(+) and SGLT2(-) cells show gene consistent changes in expression of metabolic genes, consistent with a non-cell autonomous effect of dapagliflozin treatment. This study demonstrates the protective role of SGLT2 inhibition via restoring metabolic dysfunction.
Collapse
|
23
|
Horii T, Oikawa Y, Shimada A, Mihara K. Real-world risk of cardiovascular diseases in patients with type 2 diabetes associated with sodium-glucose cotransporter 2 inhibitors in comparison with metformin: A propensity score-matched model analysis in Japan. J Diabetes Investig 2023; 14:1262-1267. [PMID: 37517084 PMCID: PMC10583649 DOI: 10.1111/jdi.14062] [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: 06/14/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023] Open
Abstract
We aimed to compare the effects of cardiovascular disease risk in Japanese patients with type 2 diabetes on sodium-glucose cotransporter 2 inhibitors (SGLT2Is) or metformin. This retrospective, real-world cohort study was carried out using a claims database and propensity score matching; 58,402 eligible patients (29,201 per group) were included. The outcomes included nonfatal myocardial infarction, angina pectoris, nonfatal stroke, hospitalization for heart failure and composite end-points. The hazard ratio (HR) for the composite end-point was 0.79, which was lower for SGLT2Is than for metformin. For male patients (HR 0.76), patients aged <65 years (HR 0.94), patients aged ≥75 years (HR 0.78) and patients with body mass index ≥25 kg/m2 (HR 0.76), the HRs for the composite end-point were significantly lower in the SGLT2I group than in the metformin group. SGLT2Is might be superior to metformin in reducing the composite risk of cardiovascular disease in patients with type 2 diabetes.
Collapse
Affiliation(s)
- Takeshi Horii
- Department of Pharmacy, Faculty of PharmacyMusashino UniversityTokyoJapan
- Department of Endocrinology and Diabetes, School of MedicineSaitama Medical UniversitySaitamaJapan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of MedicineSaitama Medical UniversitySaitamaJapan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, School of MedicineSaitama Medical UniversitySaitamaJapan
| | - Kiyoshi Mihara
- Department of Pharmacy, Faculty of PharmacyMusashino UniversityTokyoJapan
| |
Collapse
|
24
|
Ge T, Yang Y, Zhao Y. A study of the efficacy of sacubitril/valsartan plus dapagliflozin combination treatment in pulmonary arterial hypertension due to left heart disease. Perfusion 2023; 38:1697-1704. [PMID: 36173344 DOI: 10.1177/02676591221127924] [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] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To determine the efficacy of sacubitril/valsartan plus dapagliflozin in the treatment of patients with pulmonary arterial hypertension (PAH) due to left heart disease and to explore new treatment regimen for PAH due to left heart disease. METHODS This study is a randomized controlled trial (RCT) study of 120 patients with PAH due to left heart disease admitted to the cardiovascular department of our hospital from Dec. 2019 to Dec. 2021. The patients were randomized 1:1 to the study group and control group. All patients were given baseline treatments targeting left heart disease and symptoms of PAH. In addition to the baseline treatments, patients in the control group were given sacubitril/valsartan tablets, while patients in the study group were given sacubitril/valsartan tablets plus dapagliflozin tablets. After 6 months of treatment, parameters including left heart function and exercise tolerance, Hemodynamics (left ventricular end systolic diameter [LVSED], left ventricular end diastolic diameter [LVEDD], left ventricular ejection fraction [LVEF], 6 min walk distance (6MWD), mean pulmonary artery pressure (mPAP) and pulmonary artery systolic pressure (PASP)), vascular endothelial function (plasma endothelin (ET) -1 and nitric oxide [NO]), heart failure markers (plasma N-terminal pro-brain natriuretic peptide (NT-proBNP)], inflammatory factors (serum C reactive protein [CRP], interleukin (IL)-6, and tumor necrosis factor (TNF)-α], and adverse drug reactions (ADRs) were assessed in both groups. RESULTS Both groups had reduced LVESD and LVEDD, increased LVEF, and extended 6MWD after 6 months of treatment. The improvements in these parameters were significantly greater in the study group than in the control group (all P < 0.05). In addition, both the mPAP and PASP showed a decrease, and the mPAP and PASP in the study group were lower than those in the control group (p<0.05). Furthermore, both groups had decreased plasma ET-1 and NT-proBNP but increased plasma NO after 6 months of treatment. The improvements in these parameters were significantly greater in the study group than in the control group (all P < 0.05). Serum CRP, IL-6 and TNF-α levels were decreased in both groups after 6 months of treatment, and were significantly lower in the study group than in the control group (all P < 0.05). There was no significant difference in the overall incidence of ADRs between the two groups (P > 0.05). CONCLUSION Sacubitril/valsartan plus dapagliflozin in the treatment with PAH due to left heart disease can improve left heart function of patients by improving vascular endothelial functions and alleviating inflammation, which helps to reduce the PAH process. Therefore, this combination treatment is safe and effective in PAH due to left heart disease.
Collapse
Affiliation(s)
- Ting Ge
- Divison of Cardiology, Nanjing Jinling Hostpital, Nanjing, China
| | - Yang Yang
- Divison of Cardiology, Nanjing Jinling Hostpital, Nanjing, China
| | - Yanfang Zhao
- Divison of Cardiology, Nanjing Jinling Hostpital, Nanjing, China
| |
Collapse
|
25
|
Cheng JWM, Colucci V, Kalus JS, Spinler SA. Sodium-Glucose Cotransporter 2 Inhibitors Among Heart Failure With Mildly Reduced and Preserved Ejection Fraction. Ann Pharmacother 2023; 57:1291-1301. [PMID: 36800904 DOI: 10.1177/10600280231154021] [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] [Indexed: 02/20/2023] Open
Abstract
OBJECTIVE Results from large placebo-controlled randomized trials in patients with heart failure with mid-range ejection fraction (HFmrEF) and HF with preserved EF (HFpEF) have become available recently. This article discusses results of these clinical trials. DATA SOURCES Peer-reviewed articles were identified from MEDLINE (1966 to December 31, 2022) using search terms dapagliflozin, empagliflozin, SGLT-2Is, HFmrEF, and HFpEF. STUDY SELECTION AND DATA EXTRACTION Eight completed, pertinent clinical trials were included. DATA SYNTHESIS EMPEROR-Preserved, and DELIVER demonstrated that empagliflozin and dapagliflozin reduce CV death and heart failure hospitalization (HHF) in patients with HFmrEF and HFpEF, with/without diabetes when added to a standard heart failure (HF) regimen. The benefit is primarily due to reduction in HHF. Additional data from post hoc analyses of trials of dapagliflozin, ertugliflozin, and sotagliflozin suggest that these benefits may be a class effect. Benefits appear greatest in patients with left ventricular ejection fraction 41% up to about 65%. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE While many pharmacologic treatments have been proven to reduce mortality and improve cardiovascular (CV) outcomes in people with HFmrEF and HF with reduced EF (HFrEF), there are few therapy which improve CV outcome in people with HFpEF. SGLT-2I become one of the first class of pharmacologic agent that can be used to reduce HHF and CV mortality. CONCLUSION Studies showed that empagliflozin and dapagliflozin reduce the combined risk of CV death or HHF in patients with HFmrEF and HFpEF when added to a standard HF regimen. Given that benefit has now been demonstrated across the spectrum of HF, SGLT-2Is should be considered one of the standard HF pharmacotherapy.
Collapse
Affiliation(s)
- Judy W M Cheng
- Department of Pharmacy Practice, School of Pharmacy-Boston, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Vincent Colucci
- Department of Pharmacy Practice, Skaggs School of Pharmacy, University of Montana, Missoula, MT, USA
| | - James S Kalus
- Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
| | - Sarah A Spinler
- Department of Pharmacy, School of Pharmacy and Pharmaceutical Studies, Binghamton University, Binghamton, NY, USA
| |
Collapse
|
26
|
Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 127] [Impact Index Per Article: 127.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
|
27
|
Saha S, Fang X, Green CD, Das A. mTORC1 and SGLT2 Inhibitors-A Therapeutic Perspective for Diabetic Cardiomyopathy. Int J Mol Sci 2023; 24:15078. [PMID: 37894760 PMCID: PMC10606418 DOI: 10.3390/ijms242015078] [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: 09/01/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
Diabetic cardiomyopathy is a critical diabetes-mediated co-morbidity characterized by cardiac dysfunction and heart failure, without predisposing hypertensive or atherosclerotic conditions. Metabolic insulin resistance, promoting hyperglycemia and hyperlipidemia, is the primary cause of diabetes-related disorders, but ambiguous tissue-specific insulin sensitivity has shed light on the importance of identifying a unified target paradigm for both the glycemic and non-glycemic context of type 2 diabetes (T2D). Several studies have indicated hyperactivation of the mammalian target of rapamycin (mTOR), specifically complex 1 (mTORC1), as a critical mediator of T2D pathophysiology by promoting insulin resistance, hyperlipidemia, inflammation, vasoconstriction, and stress. Moreover, mTORC1 inhibitors like rapamycin and their analogs have shown significant benefits in diabetes and related cardiac dysfunction. Recently, FDA-approved anti-hyperglycemic sodium-glucose co-transporter 2 inhibitors (SGLT2is) have gained therapeutic popularity for T2D and diabetic cardiomyopathy, even acknowledging the absence of SGLT2 channels in the heart. Recent studies have proposed SGLT2-independent drug mechanisms to ascertain their cardioprotective benefits by regulating sodium homeostasis and mimicking energy deprivation. In this review, we systematically discuss the role of mTORC1 as a unified, eminent target to treat T2D-mediated cardiac dysfunction and scrutinize whether SGLT2is can target mTORC1 signaling to benefit patients with diabetic cardiomyopathy. Further studies are warranted to establish the underlying cardioprotective mechanisms of SGLT2is under diabetic conditions, with selective inhibition of cardiac mTORC1 but the concomitant activation of mTORC2 (mTOR complex 2) signaling.
Collapse
Affiliation(s)
- Sumit Saha
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.S.); (X.F.); (C.D.G.)
| | - Xianjun Fang
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.S.); (X.F.); (C.D.G.)
| | - Christopher D. Green
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.S.); (X.F.); (C.D.G.)
| | - Anindita Das
- Division of Cardiology, Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| |
Collapse
|
28
|
Wang Y, Hou R, Ni B, Jiang Y, Zhang Y. Development and validation of a prediction model based on machine learning algorithms for predicting the risk of heart failure in middle-aged and older US people with prediabetes or diabetes. Clin Cardiol 2023; 46:1234-1243. [PMID: 37519220 PMCID: PMC10577538 DOI: 10.1002/clc.24104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/13/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to develop and validate a machine learning (ML) based prediction model for the risk of heart failure (HF) in patients with prediabetes or diabetes. METHODS We used 3527 subjects aged 40 years and older with a prior diagnosis of prediabetes or diabetes from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018. The search for independent risk variables linked to HF was conducted using univariate and multivariable logistic regression analysis. The 3527 subjects were randomly divided into training set and validation set in a 7:3 ratio. Five ML models were built on the training set using five ML algorithms, including random forest (RF), and then validated on the validation set. Receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis and Bootstrap resampling method were used to measure the predictive performance of the five ML models. RESULTS Multivariate logistic regression analysis showed that age, poverty-to-income ratio, myocardial infarction condition, coronary heart disease condition, chest pain condition, and glucose-lowering medication use were independent predictors of HF. By comparing the performance of the five ML models, the RF model (AUC = 0.978) was the best prediction model. CONCLUSIONS The risk of HF in middle-aged and elderly patients with prediabetes or diabetes can be accurately predicted using ML models. The best prediction performance is presented by RF model, which can assist doctors in making clinical decisions.
Collapse
Affiliation(s)
- Yicheng Wang
- Department of Cardiovascular medicineAffiliated Fuzhou First Hospital of Fujian Medical UniversityFuzhouFujianChina
- The Third Clinical Medical CollegeFujian Medical UniversityFuzhouFujianChina
- Cardiovascular Disease Research Institute of Fuzhou CityFuzhouFujianChina
| | - Riting Hou
- Department of Cardiovascular medicineAffiliated Fuzhou First Hospital of Fujian Medical UniversityFuzhouFujianChina
- The Third Clinical Medical CollegeFujian Medical UniversityFuzhouFujianChina
- Cardiovascular Disease Research Institute of Fuzhou CityFuzhouFujianChina
| | - Binghang Ni
- Department of Cardiovascular medicineAffiliated Fuzhou First Hospital of Fujian Medical UniversityFuzhouFujianChina
- The Third Clinical Medical CollegeFujian Medical UniversityFuzhouFujianChina
- Cardiovascular Disease Research Institute of Fuzhou CityFuzhouFujianChina
| | - Yu Jiang
- Department of Cardiovascular medicineAffiliated Fuzhou First Hospital of Fujian Medical UniversityFuzhouFujianChina
- The Third Clinical Medical CollegeFujian Medical UniversityFuzhouFujianChina
- Cardiovascular Disease Research Institute of Fuzhou CityFuzhouFujianChina
| | - Yan Zhang
- Department of Cardiovascular medicineAffiliated Fuzhou First Hospital of Fujian Medical UniversityFuzhouFujianChina
- The Third Clinical Medical CollegeFujian Medical UniversityFuzhouFujianChina
- Cardiovascular Disease Research Institute of Fuzhou CityFuzhouFujianChina
| |
Collapse
|
29
|
Wood DT, Waterbury NV, Lund BC. Sodium glucose cotransporter 2 inhibitors and gout risk: a sequence symmetry analysis. Clin Rheumatol 2023; 42:2469-2475. [PMID: 37264145 DOI: 10.1007/s10067-023-06647-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/21/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To examine the association between sodium-glucose cotransporter 2 inhibitors (SGLT2-I) and gout incidence in patients with diabetes is the objective. METHOD National administrative data from the United States Veterans Health Administration were used to identify patients initiated on SGLT2-I from 2012 to 2020. Sequence symmetry analysis was performed to contrast the number of patients with incident gout within the year following SGLT2-I initiation to the number within the year preceding initiation. Exposure counterfactual analyses examined the relationship between potential therapeutic alternatives to SGLT2-I and risk for gout. RESULTS The primary outcome of incident gout was observed in 441 patients preceding SGLT2-I initiation and 273 patients following SGTL2-I (symmetry ratio (SR) = 0.62; 95% CI: 0.53-0.72). This finding remained consistent across multiple sensitivity analyses. A reduction in gout incidence was also observed in exposure counterfactual cohorts initiating dipeptidyl peptidase-4 inhibitor (SR = 0.67; 95% CI: 0.63-0.72) and thiazolidinediones (SR = 0.72; 95% CI: 0.65-0.79), but not glucagon-like peptide-1 receptor agonist (GLP1-RA) (SR = 0.93; 95% CI: 0.77-1.12). CONCLUSIONS The risk for incident gout was significantly reduced following SGLT2-I initiation. GLP1-RA had minimal to no impact on gout risk. Our findings support pleiotropic benefits of SGLT2-I use in patients with diabetes at elevated risk for gout. Key points • Early studies suggest SGLT2-inhibitors may decrease risk for gout • Our sequence symmetry analysis confirmed this observation • DPP4s and thiazolidinediones were also associated with lower gout risk • SLGT2 inhibitors may be beneficial in patients with diabetes at risk for gout.
Collapse
Affiliation(s)
- David T Wood
- Department of Pharmacy Services, Omaha Veterans Affairs Medical Center, 4101 Woolworth Ave, Omaha, NE, 68105, USA.
| | - Nancee V Waterbury
- Department of Pharmacy Services, Iowa City Veterans Affairs Health Care System, 601 Highway 6 West, Iowa City, IA, 52246, USA
| | - Brian C Lund
- Department of Pharmacy Services, Iowa City Veterans Affairs Health Care System, 601 Highway 6 West, Iowa City, IA, 52246, USA
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, 601 Highway 6 West, Iowa City, IA, 52246, USA
| |
Collapse
|
30
|
Tu W, Li L, Yi M, Chen J, Wang X, Sun Y. Dapagliflozin attenuates high glucose-and hypoxia/reoxygenation-induced injury via activating AMPK/mTOR-OPA1-mediated mitochondrial autophagy in H9c2 cardiomyocytes. Arch Physiol Biochem 2023:1-11. [PMID: 37655809 DOI: 10.1080/13813455.2023.2252200] [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: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
This study investigated the protective effect of dapagliflozin on H9c2 cardiomyocyte function under high glucose and hypoxia/reoxygenation (HG-H/R) conditions and identified the underlying molecular mechanisms. Dapagliflozin reduced the level of lactate dehydrogenase and reactive oxygen species in cardiomyocytes under HG-H/R conditions and was accompanied by a decrease in caspase-3/9 activity. In addition, Dapagliflozin significantly reduced mitochondrial permeability transition pore opening and increased ATP content, accompanied by upregulation of OPA1 with autophagy-related protein molecules and activation of the AMPK/mTOR signalling pathway in HG-H/R treated cardiomyocytes. OPA1 knockdown or compound C treatment attenuated the protective effects of dapagliflozin on the cardiomyocytes under HG-H/R conditions. Downregulation of OPA1 expression increased mitochondrial intolerance in cardiomyocytes during HG-H/R injury and the AMPK-mTOR-autophagy signalling is a key mechanism for protecting mitochondrial function and reducing cardiomyocyte apoptosis. Collectively, dapagliflozin exerted protective effects on the cardiomyocytes under HG-H/R conditions. Dapagliflozin attenuated myocardial HG-H/R injury by activating AMPK/mTOR-OPA1-mediated mitochondrial autophagy.
Collapse
Affiliation(s)
- Weiling Tu
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, P.R. China
| | - Liang Li
- Department of Cardiology, Shenzhen Bao'an Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, P.R. China
| | - Ming Yi
- Department of Cardiology, The Second Affiliated Integrated Chinese and Western Medicine Hospital of Hunan University of Chinese Medicine, Liuyang Hospital of Traditional Chinese Medicine, Liuyang, P.R. China
| | - Junyu Chen
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, P.R. China
| | - Xiaoqing Wang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, P.R. China
| | - Yan Sun
- Department of Endocrinology, Southern University of Science and Technology Hospital, Shenzhen, P.R. China
| |
Collapse
|
31
|
Iyer N, Hussein S, Singareddy S, Sn VP, Jaramillo AP, Yasir M, Nath TS. Sotagliflozin vs Dapagliflozin: A Systematic Review Comparing Cardiovascular Mortality. Cureus 2023; 15:e45525. [PMID: 37868384 PMCID: PMC10585602 DOI: 10.7759/cureus.45525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
After the debut of the results of the effect of Sotagliflozin on Cardiovascular Events in Patients with Type 2 Diabetes Post Worsening Heart Failure (SOLOIST-WHF) and Sotagliflozin in Patients With Chronic Kidney Disease and Type 2 Diabetes (SCORED) trials at the American Heart Association's 2020 Scientific session, sotagliflozin became the first drug and the third sodium glucose co-transporter-2 (SGLT-2) inhibitor to be approved for heart failure (HF) across the spectrum of ejection fraction (EF). In light of this recent major U.S. Food and Drug Administration (FDA) approval of sotagliflozin, we conducted a systematic review to compare the cardiovascular mortality rates between sotagliflozin and dapagliflozin in patients with HF. To find relevant articles, we extensively searched major research literature databases and search engines such as PubMed, MEDLINE, PubMed Central, Google Scholar, Embase, and Cochrane Library. We compared the results of significant trials involving sotagliflozin with the trials studying dapagliflozin to provide comprehensive mortality results of both drugs. The results showed that the timely initiation of sotagliflozin in HF cases significantly reduces cardiovascular mortality, hospitalizations, and urgent HF visits. Comparative trials with dapagliflozin indicate enhanced mortality reduction associated with greater initial symptom burden. The results of these major trials cannot be overlooked due to the large size of the combined trials, the randomized design, and the high standards with which they were conducted. The pathophysiology behind the cardioprotection offered by these agents is complex and multifactorial, but it is believed that due to the diuretic-like function, SGLT-2 inhibitors reduce glycemic-related toxicity, promote ketogenesis, and exert antihypertrophic, antifibrotic, and anti-remodeling properties. The benefits of dapagliflozin on cardiovascular death and worsening HF in patients with mildly reduced or preserved EF appeared especially pronounced in those with a greater degree of symptomatic impairment at baseline. Sotagliflozin led to a rise in the count of days patients were alive and not hospitalized (DAOH), which offers an extra patient-centered measure to assess the impact of the disease burden. The data in our article will help future researchers conduct large-scale trials with sotagliflozin to identify and implement it in the treatment of patients with HF as a mortality-reducing drug and to improve the quality of life for patients with HF.
Collapse
Affiliation(s)
- Nandhini Iyer
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sally Hussein
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sanjana Singareddy
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vijay Prabhu Sn
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Arturo P Jaramillo
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohamed Yasir
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Tuheen Sankar Nath
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
32
|
Chen K, Nie Z, Shi R, Yu D, Wang Q, Shao F, Wu G, Wu Z, Chen T, Li C. Time to Benefit of Sodium-Glucose Cotransporter-2 Inhibitors Among Patients With Heart Failure. JAMA Netw Open 2023; 6:e2330754. [PMID: 37615988 PMCID: PMC10450563 DOI: 10.1001/jamanetworkopen.2023.30754] [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: 04/03/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023] Open
Abstract
Importance Emerging evidence has consistently demonstrated that sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of heart failure (HF) hospitalization and cardiovascular (CV) death among patients with HF. However, it remains unclear how long a patient needs to live to potentially benefit from SGLT2 inhibitors in this population. Objectives To estimate the time to benefit from SGLT2 inhibitors among patients with HF. Design, Setting, and Participants This comparative effectiveness study systematically searched PubMed for completed randomized clinical trials about SGLT2 inhibitors and patients with HF published until September 5, 2022; 5 trials with the year of publication ranging from 2019 to 2022 were eventually included. Statistical analysis was performed from April to October 2022. Intervention Addition of SGLT2 inhibitors or placebo to guideline-recommended therapy. Main Outcomes and Measures The primary outcome was the time to first event of CV death or worsening HF, which was broadly comparable across the included trials. Results Five trials consisting of 21 947 patients with HF (7837 [35.7%] were female; mean or median age older than 65 years within each trial) were included. SGLT2 inhibitors significantly reduced the risk of worsening HF or CV death (hazard ratio [HR], 0.77 [95% CI, 0.73-0.82]). Time to first nominal statistical significance (P < .05) was 26 days (0.86 months), and statistical significance was sustained from day 118 (3.93 months) onwards. A mean of 0.19 (95% CI, 0.12-0.35) months were needed to prevent 1 worsening HF or CV death per 500 patients with SGLT2 inhibitors (absolute risk reduction [ARR], 0.002). Likewise, 0.66 (95% CI, 0.43-1.13) months was estimated to avoid 1 event per 200 patients with SGLT2 inhibitors (ARR, 0.005), 1.74 (95% CI, 1.07-2.61) months to avoid 1 event per 100 patients (ARR, 0.010), and 4.96 (95% CI, 3.18-7.26) months to avoid 1 event per 50 patients (ARR, 0.020). Further analyses indicated a shorter time to benefit for HF hospitalization and among patients with diabetes or HF with reduced ejection fraction. Conclusions and Relevance In this comparative effectiveness research study of estimating the time to benefit from SGLT2 inhibitors among patients with HF, a rapid clinical benefit in reducing CV death or worsening HF was found, suggesting that their use may be beneficial for most individuals with HF.
Collapse
Affiliation(s)
- KangYu Chen
- Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zhiqiang Nie
- Guangdong Cardiovascular Institute, Global Health Research Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Rui Shi
- Heart Rhythm Centre, National Heart and Lung Institute, The Royal Brompton and Harefield National Health Service Foundation Trust, Imperial College London, London, United Kingdom
| | - Dahai Yu
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, United Kingdom
| | - Qi Wang
- Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Fang Shao
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Jiangsu, Nanjing, China
| | - Guohong Wu
- Department of Cardiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zhenqiang Wu
- Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand
| | - Tao Chen
- Center for Health Economics, University of York, York, United Kingdom
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Centre, Xi’an, China
| | - Chao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Xi’an Jiaotong University Health Science Centre, Xi’an, China
| |
Collapse
|
33
|
De Marzo V, Savarese G, Porto I, Metra M, Ameri P. Efficacy of SGLT2-inhibitors across different definitions of heart failure with preserved ejection fraction. J Cardiovasc Med (Hagerstown) 2023; 24:537-543. [PMID: 37409599 DOI: 10.2459/jcm.0000000000001504] [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: 07/07/2023]
Abstract
AIMS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been evaluated in phase 3 randomized-controlled trials (RCTs) that enrolled individuals with heart failure and preserved ejection fraction (HFpEF) based on detailed clinical, biochemical, and echocardiographic criteria (hereafter HF-RCTs), and in cardiovascular outcomes trials (CVOTs) in diabetic patients, in which the diagnosis of HFpEF relied on medical history. METHODS AND RESULTS We performed a study-level meta-analysis of the efficacy of SGLT2i across different definitions of HFpEF. Three HF-RCTs (EMPEROR-Preserved, DELIVER, and SOLOIST-WHF) and four CVOTs (EMPA-REG OUTCOME, DECLARE-TIMI 58, VERTIS-CV, and SCORED) were included, for a total of 14 034 patients. SGLT2i reduced the risk of cardiovascular death or heart failure hospitalization (HFH) in all RCTs pooled together [risk ratio 0.75, 95% confidence interval (95% CI) 0.63-0.89, NNT 19], in HF-RCTs (risk ratio 0.71, 95% CI 0.52-0.97, NNT 13), and in CVOTs (risk ratio 0.78, 95% CI 0.60-0.99, NNT 26). SGLT2i also decreased the risk of HFH in all RCTs (risk ratio 0.81, 95% CI 0.73-0.90, NNT 45), in HF-RCTs (risk ratio 0.81, 95% CI 0.72-0.93, NNT 37), and in CVOTs (risk ratio 0.78, 95% CI 0.61-0.99, NNT 46). By contrast, SGLT2i were not superior to placebo for cardiovascular death or all-cause death in all RCTs, HF-RCTs, or CVOTs. Results were comparable after excluding one RCT at a time. Meta-regression analysis confirmed that the type of RCT (HF-RCT vs. CVOT) did not influence the SGLT2i effect. CONCLUSIONS In RCTs, SGLT2i improved the outcomes of patients with HFpEF regardless of how the latter was diagnosed.
Collapse
Affiliation(s)
- Vincenzo De Marzo
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Italo Porto
- Department of Internal Medicine, University of Genova, Genova, Italy
- Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova
| | - Marco Metra
- Cardiology Unit, ASST Spedali Civili
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy
- Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova
| |
Collapse
|
34
|
Frąk W, Hajdys J, Radzioch E, Szlagor M, Młynarska E, Rysz J, Franczyk B. Cardiovascular Diseases: Therapeutic Potential of SGLT-2 Inhibitors. Biomedicines 2023; 11:2085. [PMID: 37509724 PMCID: PMC10377079 DOI: 10.3390/biomedicines11072085] [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: 05/28/2023] [Revised: 06/21/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Cardiovascular diseases (CVD) are a global health concern, affecting millions of patients worldwide and being the leading cause of global morbidity and mortality, thus creating a major public health concern. Sodium/glucose cotransporter 2 (SGLT2) inhibitors have emerged as a promising class of medications for managing CVD. Initially developed as antihyperglycemic agents for treating type 2 diabetes, these drugs have demonstrated significant cardiovascular benefits beyond glycemic control. In our paper, we discuss the role of empagliflozin, dapagliflozin, canagliflozin, ertugliflozin, and the relatively recently approved bexagliflozin, the class of SGLT-2 inhibitors, as potential therapeutic targets for cardiovascular diseases. All mentioned SGLT-2 inhibitors have demonstrated significant cardiovascular benefits and renal protection in clinical trials, in patients with or without type 2 diabetes. These novel therapeutic approaches aim to develop more effective treatments that improve patient outcomes and reduce the burden of these conditions. However, the major scientific achievements of recent years and the many new discoveries and mechanisms still require careful attention and additional studies.
Collapse
Affiliation(s)
- Weronika Frąk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| | - Joanna Hajdys
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| | - Ewa Radzioch
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| | - Magdalena Szlagor
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| | - Ewelina Młynarska
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Żeromskiego 113, 90-549 Łódź, Poland
| |
Collapse
|
35
|
Feng B, Yu P, Yu H, Qian B, Li Y, Sun K, Shi B, Zhang N, Xu G. Therapeutic effects on the development of heart failure with preserved ejection fraction by the sodium-glucose cotransporter 2 inhibitor dapagliflozin in type 2 diabetes. Diabetol Metab Syndr 2023; 15:141. [PMID: 37386620 DOI: 10.1186/s13098-023-01116-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a common disease with high morbidity and lacks effective treatment. We investigated the protective effects of the long-term application of the sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin on diabetes-associated HFpEF in a rat model. Serum proteomics and metabolomics analysis were also conducted in type 2 diabetic patients with HFpEF treated with dapagliflozin. METHODS Male Zucker diabetic fatty (ZDF) rats were used as a model of diabetic cardiomyopathy. From weeks 16 to 28, animals were given a vehicle or dapagliflozin (1 mg/kg) once daily. Primary blood biochemistry indices, echocardiography, histopathology, and cardiac hemodynamics were determined during the study period. The key markers of myocardial fibrosis, nitro-oxidative stress, inflammation, apoptosis, autophagy, and AMPK/mTOR signaling were examined. Additionally, healthy controls and individuals with type 2 diabetes were enrolled and 16 serum samples from 4 groups were randomly selected. Serum proteome and metabolome changes after dapagliflozin treatment were analyzed in diabetic individuals with HFpEF. RESULTS Dapagliflozin effectively prevented the development of HFpEF in rats with diabetes by mitigating nitro-oxidative stress, pro-inflammatory cytokines, myocardial hypertrophy, and fibrosis, reducing apoptosis, and restoring autophagy through AMPK activating and mTOR pathway repressing. Proteomics and metabolomics revealed that cholesterol and high-density lipoprotein particle metabolism, nicotinate and nicotinamide metabolism, arginine biosynthesis, and cAMP and peroxisome proliferator-activated receptor (PPAR) signaling are the major disturbed pathways in HFpEF patients treated with dapagliflozin. CONCLUSION Long-term treatment with dapagliflozin significantly prevented the development of HFpEF in diabetic rats. Dapagliflozin could be a promising therapeutic strategy in managing HFpEF individuals with type 2 diabetes.
Collapse
Affiliation(s)
- Bin Feng
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu, People's Republic of China
| | - Peiran Yu
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China
| | - Hao Yu
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China
| | - Buyun Qian
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China
| | - Yuan Li
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China
| | - Kangyun Sun
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China
| | - Bimin Shi
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu, People's Republic of China
| | - Nannan Zhang
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China.
| | - Guidong Xu
- Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, 215008, Jiangsu, People's Republic of China.
| |
Collapse
|
36
|
Usman MS, Siddiqi TJ, Anker SD, Bakris GL, Bhatt DL, Filippatos G, Fonarow GC, Greene SJ, Januzzi JL, Khan MS, Kosiborod MN, McGuire DK, Piña IL, Rosenstock J, Vaduganathan M, Verma S, Zieroth S, Butler J. Effect of SGLT2 Inhibitors on Cardiovascular Outcomes Across Various Patient Populations. J Am Coll Cardiol 2023; 81:2377-2387. [PMID: 37344038 DOI: 10.1016/j.jacc.2023.04.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND The effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors on heart failure (HF) outcomes and cardiovascular (CV) death in patients with varying combinations of type 2 diabetes mellitus (T2DM), HF, and chronic kidney disease (CKD) are uncertain. OBJECTIVES The authors conducted a meta-analysis assessing the effects of SGLT2 inhibitors on HF outcomes and CV death across different patient populations. METHODS Online databases were queried up to November 2022 for primary and secondary analyses of trials of SGLT2 inhibitors in patients with HF, T2DM, or CKD. Outcomes of interest were composite of first heart failure hospitalization (HFH) or CV death (first HFH/CV death), first HFH, and CV death. Data were pooled by means of a random-effects model to derive HRs and 95% CIs. RESULTS Thirteen trials (n = 90,413) were included. Compared with placebo, SGLT2 inhibitors reduced the risk of first HFH/CV death by 24% in HF (HR: 0.76; 95% CI: 0.72-0.81), 23% in T2DM (HR: 0.77; 95% CI: 0.73-0.81), and 23% in CKD (HR: 0.77; 95% CI: 0.72-0.82). The benefit was consistent in HF with reduced or preserved ejection fraction, HF with or without T2DM, and HF with or without CKD. The benefit was also consistent in T2DM with or without CKD, T2DM without HF, CKD without HF, and in patients with all 3 comorbidities. SGLT2 inhibitors significantly reduced CV death by 16% in HF, 15% in T2DM, and 12% in CKD. CONCLUSIONS SGLT2 inhibitors reduce HF events and CV death in cohorts of HF, T2DM and CKD, and these effects appear consistent in patients with varying combinations of these diseases.
Collapse
Affiliation(s)
- Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - George L Bakris
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, California, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA; Parkland Health and Hospital System, Dallas, Texas, USA
| | - Ileana L Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Muthiah Vaduganathan
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Departments of Surgery and Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Baylor Scott and White Health, Dallas, Texas, USA.
| |
Collapse
|
37
|
Zhou M, Huang D, Cheng Y, Lau YM, Lai WH, Lau YM, Hai J, Lau CP, Chan EW, Yue WS, Zuo ML, Yin LX, Feng Y, Tan N, Chen J, Li XL, Tse HF, Lee CH, Chow WS, Siu CW, Wong CK. Opportunistic screening for asymptomatic left ventricular dysfunction in type 2 diabetes mellitus. Postgrad Med J 2023; 99:476-483. [PMID: 37294724 DOI: 10.1136/postgradmedj-2022-141548] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND International guidelines recommend natriuretic peptide biomarker-based screening for patients at high heart failure (HF) risk to allow early detection. There have been few reports about the incorporation of screening procedure to existing clinical practice. OBJECTIVE To implement screening of left ventricular dysfunction in patients with type 2 diabetes mellitus (DM). METHOD A prospective screening study at the DM complication screening centre was performed. RESULTS Between 2018 and 2019, 1043 patients (age: 63.7±12.4 years; male: 56.3%) with mean glycated haemoglobin of 7.25%±1.34% were recruited. 81.8% patients had concomitant hypertension, 31.1% had coronary artery disease, 8.0% had previous stroke, 5.5% had peripheral artery disease and 30.7% had chronic kidney disease (CKD) stages 3-5. 43 patients (4.1%) had an elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration above the age-specific diagnostic thresholds for HF, and 43 patients (4.1%) had newly detected atrial fibrillation (AF). The prevalence of elevated NT-proBNP increased with age from 0.85% in patients aged <50 years to 7.14% in those aged 70-79 years and worsening kidney function from 0.43% in patients with CKD stage 1 to 42.86% in CKD stage 5. In multivariate logistic regression, male gender (OR: 3.67 (1.47-9.16), p = 0.005*), prior stroke (OR: 3.26 (1.38-7.69), p = 0.007*), CKD (p<0.001*) and newly detected AF (OR: 7.02 (2.65-18.57), p<0.001*) were significantly associated with elevated NT-proBNP. Among patients with elevated NT-proBNP, their mean left ventricular ejection fraction (LVEF) was 51.4%±14.7%, and 45% patients had an LVEF <50%. CONCLUSION NT-proBNP and ECG screening could be implemented with relative ease to facilitate early detection of cardiovascular complication and improve long-term outcomes.
Collapse
Affiliation(s)
- Mi Zhou
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Duo Huang
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Yangyang Cheng
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Yee Man Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Wing Hon Lai
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Yuk-Ming Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - JoJo Hai
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Chu Pak Lau
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
| | - Wen Sheng Yue
- Medical Imaging Key Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ming-Liang Zuo
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Li Xue Yin
- Department of Echocardiography & Non-invasive Cardiology Laboratory, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Yingqing Feng
- Department of Cardiology, Guangdong General Hospital, Guangzhou, China
| | - Ning Tan
- Department of Cardiology, Guangdong General Hospital, Guangzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong General Hospital, Guangzhou, China
| | - Xin Li Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Chi Ho Lee
- Endocrinology Division, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Wing-Sun Chow
- Endocrinology Division, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Chun Ka Wong
- Cardiology Division, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| |
Collapse
|
38
|
Karakasis P, Pamporis K, Stachteas P, Patoulias D, Bougioukas KI, Fragakis N. Efficacy and safety of sodium-glucose cotransporter-2 inhibitors in heart failure with mildly reduced or preserved ejection fraction: an overview of 36 systematic reviews. Heart Fail Rev 2023:10.1007/s10741-023-10324-3. [PMID: 37284930 DOI: 10.1007/s10741-023-10324-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
The recently published randomized trials (RCTs) evaluating the effect of Sodium-glucose cotransporter-2 inhibitors (SGLT2i) in heart failure with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) led researchers to perform a plethora of systematic reviews (SRs), often providing contradictory conclusions. This overview of reviews was aimed at summarizing the evidence of these SRs, quantifying the overlap, re-analyzing the evidence in case new studies that were identified, and mapping knowledge gaps. Literature search was conducted through Medline, Scopus, and Cochrane until March 22, 2023. Overall, 36 SRs synthesizing results from 18 RCTs were identified. A substantial overlap was identified among the SRs synthesizing large heart failure or cardiovascular outcome trials (CVOTs). Regarding the composite outcome of cardiovascular (CV) mortality or hospitalization for heart failure (HHF), all authors reported a significant favorable effect. A beneficial effect was also noted for CV and all-cause mortality, albeit not significant. Our meta-analysis demonstrated a significant improvement in health-related quality-of-life (HRQoL) as assessed by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS, MD = 1.97, p < 0.001), Total Symptom Score (KCCQ-TSS, MD = 2.29, p < 0.001), Clinical Summary Score (KCCQ-CSS, MD = 1.59, p < 0.001), and the 6-min walking distance (MD = 10.78 m, p = 0.032). Regarding safety, SGLT2i were associated with a significantly lower risk of serious adverse events compared to placebo (RR = 0.94, p = 0.002). The use of SGLT2i in HFpEF is both efficient and safe. Further research is required to clarify the impact of SGTL2i on different subphenotypes of HFpEF and the cardiorespiratory capacity of these patients.
Collapse
Affiliation(s)
- Paschalis Karakasis
- Second Cardiology Department, Medical School, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece.
| | - Konstantinos Pamporis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Panagiotis Stachteas
- Second Cardiology Department, Medical School, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Patoulias
- Second Cardiology Department, Medical School, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Second Department of Internal Medicine, European Interbalkan Medical Center, 57001, Thessaloniki, Greece
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, General Hospital Hippokration, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Nikolaos Fragakis
- Second Cardiology Department, Medical School, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
39
|
Auerbach JS, Gershengorn HB, Aljure OD, Lamelas J, Patel SS, Ferreira TD, Gonzalez LA, Cabrera JL. Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors. J Cardiothorac Vasc Anesth 2023; 37:956-963. [PMID: 36872114 DOI: 10.1053/j.jvca.2023.01.041] [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: 11/20/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVES To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery. DESIGN A retrospective study. SETTING At an academic university hospital. PARTICIPANTS Adult patients undergoing cardiac surgery. INTERVENTIONS SGLT2i use versus no SGLT2i use. MEASUREMENTS AND MAIN RESULTS The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p = 0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p = 0.22), 30-day mortality (1.9% v 0.7%, p = 0.31), or sternal infections (0.0% v 0.3%, p = 0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p = 0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p = 0.042). Mortality (0.0% v 2.2%, p = 0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare. CONCLUSIONS Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.
Collapse
Affiliation(s)
- Jonathan S Auerbach
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL.
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Oscar D Aljure
- Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL
| | - Joseph Lamelas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Samira S Patel
- Care Transformation, University of Miami Hospital and Clinics, Miami, FL
| | - Tanira D Ferreira
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Lazaro A Gonzalez
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jorge L Cabrera
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| |
Collapse
|
40
|
Li R, Dai G, Guan H, Gao W, Ren L, Wang X, Qu H. Scientific evidence of sodium-glucose cotransporter-2 inhibitors for heart failure with preserved ejection fraction: an umbrella review of systematic reviews and meta-analyses. Front Cardiovasc Med 2023; 10:1143658. [PMID: 37252111 PMCID: PMC10213331 DOI: 10.3389/fcvm.2023.1143658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/02/2023] [Indexed: 05/31/2023] Open
Abstract
Background It remains controversial whether sodium-glucose cotransporter-2 inhibitors (SGLT-2is) are effective in treating heart failure with preserved ejection fraction (HFpEF). Purpose The objective of this umbrella review is to provide a summary of the available evidence regarding the efficacy and safety of SGLT-2is for the treatment of HFpEF. Methods We extracted pertinent systematic reviews and meta-analyses (SRs/MAs) from PubMed, EMBASE, and the Cochrane Library that were published between the inception of the database and December 31, 2022. Two independent investigators assessed the methodological quality, risk of bias, report quality, and evidence quality of the included SRs/MAs in randomized controlled trials (RCTs). We further evaluated the overlap of the included RCTs by calculating the corrected covered area (CCA) and assessed the reliability of the effect size by performing excess significance tests. Additionally, the effect sizes of the outcomes were repooled to obtain objective and updated conclusions. Egger's test and sensitivity analysis were used to clarify the stability and reliability of the updated conclusion. Results This umbrella review included 15 SRs/MAs, and their methodological quality, risk of bias, report quality, and evidence quality were unsatisfactory. The total CCA for 15 SRs/MAs was 23.53%, indicating a very high level of overlap. The excess significance tests did not reveal any significant results. Our updated MA demonstrated that the incidence of the composite of hospitalization for heart failure (HHF) or cardiovascular death (CVD), first HHF, total HHF, and adverse events as well as the Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) and 6 min-walk distance (6MWD) were all substantially improved in the SGLT-2i intervention group compared to the control group. However, there was limited evidence that SGLT-2is could improve CVD, all-cause death, plasma B-type natriuretic peptide (BNP) level, or plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) level. Egger's test and sensitivity analysis proved that the conclusion was stable and reliable. Conclusions SGLT-2 is a potential treatment for HFpEF with favourable safety. Given the dubious methodological quality, reporting quality, evidence quality, and high risk of bias for certain included SRs/MAs, this conclusion must be drawn with caution. Systematic Review Registration https://inplasy.com/, doi: 10.37766/inplasy2022.12.0083, identifier INPLASY2022120083.
Collapse
Affiliation(s)
- Runmin Li
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Guohua Dai
- Department of Geriatrics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hui Guan
- Department of Geriatrics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Wulin Gao
- Department of Geriatrics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Lili Ren
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xingmeng Wang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Huiwen Qu
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| |
Collapse
|
41
|
Ismayl M, Abbasi MA, Al-Abcha A, El-Am E, Lundgren S, Goldsweig AM, Anavekar NS. Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure With Mildly Reduced or Preserved Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Curr Probl Cardiol 2023; 48:101597. [PMID: 36681210 DOI: 10.1016/j.cpcardiol.2023.101597] [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: 01/05/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk of heart failure (HF) hospitalizations and cardiovascular mortality among patients with HF and left ventricular ejection fraction (LVEF) ≤40%. There is emerging evidence of the benefits of SGLT2i in HF patients with a higher LVEF (>40%). We aimed to evaluate the benefits of SGLT2i in different subgroups of patients with HF and LVEF >40%. METHODS We searched PubMed, EMBASE, clinicaltrials.gov, Cochrane, and Google Scholar for randomized controlled trials (RCTs) comparing outcomes of SGLT2i vs placebo in patients with HF and LVEF >40%. The hazard ratios (HRs) and 95% confidence intervals (CIs) in each study were used for the meta-analysis. The primary composite outcome (PCO) was HF hospitalization or cardiovascular mortality. Secondary outcomes included HF hospitalization, cardiovascular mortality, and all-cause mortality. RESULTS Six RCTs with 15,989 patients were included (median follow-up = 27.3 months, 40.8% females). In patients with HF and LVEF >40%, SGLT2i were associated with significantly lower PCO compared to placebo (HR 0.80; 95% CI 0.74-0.86; P < 0.001). This was consistent across 10 of 13 subgroups examined, including LVEF. SGLT2i also reduced HF hospitalization but not cardiovascular or all-cause mortality. Patients <65 years old, from racial minorities, or from Asia receiving SGLT2i did not demonstrate a significant reduction in PCO. CONCLUSIONS SGLT2i significantly reduce the combined risk of HF hospitalization or cardiovascular mortality among patients with HF and LVEF >40%. However, younger patients, racial minorities, and patients from Asia did not demonstrate such a reduction. Further research is necessary to identify the reasons for such disparities.
Collapse
Affiliation(s)
- Mahmoud Ismayl
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE.
| | | | | | - Edward El-Am
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Scott Lundgren
- Department of Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Andrew M Goldsweig
- Department of Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | | |
Collapse
|
42
|
Di Fusco SA, Spinelli A, Aquilani S, Borrelli N, Iannopollo G, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. Italian Association of Hospital Cardiologists practical guidance for sodium-glucose cotransporter 2 inhibitors use in patients with heart failure. Eur Heart J Suppl 2023; 25:D287-D293. [PMID: 37213801 PMCID: PMC10194818 DOI: 10.1093/eurheartjsupp/suad107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2-is) have recently been included among the first-line drugs for the treatment of heart failure with reduced ejection fraction. International guidelines recommend SGLT2-i use in association with neuro-hormonal modulators (renin-angiotensin blockers, beta blockers, and aldosterone antagonists). Although SGLT2-is are well tolerated, it is important to know potential side effects and conditions that may lead to an increased risk of adverse events in order to maximize clinical benefits. The aim of this Italian Association of Hospital Cardiologists document is to briefly report clinical evidence that supports SGLT2-i use in patients with heart failure and provide practical indications for clinical implementation.
Collapse
Affiliation(s)
| | - Antonella Spinelli
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, PO San Filippo Neri, via Martinotti 20, Rome 00135, Italy
| | - Stefano Aquilani
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, PO San Filippo Neri, via Martinotti 20, Rome 00135, Italy
| | - Nunzia Borrelli
- Unità di Malattie Cardiache Congenite dell’Adulto, AORN dei Colli—Ospedale Monaldi, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Gianmarco Iannopollo
- UOC Cardiologia, Ospedale Maggiore Carlo Alberto Pizzardi, Largo Bartolo Nigrisoli 2, 40133 Bologna, Italy
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Via Palermo 636, 95122 Catania, Italy
| | - Domenico Gabrielli
- U.O.C. Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
- Fondazione per il Tuo cuore—Heart Care Foundation, VIA Alfonso La Marmora 36 - 50121 Florence, Italy
| | - Fabrizio Oliva
- Unità di Cure Intensive Cardiologiche, Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3 - 20162 Milan, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, PO San Filippo Neri, via Martinotti 20, Rome 00135, Italy
| |
Collapse
|
43
|
Hsu CN, Hsuan CF, Liao D, Chang JKJ, Chang AJW, Hee SW, Lee HL, Teng SIF. Anti-Diabetic Therapy and Heart Failure: Recent Advances in Clinical Evidence and Molecular Mechanism. Life (Basel) 2023; 13:1024. [PMID: 37109553 PMCID: PMC10144651 DOI: 10.3390/life13041024] [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: 02/09/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Diabetic patients have a two- to four-fold increase in the risk of heart failure (HF), and the co-existence of diabetes and HF is associated with poor prognosis. In randomized clinical trials (RCTs), compelling evidence has demonstrated the beneficial effects of sodium-glucose co-transporter-2 inhibitors on HF. The mechanism includes increased glucosuria, restored tubular glomerular feedback with attenuated renin-angiotensin II-aldosterone activation, improved energy utilization, decreased sympathetic tone, improved mitochondria calcium homeostasis, enhanced autophagy, and reduced cardiac inflammation, oxidative stress, and fibrosis. The RCTs demonstrated a neutral effect of the glucagon-like peptide receptor agonist on HF despite its weight-reducing effect, probably due to it possibly increasing the heart rate via increasing cyclic adenosine monophosphate (cAMP). Observational studies supported the markedly beneficial effects of bariatric and metabolic surgery on HF despite no current supporting evidence from RCTs. Bromocriptine can be used to treat peripartum cardiomyopathy by reducing the harmful cleaved prolactin fragments during late pregnancy. Preclinical studies suggest the possible beneficial effect of imeglimin on HF through improving mitochondrial function, but further clinical evidence is needed. Although abundant preclinical and observational studies support the beneficial effects of metformin on HF, there is limited evidence from RCTs. Thiazolidinediones increase the risk of hospitalized HF through increasing renal tubular sodium reabsorption mediated via both the genomic and non-genomic action of PPARγ. RCTs suggest that dipeptidyl peptidase-4 inhibitors, including saxagliptin and possibly alogliptin, may increase the risk of hospitalized HF, probably owing to increased circulating vasoactive peptides, which impair endothelial function, activate sympathetic tones, and cause cardiac remodeling. Observational studies and RCTs have demonstrated the neutral effects of insulin, sulfonylureas, an alpha-glucosidase inhibitor, and lifestyle interventions on HF in diabetic patients.
Collapse
Affiliation(s)
- Chih-Neng Hsu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
| | - Chin-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung 824, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 840, Taiwan
| | - Daniel Liao
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Jack Keng-Jui Chang
- Biological Programs for Younger Scholar, Academia Sinica, Taipei 115, Taiwan
| | - Allen Jiun-Wei Chang
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Siow-Wey Hee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Hsiao-Lin Lee
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Sean I. F. Teng
- Department of Cardiology, Ming-Sheng General Hospital, Taoyuan 330, Taiwan
| |
Collapse
|
44
|
Sephien A, Ghobrial M, Reljic T, Prida X, Nerella N, Kumar A. Efficacy of SGLT2 inhibitors in patients with heart failure: An overview of systematic reviews. Int J Cardiol 2023; 377:79-85. [PMID: 36455697 DOI: 10.1016/j.ijcard.2022.11.052] [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: 10/09/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
AIMS Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to have benefit in patients with heart failure (HF). Multiple systematic reviews and meta-analyses (SRs and MAs) of randomized control trials (RCTs) comparing SGLT2i to placebo have been performed. However, there is uncertainty in the quality of the evidence and associated efficacy. We performed an overview of SRs and MAs of RCTs to summarize the evidence related to the efficacy of SGLT2i for the management of HF. METHODS AND RESULTS A comprehensive search of three databases (the Cochrane Library, EMBASE, and PubMed) was conducted until February 21, 2021. All SRs of RCTs evaluating the efficacy of SGLT2i in patients with HF were eligible for inclusion. The primary outcome was all-cause mortality. Methodological quality was evaluated using the AMSTAR-2 assessment tool. The overall quality of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. The initial search yielded 3431 references, of which, eight SRs and MAs met the inclusion criteria. The methodological quality ranged from critically low to high. The overall quality of evidence ranged from very low to moderate. Most of the SRs and MAs showed benefits in all-cause mortality, HF-related hospitalizations, and KCCQ score change. CONCLUSIONS SGLT2i are possibly beneficial in patients with HF, however, none of the SRs and MAs compared the efficacy between different types of SGLT2i. Furthermore, this paper emphasizes the need for consistent reproducible conduct and reporting of SRs to generate high-quality evidence and facilitate clinical decision-making.
Collapse
Affiliation(s)
- Andrew Sephien
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA.
| | - Mike Ghobrial
- Department of Internal Medicine, University of Florida-Jacksonville, Jacksonville, FL, USA
| | - Tea Reljic
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Xavier Prida
- Department of Cardiovascular Sciences, University of South Florida, Tampa, FL, USA
| | - Nishant Nerella
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA; Citrus Cardiology, Inverness, FL, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| |
Collapse
|
45
|
Ji P, Zhang Z, Yan Q, Cao H, Zhao Y, Yang B, Li J. The cardiovascular effects of SGLT2 inhibitors, RAS inhibitors, and ARN inhibitors in heart failure. ESC Heart Fail 2023; 10:1314-1325. [PMID: 36722326 PMCID: PMC10053170 DOI: 10.1002/ehf2.14298] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/26/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023] Open
Abstract
AIMS No studies have comprehensively compared the efficacy of sodium-glucose cotransporter-2 (SGLT2) inhibitors, renin-angiotensin system (RAS) inhibitors, and angiotensin receptor neprilysin (ARN) inhibitors based on different type of heart failure, including heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). The aim of this network meta-analysis was to evaluate the relative efficacy of SGLT2 inhibitor (SGLT2i), RAS inhibitor (RASi) and ARN inhibitor (ARNI) in different types of heart failure. METHODS A systemic literature search was performed from inception to 19 November 2022 for randomized control trials assessing the risk of cardiovascular (CV) death or hospitalization for heart failure (HHF) of these drugs in HF. A network meta-analysis was performed. Risk ratio (RR) with 95% confidence intervals (CI) were synthesized. RESULTS Seventeen studies were selected with a total of 61 489 patients. In patients with HFrEF, ARNI led to a reduced risk of a composite outcome of CV death or HHF when compared with placebo (RR = 0.83, 95% CI 0.77-0.89). Similar trends were observed when focusing on the outcome of CV death or HHF alone. In patients with HFpEF, SGLT2i showed the beneficial effects on the CV death or HHF events when compared with placebo and RASi (RR = 0.82, 95% CI 0.74-0.92; RR = 1.16, 95% CI 1.02-1.31). For CV death, all these three drugs could not show beneficial effects in HFpEF. For the incidence of HHF in HFpEF, both SGLT2i and ARNI demonstrated the beneficial effects but SGLT2i was superior to ARNI. There were no differences in the events of discontinuation under these drugs when compared with placebo or each other in either HFrEF or HFpEF patients. SGLT2i showed the least renal injury among these interventions in HFrEF and there were no differences in the incidence of renal injury of these interventions in HFpEF. CONCLUSIONS Among these drugs, ARNI showed the greatest ability to lower the incidence of CV death or HHF and SGLT2i exerted the least renal injury in patients with HFrEF. In patients with HFpEF, SGLT2i was associated with a reduction in the risk of CV death or HHF. There were no differences in the incidence of renal injury of these interventions in HFpEF. The intolerance of these drugs were comparable in both HFrEF and HFpEF.
Collapse
Affiliation(s)
- Peng‐juan Ji
- Department of CardiologyShan Xi Medical University Second Hospital, Shan Xi Medical UniversityTai YuanShan XiChina
| | - Zhuo‐ya Zhang
- Department of Biochemistry and Molecular BiologySchool of Basic Medicine, Shan Xi Medical UniversityTai YuanShan XiChina
| | - Qi Yan
- Department of Endocrinology and MetabolismShan Xi Medical University Second Hospital, Shan Xi Medical UniversityTai YuanShan XiChina
| | - Hui‐li Cao
- Department of CardiologyShan Xi Medical University Second Hospital, Shan Xi Medical UniversityTai YuanShan XiChina
| | - Ya‐jing Zhao
- Department of CardiologyShan Xi Medical University Second Hospital, Shan Xi Medical UniversityTai YuanShan XiChina
| | - Bin Yang
- Department of CardiologyShan Xi Medical University Second Hospital, Shan Xi Medical UniversityTai YuanShan XiChina
| | - Jin Li
- Department of Endocrinology and MetabolismShan Xi Medical University Second Hospital, Shan Xi Medical UniversityTai YuanShan XiChina
| |
Collapse
|
46
|
Ji L, Mishra M, De Geest B. The Role of Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure Management: The Continuing Challenge of Clinical Outcome Endpoints in Heart Failure Trials. Pharmaceutics 2023; 15:1092. [PMID: 37111578 PMCID: PMC10140883 DOI: 10.3390/pharmaceutics15041092] [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: 02/22/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors in the management of heart failure with preserved ejection fraction (HFpEF) may be regarded as the first effective treatment in these patients. However, this proposition must be evaluated from the perspective of the complexity of clinical outcome endpoints in heart failure. The major goals of heart failure treatment have been categorized as: (1) reduction in (cardiovascular) mortality, (2) prevention of recurrent hospitalizations due to worsening heart failure, and (3) improvement in clinical status, functional capacity, and quality of life. The use of the composite primary endpoint of cardiovascular death and hospitalization for heart failure in SGLT2 inhibitor HFpEF trials flowed from the assumption that hospitalization for heart failure is a proxy for subsequent cardiovascular death. The use of this composite endpoint was not justified since the effect of the intervention on both components was clearly distinct. Moreover, the lack of convincing and clinically meaningful effects of SGLT2 inhibitors on metrics of heart failure-related health status indicates that the effect of this class of drugs in HFpEF patients is essentially restricted to an effect on hospitalization for heart failure. In conclusion, SGLT2 inhibitors do not represent a substantial breakthrough in the management of HFpEF.
Collapse
Affiliation(s)
| | | | - Bart De Geest
- Centre for Molecular and Vascular Biology, Catholic University of Leuven, 3000 Leuven, Belgium; (L.J.); (M.M.)
| |
Collapse
|
47
|
Aziri B, Begic E, Jankovic S, Mladenovic Z, Stanetic B, Kovacevic‐Preradovic T, Iglica A, Mujakovic A. Systematic review of sodium‐glucose cotransporter 2 inhibitors: a hopeful prospect in tackling heart failure‐related events. ESC Heart Fail 2023; 10:1499-1530. [PMID: 36967133 DOI: 10.1002/ehf2.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/13/2023] [Accepted: 02/16/2023] [Indexed: 03/28/2023] Open
Abstract
In modern cardiology, sodium-glucose cotransporter 2 (SGLT2) inhibitors are critical components of heart failure (HF) treatment algorithms and exert their effects primarily by preventing glucose reabsorption and facilitating its urinary excretion. The objective was to systematically review randomized controlled trials (RCTs) assessing the effects of SGLT2 inhibitors, particularly canagliflozin, empagliflozin, dapagliflozin, ertugliflozin, sotagliflozin (dual SGLT inhibitor), and their use in HF. Systematic searches of PubMed/Medline, The Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases were performed. There were no restrictions imposed on the date and status of publication; however, there were restrictions on language for the searched studies. A total of 1139 records were identified in the bibliographic searches from both databases and the register of choice for this systematic review. Following duplicate removal, screening for titles and abstracts, and thorough assessment of full-text articles, 12 RCTs met the inclusion criteria. Altogether, 83 878 patients were included in this review. Among the included studies, two RCTs, with six respective reports, investigated canagliflozin, four RCTs with 13 derived reports investigated dapagliflozin, three RCTs with 12 separate reports studied the effects of empagliflozin, one RCT and its three respective reports assessed ertugliflozin's effects, and two RCTs with one added report investigated the dual inhibitor sotagliflozin. Pooled meta-analytic effects of SGLT2 inhibitors were as follows: on atrial fibrillation odds ratio (OR) = 0.83, 95% confidence interval (CI): 0.68-1.01, prediction interval (PI): 0.57-1.19; on HF hospitalization OR = 0.69, 95% CI: 0.60-0.78, PI: 0.60-0.78; on cardiovascular death OR = 0.82, 95% CI: 0.58-1.15, PI: 0.42-1.60; and on major adverse cardiovascular events OR = 0.90, 95% CI: 0.77-1.06, PI: 0.71-1.15. SGLT2 inhibitors significantly improve the quality of life in HF patients. Their beneficial effects on HF, especially in left ventricular dysfunction, have made their use possible irrespective of diabetes mellitus or atrial fibrillation status.
Collapse
|
48
|
Banerjee M, Pal R, Nair K, Mukhopadhyay S. SGLT2 inhibitors and cardiovascular outcomes in heart failure with mildly reduced and preserved ejection fraction: A systematic review and meta-analysis. Indian Heart J 2023; 75:122-127. [PMID: 36914068 PMCID: PMC10123444 DOI: 10.1016/j.ihj.2023.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/10/2023] [Accepted: 03/09/2023] [Indexed: 03/13/2023] Open
Abstract
AIM To provide a pooled effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on cardiovascular outcomes in patients with heart failure with preserved ejection fraction (HFpEF: ≥50%) or/and mildly reduced EF (HFmrEF: 41-49%) regardless of baseline diabetes. METHODS We systemically searched PubMed/MEDLINE, Embase, Web of Science databases and clinical trial registries using appropriate keywords till August 28, 2022, to identify randomized controlled trials (RCTs) or post-hoc analysis of RCTs, reporting cardiovascular death (CVD) and/or urgent visits/hospitalization for heart failure(HHF) in patients with HFmrEF/HFpEF receiving SGLTi vs. placebo. Hazard ratios (HR) with 95% confidence intervals (CI) for outcomes were pooled together using generic inverse variance method with fixed-effects model. RESULTS We identified six RCTs, pooling data retrieved from 15,769 patients with HFmrEF/HFpEF. Pooled analysis showed that compared to placebo, SGLT2i use was significantly associated with improved CVD/HHF outcomes in HFmrEF/HFpEF (pooled HR 0.80, 95% CI: 0.74, 0.86, p < 0.001, I2 = 0%). When separately analyzed, benefits of SGLT2i remained significant across HFpEF (N = 8891, HR 0.79, 95% CI: 0.71, 0.87, p < 0.001, I2 = 0%) and HFmrEF (N = 4555, HR 0.77, 95% CI: 0.67, 0.89, p < 0.001, I2 = 40%). Consistent benefits were observed also in HFmrEF/HFpEF subgroup without baseline diabetes (N = 6507, HR 0.80, 95% CI: 0.70, 0.91, p < 0.001, I2 = 0%). Sensitivity analysis including the DELIVER and EMPEROR-Preserved trials found a trend towards significant beneficial effects on CV deaths with no heterogeneity (HR 0.90, 95% CI: 0.79, 1.02, p = 0.08, I2 = 0%). CONCLUSIONS This meta-analysis established the place of SGLT2i as a foundational therapy among patients with HF with preserved and mildly reduced EF regardless of diabetes.
Collapse
Affiliation(s)
- Mainak Banerjee
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India.
| | - Rimesh Pal
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kirthana Nair
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology, Institute of Postgraduate Medical Education and Research, Kolkata, 700020, India.
| |
Collapse
|
49
|
Gitto M, Villaschi A, Federici M, Condorelli G, Stefanini GG. The emerging role of sodium-glucose cotransporter 2 inhibitors in heart failure. Curr Pharm Des 2023; 29:CPD-EPUB-129586. [PMID: 36799420 DOI: 10.2174/1381612829666230217143324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/24/2022] [Accepted: 12/30/2022] [Indexed: 02/18/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively novel drug class that most cardiologists are becoming familiar with. By contrasting glucose reabsorption in the proximal convoluted tubule of the nephron, SGLT2 inhibition results in glycosuria with improved glycemic control. Although originally introduced as anti-diabetic medications, the cardiovascular effects of SGLT2i have progressively emerged, leading them to become one of the four pillars for the treatment of heart failure with reduced ejection fraction (HFrEF) according to the 2021 guidelines from the European Society of Cardiology. Also, two recent randomized trials have demonstrated SGLT2i as the first compound with proven prognostic impact in heart failure with preserved ejection fraction (HFpEF), setting a milestone in the treatment for this condition. While the exact pathogenic mechanisms mediating the substantial reduction in cardiovascular death and heart failure (HF) hospitalizations are still controversial, there is growing clinical evidence on the efficacy and safety of SGLT2i in various subsets of patients with HF. As known, heart failure is a complex and heterogeneous clinical syndrome with a magnitude of phenotypes and a variety of underlying hemodynamic and physiological aspects which cannot be fully incorporated into the traditional left ventricular ejection fraction based classification adopted in clinical trials. The aim of this review is to provide an overview of the cardiovascular benefits and indications of SGLT2i across different HF patterns and to highlight current gaps in knowledge that should be addressed by future research.
Collapse
Affiliation(s)
- Mauro Gitto
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Center for Atherosclerosis, Policlinico Tor Vergata, Rome, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| |
Collapse
|
50
|
Treewaree S, Kulthamrongsri N, Owattanapanich W, Krittayaphong R. Is it time for class I recommendation for sodium-glucose cotransporter-2 inhibitors in heart failure with mildly reduced or preserved ejection fraction?: An updated systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1046194. [PMID: 36824458 PMCID: PMC9941559 DOI: 10.3389/fcvm.2023.1046194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
Background In heart failure with reduced ejection fraction (HFrEF), sodium-glucose cotransporter-2 (SGLT2) inhibitors were demonstrated to lower cardiovascular mortality (CV death) and hospitalization for heart failure (HHF); however, the advantages of SGLT2 inhibitors in heart failure with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) are less clear. SGLT2 inhibitors were reported to enhance quality of life (QoL) in HFmrEF or HFpEF patients; however, the findings among studies are inconsistent. Objective To conduct an updated systematic review and meta-analysis of recent data to assess the effect of SGLT2 inhibitors on cardiovascular outcomes and QoL in patients with HFmrEF or HFpEF. Method Three databases were searched for studies that evaluated SGLT2 inhibitors and their effect on cardiovascular outcomes, including CV death, HHF, all-cause death, and the composite outcome of CV death, HHF, and urgent visit for heart failure (HF), and patient QoL (Kansas City Cardiomyopathy Questionnaire [KCCQ] score compared to baseline, and increase in KCCQ score ≥ 5 points) that were published during January 2000-August 2022. The meta-analysis was performed using the inverse variance method and random-effects model. INPLASY registration: INPLASY202290023. Results Sixteen studies (9 recent RCTs) were included, and a total of 16,710 HFmrEF or HFpEF patients were enrolled. SGLT2 inhibitors significantly reduced composite cardiovascular outcome (CV death/HHF/urgent visit for HF; pooled hazard ratio [HR]: 0.80, 95% confidence interval [95%CI]: 0.74-0.86) and HHF alone (HR: 0.74, 95%CI: 0.67-0.82), but there was no significant reduction in CV death alone (HR: 0.93, 95%CI: 0.82-1.05). Benefit of SGLT2 inhibitors for decreasing CV death/HHF was observed across all subgroups, including left ventricular ejection fraction (LVEF) range, diabetes status, New York Heart Association functional class, and baseline renal function. For total HHF, SGLT2 inhibitors conferred benefit in both LVEF 50-60% (HR: 0.64, 95%CI: 0.54-0.76), and LVEF >60% (HR: 0.84, 95%CI: 0.71-0.98). Significant change was observed in the KCCQ-clinical summary score compared to baseline (mean difference: 1.33, 95%CI: 1.31-1.35), and meaningful improvement in QoL was shown across all 3 types of increase in KCCQ score ≥ 5 points. Conclusion This study demonstrates the benefits of SGLT2 inhibitors for improving cardiovascular outcomes and QoL in HFmrEF or HFpEF patients.
Collapse
Affiliation(s)
- Sukrit Treewaree
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Narathorn Kulthamrongsri
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|