1
|
Biegus J, Voors AA, Collins SP, Kosiborod MN, Teerlink JR, Angermann CE, Tromp J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Salsali A, Blatchford JP, Ponikowski P. Impact of empagliflozin on decongestion in acute heart failure: the EMPULSE trial. Eur Heart J 2023; 44:41-50. [PMID: 36254693 PMCID: PMC9805406 DOI: 10.1093/eurheartj/ehac530] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS Effective and safe decongestion remains a major goal for optimal management of patients with acute heart failure (AHF). The effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on decongestion-related endpoints in the EMPULSE trial (NCT0415775) were evaluated. METHODS AND RESULTS A total of 530 patients hospitalized for AHF were randomized 1:1 to either empagliflozin 10 mg once daily or placebo for 90 days. The outcomes investigated were: weight loss (WL), WL adjusted for mean daily loop diuretic dose (WL-adjusted), area under the curve of change from baseline in N-terminal pro-B-type natriuretic peptide levels, hemoconcentration, and clinical congestion score after 15, 30, and 90 days of treatment. Compared with placebo, patients treated with empagliflozin demonstrated significantly greater reductions in all studied markers of decongestion at all time-points, adjusted mean differences (95% confidence interval) at Days 15, 30, and 90 were: for WL -1.97 (-2.86, -1.08), -1.74 (-2.73, -0.74); -1.53 (-2.75, -0.31) kg; for WL-adjusted: -2.31 (-3.77, -0.85), -2.79 (-5.03, -0.54), -3.18 (-6.08, -0.28) kg/40 mg furosemide i.v. or equivalent; respectively (all P < 0.05). Greater WL at Day 15 (i.e. above the median WL in the entire population) was associated with significantly higher probability for clinical benefit at Day 90 (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in Kansas City Cardiomyopathy Questionnaire total symptom score change from baseline to 90 days) with the win ratio of 1.75 (95% confidence interval 1.37, 2.23; P < 0.0001). CONCLUSION Initiation of empagliflozin in patients hospitalized for AHF resulted in an early, effective and sustained decongestion which was associated with clinical benefit at Day 90.
Collapse
Affiliation(s)
- Jan Biegus
- Corresponding author. Tel: +48 71 733 11 12,
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O Box 30001, 9700 RB Groningen, HPC AB 31, The Netherlands
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
- The George Institute for Global Health and the University of New South Wales, Sydney, New South Wales, Australia
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, 4150 Clement Street San Francisco, CA 94121, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Am Schwarzenberg 15, Haus A15 97078 Würzburg, Germany
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore; 12 Science Drive 2, #10-01, Singapore 117549
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- UnIC@RISE, Department of Surgery and Physiology, Cardiovascular Research and Development Center, University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, 3300 Gallows Road Falls Church, Virginia 22042, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Binger Straße 173, 55216 Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Afshin Salsali
- Novo Nordisk pharmaceutical company, Vandtårnsvej 110, 2860 Søborg, Copenhagen, Denmark
- Faculty of Medicine, Rutgers University, New Brunswick, NJ, 125 Paterson street, New Brunswick, NJ 08901, USA
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Sky Tower, Borsigstr. 4, D-74321 Bietigheim-Bissingen, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wroclaw 50-556, Poland
| |
Collapse
|
2
|
Voors AA, Damman K, Teerlink JR, Angermann CE, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. Renal effects of empagliflozin in patients hospitalized for acute heart failure: from the EMPULSE trial. Eur J Heart Fail 2022; 24:1844-1852. [PMID: 36066557 PMCID: PMC9828037 DOI: 10.1002/ejhf.2681] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 01/12/2023] Open
Abstract
AIM The sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin improved clinical outcomes in patients hospitalized for acute heart failure. In patients with chronic heart failure, SGLT2 inhibitors cause an early decline in estimated glomerular filtration rate (eGFR) followed by a slower eGFR decline over time than placebo. However, the effects of SGLT2 inhibitors on renal function during a hospital admission for acute heart failure remain largely unknown. METHODS AND RESULTS Between 1 and 5 days after a hospitalization for acute heart failure, 530 patients with an eGFR >20 ml/min/1.73 m2 were randomized to 10 mg of empagliflozin or placebo and treated for 90 days. Renal function and electrolytes were measured at baseline, and after 15, 30 and 90 days. We evaluated the effect of empagliflozin on eGFR over time and the impact of baseline eGFR on the primary hierarchical outcome of death, worsening heart failure events and quality of life. Mean baseline eGFR was 52.4 ml/min/1.73 m2 in the empagliflozin group and 55.7 ml/min/1.73 m2 in the placebo group. Empagliflozin caused an initial decline in eGFR (-2 ml/min/1.73 m2 at day 15 compared to placebo). At day 90, eGFR was similar between empagliflozin and placebo. Investigator-reported acute renal failure occurred in 7.7% of empagliflozin versus 12.1% of placebo patients. The overall clinical benefit (hierarchical composite of all-cause death, heart failure events and quality of life) of empagliflozin was unaffected by baseline eGFR. CONCLUSION In patients hospitalized for acute heart failure, empagliflozin caused an early modest decline in renal function which was no longer evident after 90 days. Acute renal events were similar in both groups. The clinical benefit of empagliflozin was consistent regardless of baseline renal function.
Collapse
Affiliation(s)
- Adriaan A. Voors
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Christiane E. Angermann
- Comprehensive Heart Failure CentreUniversity & University Hospital of WürzburgWürzburgGermany
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical CareTennessee Valley Healthcare Facility VA Medical CenterNashvilleTNUSA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMSUSA,The George Institute for Global Health and The University of New South WalesSydneyNSWAustralia
| | - Jan Biegus
- Institute of Heart DiseasesMedical UniversityWroclawPoland
| | - João Pedro Ferreira
- Inserm INI‐CRCT, CHRUUniversité de LorraineNancyFrance,Cardiovascular Research and Development Center, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
| | - Michael E. Nassif
- Saint Luke's Mid America Heart Institute and the University of MissouriKansas CityMSUSA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public HealthNational University of Singapore, and the National University Health SystemSingapore
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbHIngelheimGermany,First Department of Medicine faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc.RidgefieldCTUSA,Faculty of MedicineRutgers UniversityNew BrunswickNJUSA
| | | | | |
Collapse
|
3
|
Pocock SJ, Ferreira JP, Packer M, Zannad F, Filippatos G, Kondo T, McMurray JJ, Solomon SD, Januzzi JL, Iwata T, Salsali A, Butler J, Anker SD. Biomarker-driven prognostic models in chronic heart failure with preserved ejection fraction: the EMPEROR-Preserved trial. Eur J Heart Fail 2022; 24:1869-1878. [PMID: 35796209 PMCID: PMC9796853 DOI: 10.1002/ejhf.2607] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS Biomarker-driven prognostic models incorporating N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) in heart failure (HF) with preserved ejection fraction (HFpEF) are lacking. We aimed to generate a biomarker-driven prognostic tool for patients with chronic HFpEF enrolled in EMPEROR-Preserved. METHODS AND RESULTS Multivariable Cox regression models were created for (i) the primary composite outcome of HF hospitalization or cardiovascular death, (ii) all-cause death, (iii) cardiovascular death, and (iv) HF hospitalization. PARAGON-HF was used as a validation cohort. NT-proBNP and hs-cTnT were the dominant predictors of the primary outcome, and in addition, a shorter time since last hospitalization, New York Heart Association (NYHA) class III or IV, history of chronic obstructive pulmonary disease (COPD), insulin-treated diabetes, low haemoglobin, and a longer time since HF diagnosis were key predictors (eight variables, all p < 0.001). The consequent primary outcome risk score discriminated well (c-statistic = 0.75) with patients in the top 10th of risk having an event rate >22× higher than those in the bottom 10th. A model for HF hospitalization alone had even better discrimination (c = 0.79). Empagliflozin reduced the risk of cardiovascular death or hospitalization for HF in patients across all risk levels. NT-proBNP and hs-cTnT were also the dominant predictors of all-cause and cardiovascular mortality followed by history of COPD, low albumin, older age, left ventricular ejection fraction ≥50%, NYHA class III or IV and insulin-treated diabetes (eight variables, all p < 0.001). The mortality risk model had similar discrimination for all-cause and cardiovascular mortality (c-statistic = 0.72 for both). External validation provided c-statistics of 0.71, 0.71, 0.72, and 0.72 for the primary outcome, HF hospitalization alone, all-cause death, and cardiovascular death, respectively. CONCLUSIONS The combination of NT-proBNP and hs-cTnT along with a few readily available clinical variables provides effective risk discrimination both for morbidity and mortality in patients with HFpEF. A predictive tool-kit facilitates the ready implementation of these risk models in routine clinical practice.
Collapse
Affiliation(s)
- Stuart J. Pocock
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
| | - João Pedro Ferreira
- UnIC@Rise, Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development CenterUniversity of PortoPortoPortugal,Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)Université de LorraineNancyFrance
| | - Milton Packer
- Baylor Heart and Vascular HospitalBaylor University Medical CenterDallasTXUSA,Imperial CollegeLondonUK
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)Université de LorraineNancyFrance
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of CardiologyAttikon University HospitalAthensGreece
| | - Toru Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan,British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | | | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Javed Butler
- Baylor Scott and White Research InstituteDallasTXUSA,Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Stefan D. Anker
- Department of Cardiology, and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site BerlinCharité UniversitätsmedizinBerlinGermany
| |
Collapse
|
4
|
Butler J, Shahzeb Khan M, Lindenfeld J, Abraham WT, Savarese G, Salsali A, Zeller C, Peil B, Filippatos G, Ponikowski P, Anker SD. Minimally Clinically Important Difference in Health Status Scores in Patients With HFrEF vs HFpEF. JACC Heart Fail 2022; 10:651-661. [PMID: 35780032 DOI: 10.1016/j.jchf.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/02/2022] [Accepted: 03/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Differences in clinically important thresholds in patient-reported outcomes measures such as the Kansas City Cardiomyopathy Questionnaire (KCCQ) remain less well-established in patients with heart failure with preserved ejection fraction (HFpEF) versus heart failure with reduced ejection fraction (HFrEF). OBJECTIVES The purpose of this study was to estimate meaningful thresholds for improvement or deterioration in the KCCQ-Total Symptom Score (TSS) in patients with HFrEF versus HFpEF. METHODS This secondary analysis of EMPERIAL program used anchor- and distribution-based approaches to estimate thresholds for improvement or deterioration in the KCCQ-TSS using Patient Global Impression of Severity (PGIS) as the primary anchor. Mean change in KCCQ-TSS from baseline to week 12 was calculated for each PGIS. RESULTS A total of 312 HFrEF and 315 HFpEF patients were enrolled. At week 12, mean changes in KCCQ-TSS corresponding to PGIS changes of "any improvement," "1-category improvement," and "1-category deterioration" were 13 ± 17, 12 ± 17, -3 ± 16 points in HFrEF, and 15 ± 18, 13 ± 17, -7 ± 18 points in HFpEF. Threshold for meaningful within-patient change in KCCQ-TSS was ≥9 points in HFrEF and ≥7 points in HFpEF patients. Sensitivity and specificity of ≥9 points/≥7 points change was 0.65 and 0.70 for HFrEF and 0.64 and 0.66 for HFpEF. Cumulative distribution function curves of KCCQ-TSS change from baseline to week 12 showed a shift to higher scores in both HFrEF and HFpEF patients. CONCLUSIONS In the EMPERIAL program, a change in KCCQ-TSS of ≥9 points in HFrEF and ≥7 points in HFpEF represents the minimal clinically important difference for improvement, confirming the broad range of 5-10 points as meaningful thresholds.
Collapse
Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA.
| | | | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet; and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA; Faculty of Medicine, Rutgers University, New Brunswick, New Jersey
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim AM Rhein, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
5
|
Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Comin-Colet J, Ferreira JP, Mentz RJ, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Voors AA. Effects of Empagliflozin on Symptoms, Physical Limitations, and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial. Circulation 2022; 146:279-288. [PMID: 35377706 PMCID: PMC9311476 DOI: 10.1161/circulationaha.122.059725] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalized for acute heart failure experience poor health status, including a high burden of symptoms and physical limitations, and poor quality of life. SGLT2 (sodium-glucose cotransporter 2) inhibitors improve health status in chronic heart failure, but their effect on these outcomes in acute heart failure is not well characterized. We investigated the effects of the SGLT2 inhibitor empagliflozin on symptoms, physical limitations, and quality of life, using the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the EMPULSE trial (Empagliflozin in Patients Hospitalized With Acute Heart Failure Who Have Been Stabilized). METHODS Patients hospitalized for acute heart failure were randomized to empagliflozin 10 mg daily or placebo for 90 days. The KCCQ was assessed at randomization and 15, 30, and 90 days. The effects of empagliflozin on the primary end point of clinical benefit (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in KCCQ Total Symptom Score [TSS] change from baseline to 90 days) were examined post hoc across the tertiles of baseline KCCQ-TSS. In prespecified analyses, changes (randomization to day 90) in KCCQ domains, including TSS, physical limitations, quality of life, clinical summary, and overall summary scores were evaluated using a repeated measures model. RESULTS In total, 530 patients were randomized (265 each arm). Baseline KCCQ-TSS was low overall (mean [SD], 40.8 [24.0] points). Empagliflozin-treated patients experienced greater clinical benefit across the range of KCCQ-TSS, with no treatment effect heterogeneity (win ratio [95% CIs] from lowest to highest tertile: 1.49 [1.01-2.20], 1.37 [0.94-1.99], and 1.48 [1.00-2.20], respectively; P for interaction=0.94). Beneficial effects of empagliflozin on health status were observed as early as 15 days and persisted through 90 days, at which point empagliflozin-treated patients experienced a greater improvement in KCCQ TSS, physical limitations, quality of life, clinical summary, and overall summary (placebo-adjusted mean differences [95% CI]: 4.45 [95% CI, 0.32-8.59], P=0.03; 4.80 [95% CI, 0.00-9.61], P=0.05; 4.66 [95% CI, 0.32-9.01], P=0.04; 4.85 [95% CI, 0.77-8.92], P=0.02; and 4.40 points [95% CI, 0.33-8.48], P=0.03, respectively). CONCLUSIONS Initiation of empagliflozin in patients hospitalized for acute heart failure produced clinical benefit regardless of the degree of symptomatic impairment at baseline, and improved symptoms, physical limitations, and quality of life, with benefits seen as early as 15 days and maintained through 90 days. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT0415775.
Collapse
Affiliation(s)
- Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Christiane E. Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Germany (C.E.A.)
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN (S.P.C.).,Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville (S.P.C.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, The Institute of Biomedical Research of Bellvitge (IDIBELL), Barcelona, Spain (J.C.-C.)
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (J.P.F.).,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (R.J.M.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.)
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore (J.T.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Germany (M.B.).,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany (M.B.)
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany (J.P.B.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.).,Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Adriaan A. Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (A.A.V.)
| |
Collapse
|
6
|
Doehner W, Anker SD, Butler J, Zannad F, Filippatos G, Ferreira JP, Salsali A, Kaempfer C, Brueckmann M, Pocock SJ, Januzzi JL, Packer M. Uric acid and sodium-glucose cotransporter-2 inhibition with empagliflozin in heart failure with reduced ejection fraction: the EMPEROR-reduced trial. Eur Heart J 2022; 43:3435-3446. [PMID: 35788657 PMCID: PMC9492270 DOI: 10.1093/eurheartj/ehac320] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/10/2022] [Accepted: 06/03/2022] [Indexed: 12/13/2022] Open
Abstract
Background The sodium-glucose cotransporter-2 inhibitor empagliflozin decreases the risk of cardiovascular death or hospitalization for heart failure (HF) in patients with HF with reduced ejection fraction. Empagliflozin reduces serum uric acid (SUA), but the relevance of this effect in patients with HF is unclear. This study aimed to investigate the effect of empagliflozin on SUA levels and the therapeutic efficacy of empagliflozin in relation to SUA. Methods The association between SUA and the composite primary outcome of cardiovascular death or hospitalization for worsening HF, its components, and all-cause mortality was investigated in 3676 patients of the EMPEROR-Reduced trial (98.6% of the study cohort). The treatment effect of empagliflozin was studied in relation to SUA as continuous variable, to clinical hyperuricaemia (SUA >5.7 mg/dL for women, >7.0 mg/dL for men) and in subgroups of patients of tertiles of SUA. Results Hyperuricaemia was prevalent in 53% of patients with no sex differences. Elevated SUA (highest tertile, mean SUA 9.38 ± 1.49 mg/dL) was associated with advanced severity of HF and with worst outcome [composite outcome, hazard ratio (HR) 1.64 (95% confidence interval, CI 1.28–2.10); cardiovascular mortality, HR 1.98 (95% CI 1.35–2.91); all-cause mortality, HR 1.8 (95% CI 1.29–2.49), all P < 0.001] in multivariate adjusted analyses, as compared with the lowest tertile. SUA was reduced following treatment with empagliflozin at 4 weeks (vs. placebo: −1.12 ± 0.04 mg/dL, P < 0.0001) and remained lower throughout follow-up, with a similar reduction in all prespecified subgroups. Empagliflozin reduced events of clinically relevant hyperuricaemia (acute gout, gouty arthritis or initiation of anti-gout therapy) by 32% [HR 0.68 (95% CI 0.52–0.89), P = 0.004]. The beneficial effect of empagliflozin on the primary endpoint was independent of baseline SUA [HR 0.76 (95% CI 0.65–0.88), P < 0.001) and of the change in SUA at 4 weeks [HR 0.81 (95% CI 0.69–0.95), P = 0.012]. As a hypothesis-generating finding, an interaction between SUA and treatment effect suggested a benefit of empagliflozin on mortality (cardiovascular and all-cause mortality) in patients in elevated SUA (P for interaction = 0.005 and = 0.011, respectively). Conclusion Hyperuricaemia is common in HF and is an independent predictor of advanced disease severity and increased mortality. Empagliflozin induced a rapid and sustained reduction of SUA levels and of clinical events related to hyperuricaemia. The benefit of empagliflozin on the primary outcome was observed independently of SUA.
Collapse
Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (CVK), and German Centre for Cardiovascular Research Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (CVK), and German Centre for Cardiovascular Research Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX 75226 USA.,Department of Medicine, University of Mississippi School of Medicine, Jackson, MS 39216, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy 54500, France
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, 12461, Haidari Athens, Greece
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy 54500, France.,UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Afshin Salsali
- Heart Failure and Diabetes Global Development, Boehringer Ingelheim Pharmaceuticals, Inc, 900 Ridgebury Rd, Ridgefield, CT 06877, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ 07103, USA
| | - Carolyn Kaempfer
- Faculty of Medicine, Rutgers University, New Brunswick, NJ 07103, USA.,mainanalytics GmbH, Sulzbach, Otto-Volger-Str. 3c, 65843 Sulzbach/Taunus, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International, Binger Str. 173, 55218 Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Milton Packer
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.,Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas ,TX 75226 USA.,Imperial College, London SW7 2BX, UK
| |
Collapse
|
7
|
Voors AA, Angermann CE, Teerlink JR, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Borleffs CJW, Ma C, Comin-Colet J, Fu M, Janssens SP, Kiss RG, Mentz RJ, Sakata Y, Schirmer H, Schou M, Schulze PC, Spinarova L, Volterrani M, Wranicz JK, Zeymer U, Zieroth S, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med 2022; 28:568-574. [PMID: 35228754 PMCID: PMC8938265 DOI: 10.1038/s41591-021-01659-1] [Citation(s) in RCA: 310] [Impact Index Per Article: 155.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/14/2021] [Indexed: 12/22/2022]
Abstract
The sodium–glucose cotransporter 2 inhibitor empagliflozin reduces the risk of cardiovascular death or heart failure hospitalization in patients with chronic heart failure, but whether empagliflozin also improves clinical outcomes when initiated in patients who are hospitalized for acute heart failure is unknown. In this double-blind trial (EMPULSE; NCT04157751), 530 patients with a primary diagnosis of acute de novo or decompensated chronic heart failure regardless of left ventricular ejection fraction were randomly assigned to receive empagliflozin 10 mg once daily or placebo. Patients were randomized in-hospital when clinically stable (median time from hospital admission to randomization, 3 days) and were treated for up to 90 days. The primary outcome of the trial was clinical benefit, defined as a hierarchical composite of death from any cause, number of heart failure events and time to first heart failure event, or a 5 point or greater difference in change from baseline in the Kansas City Cardiomyopathy Questionnaire Total Symptom Score at 90 days, as assessed using a win ratio. More patients treated with empagliflozin had clinical benefit compared with placebo (stratified win ratio, 1.36; 95% confidence interval, 1.09–1.68; P = 0.0054), meeting the primary endpoint. Clinical benefit was observed for both acute de novo and decompensated chronic heart failure and was observed regardless of ejection fraction or the presence or absence of diabetes. Empagliflozin was well tolerated; serious adverse events were reported in 32.3% and 43.6% of the empagliflozin- and placebo-treated patients, respectively. These findings indicate that initiation of empagliflozin in patients hospitalized for acute heart failure is well tolerated and results in significant clinical benefit in the 90 days after starting treatment. In a multinational trial, empagliflozin has clinical benefit when administered to hospitalized patients with acute heart failure, extending the reach of SGLT2 inhibitor therapy to this patient population.
Collapse
Affiliation(s)
- Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Würzburg, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.,George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT (Cardiovascular and Renal Clinical Trialists), Centre Hospitalier Régional Universitaire, Nancy, France.,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | | | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Michael Fu
- Section of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Stefan P Janssens
- Department of Cardiovascular Sciences, Clinical Cardiology, Belgium University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Henrik Schirmer
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital Copenhagen, Copenhagen, Denmark
| | | | - Lenka Spinarova
- First Department of Medicine, Masaryk University Hospital, Brno, Czech Republic
| | | | - Jerzy K Wranicz
- Department of Electrocardiology, Medical University of Lodz, Central Clinical Hospital, Lodz, Poland
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| |
Collapse
|
8
|
Teerlink J, Voors A, Collins S, Kosiborod M, Biegus J, Ferreira J, Nassif M, Psotka M, Tromp J, Blatchford J, Salsali A, Kraus B, Ponikowski P, Angermann C. Empagliflozin in Patients Hospitalised for De Novo Versus Decompensated Chronic Heart Failure: Insights From the EMPULSE Trial. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
9
|
Ferreira JP, Anker SD, Butler J, Filippatos G, Iwata T, Salsali A, Zeller C, Pocock SJ, Zannad F, Packer M. Impact of Anemia and the Effect of Empagliflozin in HFrEF: findings from EMPEROR-Reduced. Eur J Heart Fail 2021; 24:708-715. [PMID: 34957660 PMCID: PMC9303456 DOI: 10.1002/ejhf.2409] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/07/2021] [Accepted: 12/22/2021] [Indexed: 12/01/2022] Open
Abstract
Aims Anaemia is frequent among patients with heart failure (HF) and reduced ejection fraction (HFrEF) and is associated with poor outcomes. Sodium–glucose co‐transporter 2 inhibitors (SGLT2i) increase haematocrit and may correct anaemia. This study aims to investigate the impact of empagliflozin on haematocrit and anaemia, and whether anaemia influenced the effect of empagliflozin in EMPEROR‐Reduced. Methods and results Mixed‐effects models and survival analysis. A total of 3726 patients (out of 3730) had baseline haematocrit values, 3013 (81%) had no anaemia and 713 (19%) had anaemia. Patients with anaemia were older (70.4 vs. 66.0 years), had lower body mass index (26.6 vs. 28.2 kg/m2), lower estimated glomerular filtration rate (54.2 vs. 63.9 ml/min/1.73 m2), and higher N‐terminal pro‐B‐type natriuretic peptide (2362 vs. 1800 pg/ml). Compared to patients without anaemia, those with anaemia had 1.5 to 2.5‐fold higher rates of cardiovascular and all‐cause mortality, total HF hospitalizations, and kidney composite outcomes. The effect of empagliflozin to reduce the primary composite outcome of cardiovascular death or HF hospitalizations, total HF hospitalizations, and kidney composite outcome was not modified by baseline anaemia status (interaction p > 0.1 for all). Compared to placebo, empagliflozin rapidly (as early as week 4) increased haematocrit and haemoglobin and reduced the rates of new‐onset anaemia throughout the follow‐up (22.6% in placebo vs. 12.3% in empagliflozin; hazard ratio 0.49, 95% confidence interval 0.41–0.59; p < 0.001). Conclusions Anaemia was associated with poor outcomes. Empagliflozin reduced new‐onset anaemia throughout the follow‐up and improved HF and kidney outcomes irrespective of anaemia status at baseline.
Collapse
Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)NancyFrance
- Cardiovascular Research and Development Center, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
| | - Stefan D. Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin BerlinBerlinGermany
| | - Javed Butler
- Department of MedicineUniversity of MississippiJacksonMSUSA
| | - Gerasimos Filippatos
- Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens, School of MedicineAthensGreece
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
- Faculty of MedicineRutgers UniversityNew BrunswickNJUSA
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Stuart J. Pocock
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)NancyFrance
| | - Milton Packer
- Baylor Heart and Vascular Institute Baylor University Medical CenterDallasTXUSA
- Imperial CollegeLondonUK
| |
Collapse
|
10
|
Lund SS, Sattar N, Salsali A, Neubacher D, Ginsberg HN. Potential contribution of haemoconcentration to changes in lipid variables with empagliflozin in patients with type 2 diabetes: A post hoc analysis of pooled data from four phase 3 randomized clinical trials. Diabetes Obes Metab 2021; 23:2763-2774. [PMID: 34463415 PMCID: PMC9290508 DOI: 10.1111/dom.14534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 01/24/2023]
Abstract
AIM To examine the association between changes in lipids and markers of haemoconcentration (haematocrit and serum albumin) with empagliflozin, a sodium-glucose co-transporter-2 inhibitor, in patients with type 2 diabetes (T2D) using pooled data from four phase 3 randomized trials. MATERIALS AND METHODS Patients with T2D received placebo (n = 825), empagliflozin 10 mg (n = 830) or 25 mg (n = 822) for 24 weeks. In post hoc mediation analyses, we assessed total changes in LDL-cholesterol, HDL-cholesterol, triglycerides, apolipoprotein (Apo) B, and Apo A-I, and changes in these variables associated with, and independent of, changes in haematocrit and serum albumin at week 24 using ANCOVA models. RESULTS Empagliflozin versus placebo increased serum LDL-cholesterol, HDL-cholesterol, and Apo A-I, decreased triglycerides (empagliflozin 10 mg only), and (non-significantly) increased Apo B. Empagliflozin modestly increased haematocrit and serum albumin. In mediation analyses, haematocrit changes (increases) with empagliflozin were associated with significant changes (increases) in all lipid variables, including Apo B. Except for triglycerides (non-significant), similar lipid variable associations were observed with serum albumin changes. Haematocrit- and serum albumin-independent changes in lipids with empagliflozin were significant for HDL-cholesterol (increases), mostly significant for triglycerides (decreases), and less so for other lipid fractions. CONCLUSION Haematocrit and serum albumin increases were associated with increases in lipid fractions with empagliflozin. Empagliflozin-associated changes in serum lipids, particularly LDL-cholesterol increases, may be partly attributable to haemoconcentration resulting from increased urinary volume and subsequent volume contraction.
Collapse
Affiliation(s)
- Søren S. Lund
- Boehringer Ingelheim International GmbHIngelheimGermany
| | | | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, IncRidgefieldConnecticutUSA
| | | | - Henry N. Ginsberg
- Vagelos College of Physicians and Surgeons of Columbia UniversityNew YorkNew YorkUSA
| |
Collapse
|
11
|
Fitchett D, Inzucchi SE, Zinman B, Wanner C, Schumacher M, Schmoor C, Ohneberg K, Ofstad AP, Salsali A, George JT, Hantel S, Bluhmki E, Lachin JM, Zannad F. Mediators of the improvement in heart failure outcomes with empagliflozin in the EMPA-REG OUTCOME trial. ESC Heart Fail 2021; 8:4517-4527. [PMID: 34605192 PMCID: PMC8712833 DOI: 10.1002/ehf2.13615] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 01/07/2023] Open
Abstract
Aims In the EMPA‐REG OUTCOME trial, empagliflozin reduced risk of death from heart failure (HF) or hospitalization for heart failure (HHF) versus placebo in patients with type 2 diabetes mellitus (T2DM) and established cardiovascular (CV) disease. We evaluated post hoc the degree to which covariates mediated the effects of empagliflozin on HHF or HF death. Methods and results A mediator had to fulfil the following criteria: (i) affected by active treatment, (ii) associated with the outcome, and finally (iii) adjustment for it results in a reduced treatment effect compared with unadjusted analysis. Potential mediators were calculated as change from baseline or updated mean and evaluated in univariable analyses as time‐dependent covariates in Cox regression of time to HHF or HF death; those with the largest mediating effects were then included in a multivariable analysis. Increases in heart rate, log urine albumin‐to‐creatinine ratio (UACR), waist circumference, and uric acid were associated with increased risk of HHF or HF death; increases in high‐density lipoprotein cholesterol, estimated glomerular filtration rate, haematocrit, haemoglobin, and albumin were associated with reduced risk of HHF or HF death. In univariable analyses, change from baseline in haematocrit, haemoglobin, albumin, uric acid, and logUACR mediated 51%, 54%, 23%, 24%, and 27% of the risk reduction with empagliflozin versus placebo, respectively. Multivariable analysis including haemoglobin, logUACR, and uric acid mediated 85% of risk reduction with similar results when updated means were evaluated. Conclusions Changes in haematocrit and haemoglobin were the most important mediators of the reduction in HHF and death from HF in patients with T2DM and established CV disease treated with empagliflozin. Albumin, uric acid, and logUACR had smaller mediating effects in this population.
Collapse
Affiliation(s)
- David Fitchett
- Division of Cardiology, St Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| | | | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | - Christoph Wanner
- Department of Medicine, Division of NephrologyWürzburg University ClinicWürzburgGermany
| | - Martin Schumacher
- Institute for Medical Biometry and Statistics and Clinical Trials Unit, Faculty of Medicine, and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Claudia Schmoor
- Institute for Medical Biometry and Statistics and Clinical Trials Unit, Faculty of Medicine, and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Kristin Ohneberg
- Institute for Medical Biometry and Statistics and Clinical Trials Unit, Faculty of Medicine, and Medical CenterUniversity of FreiburgFreiburgGermany
| | | | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | | | - Stefan Hantel
- Boehringer Ingelheim International GmbHIngelheimGermany
| | - Erich Bluhmki
- Boehringer Ingelheim International GmbHIngelheimGermany
| | - John M. Lachin
- Biostatistics CenterThe George Washington UniversityRockvilleMDUSA
| | - Faiez Zannad
- Universite de Lorraine, INSERM, Centre d'Investigations Cliniques‐1433 and INSERM U1116, CHRU NancyLorraineFrance
| |
Collapse
|
12
|
Anker SD, Ponikowski P, Wanner C, Pfarr E, Hauske S, Peil B, Salsali A, Ritter I, Koitka-Weber A, Brueckmann M, Lindenfeld J, Abraham WT. Kidney Function After Initiation and Discontinuation of Empagliflozin in Heart Failure Patients With and Without Type 2 Diabetes: Insights From the EMPERIAL Trials. Circulation 2021; 144:1265-1267. [PMID: 34397263 DOI: 10.1161/circulationaha.121.054669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stefan D Anker
- Department of Cardiology, Charité University, Berlin, Germany (S.D.A., W.T.A.)
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Poland (P.P.)
| | - Christoph Wanner
- Division of Nephrology, Würzburg University Clinic, Wurzburg, Germany (C.W., A.K.-W.)
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany (E.P., B.P.)
| | - Sibylle Hauske
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany (S.H.)
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany (E.P., B.P.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT (A.S.)
- Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Ivana Ritter
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
| | - Audrey Koitka-Weber
- Division of Nephrology, Würzburg University Clinic, Wurzburg, Germany (C.W., A.K.-W.)
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia (A.K.-W.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (S.H., I.R., A.K.-W., M.B.)
- Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany (M.B.)
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.L.)
| | - William T Abraham
- Department of Cardiology, Charité University, Berlin, Germany (S.D.A., W.T.A.)
- Division of Cardiovascular Medicine, The Ohio State University, Columbus (W.T.A.)
| |
Collapse
|
13
|
Abraham WT, Lindenfeld J, Ponikowski P, Agostoni P, Butler J, Desai AS, Filippatos G, Gniot J, Fu M, Gullestad L, Howlett JG, Nicholls SJ, Redon J, Schenkenberger I, Silva-Cardoso J, Störk S, Krzysztof Wranicz J, Savarese G, Brueckmann M, Jamal W, Nordaby M, Peil B, Ritter I, Ustyugova A, Zeller C, Salsali A, Anker SD. Effect of empagliflozin on exercise ability and symptoms in heart failure patients with reduced and preserved ejection fraction, with and without type 2 diabetes. Eur Heart J 2021; 42:700-710. [PMID: 33351892 DOI: 10.1093/eurheartj/ehaa943] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/31/2020] [Accepted: 11/05/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS The EMPERIAL (Effect of EMPagliflozin on ExeRcise ability and HF symptoms In patients with chronic heArt faiLure) trials evaluated the effects of empagliflozin on exercise ability and patient-reported outcomes in heart failure (HF) with reduced and preserved ejection fraction (EF), with and without type 2 diabetes (T2D), reporting, for the first time, the effects of sodium-glucose co-transporter-2 inhibition in HF with preserved EF (HFpEF). METHODS AND RESULTS HF patients with reduced EF (HFrEF) (≤40%, N = 312, EMPERIAL-Reduced) or preserved EF (>40%, N = 315, EMPERIAL-Preserved), with and without T2D, were randomized to empagliflozin 10 mg or placebo for 12 weeks. The primary endpoint was 6-minute walk test distance (6MWTD) change to Week 12. Key secondary endpoints included Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) and Chronic Heart Failure Questionnaire Self-Administered Standardized format (CHQ-SAS) dyspnoea score. 6MWTD median (95% confidence interval) differences, empagliflozin vs. placebo, at Week 12 were -4.0 m (-16.0, 6.0; P = 0.42) and 4.0 m (-5.0, 13.0; P = 0.37) in EMPERIAL-Reduced and EMPERIAL-Preserved, respectively. As the primary endpoint was non-significant, all secondary endpoints were considered exploratory. Changes in KCCQ-TSS and CHQ-SAS dyspnoea score were non-significant. Improvements with empagliflozin in exploratory pre-specified analyses of KCCQ-TSS responder rates, congestion score, and diuretic use in EMPERIAL-Reduced are hypothesis generating. Empagliflozin adverse events were consistent with those previously reported. CONCLUSION The primary outcome for both trials was neutral. Empagliflozin was well tolerated in HF patients, with and without T2D, with a safety profile consistent with that previously reported in T2D. Hypothesis-generating improvements in exploratory analyses of secondary endpoints with empagliflozin in HFrEF were observed.
Collapse
Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, 473 West 12th Ave., Columbus, OH 43210, USA
| | - JoAnn Lindenfeld
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Piotr Ponikowski
- Wroclaw Medical University, Wybrzeże L. Pasteura 1, 50-367, Wroclaw, Poland
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino-IRCCS, Via Carlo Parea, 4 - 20138, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19 20122, Milan, Italy
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS-39216, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens 157 72, Greece.,University of Cyprus, School of Medicine, Shacolas Educational Centre for Clinical Medicine, Palaios dromos Lefkosias Lemesou No.215/6, 2029 Aglantzia, Nicosia, Cyprus
| | - Jacek Gniot
- Department of Cardiology, Independent Public Healthcare, General Hospital in Puławy; ul. Bema 1; 24 - 100 Pulawy, Poland
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Søsterhjemmet, Kirkeveien 166, 2.etasje, 0450 Oslo, Norway.,KG Jebsen Center for Cardiac Research, University of Oslo, Sogn Arena, Klaus Torgårds vei 3, 2. Etg, 0372 Oslo, Norway.,Center for Heart Failure Research, Department of Cardiology Medicine (Building 3), 1st floor, Oslo University Hospital, Kirkeveien 166, 0407 Oslo, Norway
| | - Jonathan G Howlett
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Monash University, 27 Rainforest Walk, Clayton VIC 3800, Melbourne, Australia
| | - Josep Redon
- INCLIVA Research Institute, University of Valencia, vinguda de Menéndez y Pelayo, 4, 46010 Valencia, and CIBERObn, Madrid, Spain
| | | | - José Silva-Cardoso
- CardioCare, CINTESIS-Center for Health Technology and Services Research, and Director of the Cardiology Service, Porto University Medical School, São João University Medical Centre, Rua Dr. Plácido da Costa, s/n 4200-450, Porto, Portugal
| | - Stefan Störk
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, Würzburg University and University Hospital Würzburg, Straubmühlweg 2, 97078 Würzburg, Germany
| | - Jerzy Krzysztof Wranicz
- Department of Electrocardiology, Medical University of Lodz, al. Tadeusza Kościuszki 4, 90-41, Lodz, Poland
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, Solna Karolinska University Hospital D1:04, SE-171 76 Stockholm, Sweden
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Ludolf-Krehl-Str. 13-17, 68167 Mannheim, Germany
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Ivana Ritter
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Anastasia Ustyugova
- Boehringer Ingelheim International GmbH, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88397 Biberach an der Riß, Germany
| | - Afshin Salsali
- Heart Failure and DM Global Development, Boehringer Ingelheim Pharmaceuticals, Inc, 900 Ridgebury Rd, Ridgefield, CT 06877, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Föhrer Str. 15, 13353 Berlin, Germany
| |
Collapse
|
14
|
Tromp J, Ponikowski P, Salsali A, Angermann CE, Biegus J, Blatchford J, Collins SP, Ferreira JP, Grauer C, Kosiborod M, Nassif ME, Psotka MA, Brueckmann M, Teerlink JR, Voors AA. Sodium-glucose co-transporter 2 inhibition in patients hospitalized for acute decompensated heart failure: rationale for and design of the EMPULSE trial. Eur J Heart Fail 2021; 23:826-834. [PMID: 33609072 PMCID: PMC8358952 DOI: 10.1002/ejhf.2137] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
Aims Treatment with sodium–glucose co‐transporter 2 (SGLT2) inhibitors improves outcomes in patients with chronic heart failure (HF) with reduced ejection fraction. There is limited experience with the in‐hospital initiation of SGLT2 inhibitors in patients with acute HF (AHF) with or without diabetes. EMPULSE is designed to assess the clinical benefit and safety of the SGLT2 inhibitor empagliflozin compared with placebo in patients hospitalized with AHF. Methods EMPULSE is a randomized, double‐blind, parallel‐group, placebo‐controlled multinational trial comparing the in‐hospital initiation of empagliflozin (10 mg once daily) with placebo. Approximately 500 patients admitted for AHF with dyspnoea, signs of fluid overload, and elevated natriuretic peptides will be randomized 1:1 stratified to HF status (de‐novo and decompensated chronic HF) to either empagliflozin or placebo at approximately 165 sites across North America, Europe and Asia. Patients will be enrolled regardless of ejection fraction and diabetes status and will be randomized during hospitalization and after stabilization (between 24 h and 5 days after admission), with treatment continued up to 90 days after initiation. The primary outcome is clinical benefit at 90 days, consisting of a composite of all‐cause death, HF events, and ≥5 point change from baseline in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ‐TSS), assessed using a ‘win‐ratio’ approach. Secondary outcomes include assessments of safety, change in KCCQ‐TSS from baseline to 90 days and change in natriuretic peptides from baseline to 30 days. Conclusion The EMPULSE trial will evaluate the clinical benefit and safety of empagliflozin in patients hospitalized for AHF.
Collapse
Affiliation(s)
- Jasper Tromp
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Duke-NUS Medical School, Singapore.,National Heart Centre Singapore, Singapore
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Jon Blatchford
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Claudia Grauer
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA.,The George Institute for Global Health and the University of New South Wales, Sydney, NSW, Australia
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
15
|
Nishimura R, Tanaka Y, Koiwai K, Ishida K, Salsali A, Kaspers S, Kohler S, Lund SS. Effect of Empagliflozin on Free Fatty Acids and Ketone Bodies in Japanese Patients with Type 2 Diabetes Mellitus: A Randomized Controlled Trial. Adv Ther 2019; 36:2769-2782. [PMID: 31444706 DOI: 10.1007/s12325-019-01045-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION We report a randomized, double-blind, placebo-controlled, 4-week study to investigate the effect of empagliflozin on free fatty acids and blood ketone bodies in Japanese patients with type 2 diabetes mellitus. METHODS Patients (baseline mean [standard deviation] glycated hemoglobin 7.91% [0.80%]; body mass index 24.3 [3.2] kg/m2) were randomized to empagliflozin 10 mg (n = 20), empagliflozin 25 mg (n = 19), or placebo (n = 21) daily as monotherapy for 28 days. Meal tolerance tests (MTTs; breakfast, lunch, dinner) were performed on day - 1, day 1 (first day of treatment), and day 28. On day 1 and day 28, study drug was administered 1 h before breakfast. Free fatty acids and blood ketone bodies were measured before and 1, 2, and 3 h after each MTT, and the next morning (overnight fast). RESULTS Empagliflozin significantly reduced plasma glucose and insulin and reduced body weight vs. placebo. Empagliflozin increased free fatty acids and total ketones bodies at day 1 and day 28. At day 28, the adjusted mean (95% confidence interval) difference vs. placebo in the time-corrected area under curve over 24 h for total ketone bodies was 67.1 (12.3, 121.8) µmol·h/L·h (P = 0.017) with empagliflozin 10 mg and 178.1 (123.9, 232.2) µmol·h/L·h (P < 0.001) with empagliflozin 25 mg. Increases in ketones with empagliflozin vs. placebo peaked just before and declined after meals, with the highest peak before breakfast. Changes in total ketone bodies appeared to be associated with changes in plasma glucose, insulin, and free fatty acids. CONCLUSION Empagliflozin modestly increased free fatty acids and blood ketone bodies after a single dose and 28 days' treatment. Increases in ketones appeared to be related to the duration of fasting and were most pronounced before breakfast. Increases in ketones appeared to be associated with changes in well-known metabolic determinants of ketone production. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01947855. FUNDING Boehringer Ingelheim & Eli Lilly and Company.
Collapse
Affiliation(s)
| | - Yuko Tanaka
- Nippon Boehringer Ingelheim Co. Ltd., Tokyo, Japan.
| | | | | | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Stefan Kaspers
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Sven Kohler
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Søren S Lund
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| |
Collapse
|
16
|
Anker SD, Butler J, Filippatos GS, Jamal W, Salsali A, Schnee J, Kimura K, Zeller C, George J, Brueckmann M, Zannad F, Packer M. Evaluation of the effects of sodium-glucose co-transporter 2 inhibition with empagliflozin on morbidity and mortality in patients with chronic heart failure and a preserved ejection fraction: rationale for and design of the EMPEROR-Preserved Trial. Eur J Heart Fail 2019; 21:1279-1287. [PMID: 31523904 DOI: 10.1002/ejhf.1596] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/27/2019] [Accepted: 07/30/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The principal biological processes that characterize heart failure with a preserved ejection fraction (HFpEF) are systemic inflammation, epicardial adipose tissue accumulation, coronary microcirculatory rarefaction, myocardial fibrosis and vascular stiffness; the resulting impairment of left ventricular and aortic distensibility (especially when accompanied by impaired glomerular function and sodium retention) causes increases in cardiac filling pressures and exertional dyspnoea despite the relative preservation of left ventricular ejection fraction. Independently of their actions on blood glucose, sodium-glucose co-transporter 2 (SGLT2) inhibitors exert a broad range of biological effects (including actions to inhibit cardiac inflammation and fibrosis, antagonize sodium retention and improve glomerular function) that can ameliorate the pathophysiological derangements in HFpEF. Such SGLT2 inhibitors exert favourable effects in experimental models of HFpEF and have been found in large-scale trials to reduce the risk for serious heart failure events in patients with type 2 diabetes, many of whom were retrospectively identified as having HFpEF. STUDY DESIGN The EMPEROR-Preserved Trial is enrolling ≈5750 patients with HFpEF (ejection fraction >40%), with and without type 2 diabetes, who are randomized to receive placebo or empagliflozin 10 mg/day, which is added to all appropriate treatments for HFpEF and co-morbidities. STUDY AIMS The primary endpoint is the time-to-first-event analysis of the combined risk for cardiovascular death or hospitalization for heart failure. The trial will also evaluate the effects of empagliflozin on renal function, cardiovascular death, all-cause mortality and recurrent hospitalization events, and will assess a wide range of biomarkers that reflect important pathophysiological mechanisms that may drive the evolution of HFpEF. The EMPEROR-Preserved Trial is well positioned to determine if empagliflozin can have a meaningful impact on the course of HFpEF, a disorder for which there are currently few therapeutic options.
Collapse
Affiliation(s)
- Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Centre for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site, Berlin, Germany
| | - Javed Butler
- University of Mississippi School of Medicine, Jackson, MI, USA
| | - Gerasimos S Filippatos
- School of Medicine, National and Kapodistrian University of Athens, Athens University Hospital Attikon, Athens, Greece.,School of Medicine, University of Cyprus, Nicosia, Cyprus
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Janet Schnee
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Karen Kimura
- Boehringer Ingelheim Canada Ltd, Burlington, ON, Canada
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Faiez Zannad
- Inserm INI-CRCT, CHRU, University of Lorraine, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | | |
Collapse
|
17
|
Packer M, Butler J, Filippatos GS, Jamal W, Salsali A, Schnee J, Kimura K, Zeller C, George J, Brueckmann M, Anker SD, Zannad F. Evaluation of the effect of sodium-glucose co-transporter 2 inhibition with empagliflozin on morbidity and mortality of patients with chronic heart failure and a reduced ejection fraction: rationale for and design of the EMPEROR-Reduced trial. Eur J Heart Fail 2019; 21:1270-1278. [PMID: 31584231 DOI: 10.1002/ejhf.1536] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 12/23/2022] Open
Abstract
Drugs that inhibit the sodium-glucose co-transporter 2 (SGLT2) have been shown to reduce the risk of hospitalizations for heart failure in patients with type 2 diabetes. In populations that largely did not have heart failure at the time of enrolment, empagliflozin, canagliflozin and dapagliflozin decreased the risk of serious new-onset heart failure events by ≈30%. In addition, in the EMPA-REG OUTCOME trial, empagliflozin reduced the risk of both pump failure and sudden deaths, the two most common modes of death among patients with heart failure. In none of the three trials could the benefits of SGLT2 inhibitors on heart failure be explained by the actions of these drugs as diuretics or anti-hyperglycaemic agents. These observations raise the possibility that SGLT2 inhibitors could reduce morbidity and mortality in patients with established heart failure, including those without diabetes. The EMPEROR-Reduced trial is enrolling ≈3600 patients with heart failure and a reduced left ventricular ejection fraction (≤ 40%), half of whom are expected not to have diabetes. Patients are being randomized to placebo or empagliflozin 10 mg daily, which is added to all appropriate treatment with inhibitors of the renin-angiotensin system and neprilysin, beta-blockers and mineralocorticoid receptor antagonists. The primary endpoint is the time-to-first event analysis of the combined risk of cardiovascular death and hospitalization for heart failure, but the trial will also evaluate the effects of empagliflozin on renal function, cardiovascular death, all-cause mortality, and recurrent hospitalization events. By adjusting eligibility based on natriuretic peptide levels to the baseline ejection fraction, the trial will preferentially enrol high-risk patients. A large proportion of the participants is expected to have an ejection fraction < 30%, and the estimated annual event rate is expected to be at least 15%. The EMPEROR-Reduced trial is well-positioned to determine if the addition of empagliflozin can add meaningfully to current approaches that have established benefits in the treatment of chronic heart failure with left ventricular systolic dysfunction.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Javed Butler
- University of Mississippi School of Medicine, Jackson, MI, USA
| | - Gerasimos S Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece.,School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Janet Schnee
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Karen Kimura
- Boehringer Ingelheim Canada Ltd., Burlington, Canada
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site, Berlin, Germany, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Faiez Zannad
- Inserm INI-CRCT, CHRU, Université de Lorraine, Nancy, France
| | | |
Collapse
|
18
|
Abraham WT, Ponikowski P, Brueckmann M, Zeller C, Macesic H, Peil B, Brun M, Ustyugova A, Jamal W, Salsali A, Lindenfeld J, Anker SD. Rationale and design of the EMPERIAL-Preserved and EMPERIAL-Reduced trials of empagliflozin in patients with chronic heart failure. Eur J Heart Fail 2019; 21:932-942. [PMID: 31218819 PMCID: PMC6774309 DOI: 10.1002/ejhf.1486] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Heart failure (HF) is associated with considerable symptom burden and impairment in physical functioning and quality of life. The sodium-glucose co-transporter 2 inhibitor empagliflozin reduced the risk of HF hospitalisation and cardiovascular death in patients with type 2 diabetes and established cardiovascular disease in the EMPA-REG OUTCOME trial, and could potentially improve congestion symptoms and exercise capacity in patients with HF. We describe the designs of the EMPERIAL-Preserved and EMPERIAL-Reduced trials of empagliflozin in patients with chronic stable HF, with or without type 2 diabetes. METHODS EMPERIAL-Preserved and EMPERIAL-Reduced are randomised, placebo-controlled trials designed to investigate the effects of empagliflozin on exercise capacity and patient-reported outcomes in patients with chronic stable HF with preserved ejection fraction [HFpEF; left ventricular ejection fraction (LVEF) > 40%] and HF with reduced ejection fraction (HFrEF; LVEF ≤ 40%), respectively. In each trial, approximately 300 patients will be randomised 1:1 to receive empagliflozin 10 mg or placebo once daily for 12 weeks. In both trials, the primary endpoint is the change from baseline in 6-min walk test distance at week 12. Key secondary endpoints are the change from baseline in Kansas City Cardiomyopathy Questionnaire total symptom score and change from baseline in dyspnoea score of the Chronic Heart Failure Questionnaire at week 12. CONCLUSION The EMPERIAL-Preserved and EMPERIAL-Reduced trials will determine the effects of empagliflozin on exercise capacity and patient-reported outcomes in patients with HFpEF and HFrEF, respectively, and provide insight into the potential of empagliflozin in the treatment of patients with HF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03448406 (EMPERIAL-Preserved), NCT03448419 (EMPERIAL-Reduced).
Collapse
Affiliation(s)
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Michèle Brun
- Boehringer Ingelheim France, Reims Cedex, France
| | | | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | | | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany
| | | |
Collapse
|
19
|
Ridderstråle M, Rosenstock J, Andersen KR, Woerle HJ, Salsali A. Empagliflozin compared with glimepiride in metformin-treated patients with type 2 diabetes: 208-week data from a masked randomized controlled trial. Diabetes Obes Metab 2018; 20:2768-2777. [PMID: 29961998 DOI: 10.1111/dom.13457] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/20/2018] [Accepted: 06/27/2018] [Indexed: 01/02/2023]
Abstract
AIM To report results at week 208, including a 104-week masked extension, of the EMPA-REG H2H-SU trial in patients with type 2 diabetes with inadequate glycaemic control on metformin, in which empagliflozin 25 mg given for 104 weeks provided a sustained reduction in glycated haemoglobin (HbA1c) with a small but statistically significant benefit vs glimepiride, sustained reductions in weight and blood pressure, and low risk of hypoglycaemia. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes and HbA1c 53-86 mmol/mol (7% to 10%) were randomized to empagliflozin 25 mg or glimepiride 1 to 4 mg for 104 weeks as add-on to metformin. Patients who completed the randomized treatment period could participate in a 104-week extension in which they continued the double-blind treatment allocated at randomization. RESULTS Of 765 and 780 patients treated with empagliflozin and glimepiride, 576 and 549 patients, respectively, entered the extension period of the study. At week 208, the adjusted mean difference in change from baseline in HbA1c with empagliflozin vs glimepiride was -1.96 mmol/mol, 95% CI -3.57, -0.35 (-0.18%, 95% CI -0.33, -0.03); P = 0.0172. Rescue therapy was given to 23% of patients on empagliflozin and 34% on glimepiride (odds ratio 0.56 [95% CI 0.45, 0.71]; P < 0.0001). Confirmed hypoglycaemic adverse events (plasma glucose ≤3.9 mmol/L and/or requiring assistance) occurred in 3% of patients on empagliflozin and 28% on glimepiride (odds ratio 0.08 [95% CI 0.05, 0.13]; P < 0.0001). CONCLUSIONS In patients with type 2 diabetes, empagliflozin 25 mg as add-on to metformin for 208 weeks reduced HbA1c with a significantly lower risk of hypoglycaemia and a significantly smaller proportion of patients receiving rescue therapy compared with glimepiride.
Collapse
Affiliation(s)
| | | | | | - Hans J Woerle
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut
| |
Collapse
|
20
|
Kohler S, Kaspers S, Salsali A, Zeller C, Woerle HJ. Analysis of Fractures in Patients With Type 2 Diabetes Treated With Empagliflozin in Pooled Data From Placebo-Controlled Trials and a Head-to-Head Study Versus Glimepiride. Diabetes Care 2018; 41:1809-1816. [PMID: 29907581 DOI: 10.2337/dc17-1525] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 05/14/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the effect of empagliflozin on bone fractures and bone mineral density in patients with type 2 diabetes in pooled placebo-controlled trial data and a head-to-head study versus glimepiride. RESEARCH DESIGN AND METHODS Pooled data were analyzed from patients who were randomized 1:1:1 to empagliflozin 10 mg, empagliflozin 25 mg, or placebo in phase I-III clinical trials. Data were also analyzed from the EMPA-REG H2H-SU trial in which patients received empagliflozin 25 mg or glimepiride as an add-on to metformin for 104 weeks with a 104-week extension. Bone fracture adverse events (AEs) were evaluated through a search of investigator-reported (nonadjudicated) events. RESULTS In the pooled analysis, bone fracture AEs were reported in 119 of 4,221 (2.8%), 105 of 4,196 (2.5%), and 123 of 4,203 (2.9%) patients in the empagliflozin 10 mg, empagliflozin 25 mg, and placebo groups, respectively (rates of 1.55, 1.36, and 1.69/100 patient-years, respectively). In the EMPA-REG H2H-SU trial, bone fracture AEs were reported in 31 of 765 (4.1%) patients receiving empagliflozin 25 mg and in 33 of 780 (4.2%) patients receiving glimepiride (rates of 1.28 and 1.40/100 patient-years, respectively). CONCLUSIONS Empagliflozin did not increase the risk of bone fracture compared with placebo in a pooled analysis of >12,000 patients or compared with glimepiride in a 4-year head-to-head study.
Collapse
Affiliation(s)
- Sven Kohler
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Stefan Kaspers
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH, Biberach an der Riss, Germany
| | - Hans J Woerle
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| |
Collapse
|
21
|
Ferdinand KC, Lee J, Meng L, George J, Salsali A, Seman L. EMPAGLIFLOZIN IMPROVES BLOOD PRESSURE AS WELL AS GLYCEMIC CONTROL IN AFRICAN AMERICAN PATIENTS WITH TYPE 2 DIABETES AND HYPERTENSION: A 24-WEEK RANDOMIZED CONTROLLED TRIAL. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32291-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
22
|
Abstract
OBJECTIVE Black/African American individuals have a higher prevalence of type 2 diabetes mellitus (T2DM), diabetes-related complications and hypertension, but they are often underrepresented in clinical trials. The sodium-glucose co-transporter 2 inhibitor, empagliflozin, was associated with significant improvements in glucose control (via hemoglobin [Hb] A1c) and reductions in blood pressure (BP; via office and ambulatory BP monitoring) in a primarily white population with T2DM and hypertension. The aim of this ongoing study is to assess the safety and efficacy of empagliflozin in terms of glucose- and BP-lowering in a self-identified black/African American population with T2DM and hypertension. METHODS This was a multicenter, randomized, double-blind, placebo-controlled, parallel-group, phase 3b study carried out at 85 centers in the USA. It was designed to assess the safety and efficacy of empagliflozin (10 or 25 mg/day) versus placebo in black/African American patients with uncontrolled T2DM and hypertension. Patients receiving stable glucose-lowering therapy prestudy continued at the same dose during the trial; BP-lowering medication was also held stable. The primary endpoint was the change from baseline in HbA1c at Week 24. Key secondary endpoints were change from baseline in: mean 24-hour ambulatory systolic BP (SBP) at Week 12, mean trough ambulatory SBP at Week 12, body weight at Week 24 and trough seated SBP at Week 12. RESULTS The study will report final data in 2018. CONCLUSIONS Results of this study will add to our understanding of the efficacy and safety of empagliflozin in self-identified black/African American patients with T2DM and hypertension. (ClinicalTrials.gov identifier: NCT02182830.).
Collapse
Affiliation(s)
| | - Leo Seman
- b Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , CT , USA
| | - Afshin Salsali
- b Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , CT , USA
| |
Collapse
|
23
|
Butler J, Hamo CE, Filippatos G, Pocock SJ, Bernstein RA, Brueckmann M, Cheung AK, George JT, Green JB, Januzzi JL, Kaul S, Lam CSP, Lip GYH, Marx N, McCullough PA, Mehta CR, Ponikowski P, Rosenstock J, Sattar N, Salsali A, Scirica BM, Shah SJ, Tsutsui H, Verma S, Wanner C, Woerle HJ, Zannad F, Anker SD. The potential role and rationale for treatment of heart failure with sodium-glucose co-transporter 2 inhibitors. Eur J Heart Fail 2017; 19:1390-1400. [PMID: 28836359 DOI: 10.1002/ejhf.933] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/27/2017] [Accepted: 06/05/2017] [Indexed: 12/28/2022] Open
Abstract
Heart failure (HF) and type 2 diabetes mellitus (T2DM) are both growing public health concerns contributing to major medical and economic burdens to society. T2DM increases the risk of HF, frequently occurs concomitantly with HF, and worsens the prognosis of HF. Several anti-hyperglycaemic medications have been associated with a concern for worse HF outcomes. More recently, the results of the EMPA-REG OUTCOME trial showed that the sodium-glucose co-transporter 2 (SGLT2) inhibitor empagliflozin was associated with a pronounced and precocious 38% reduction in cardiovascular mortality in subjects with T2DM and established cardiovascular disease [Correction added on 8 September 2017, after first online publication: "32%" in the previous sentence was corrected to "38%"]. These benefits were more related to a reduction in incident HF events rather than to ischaemic vascular endpoints. Several mechanisms have been put forward to explain these benefits, which also raise the possibility of using these drugs as therapies not only in the prevention of HF, but also for the treatment of patients with established HF regardless of the presence or absence of diabetes. Several large trials are currently exploring this postulate.
Collapse
Affiliation(s)
- Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Carine E Hamo
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Martina Brueckmann
- Boehringer Ingelheim Pharmaceuticals Inc., Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, UT, USA
| | - Jyothis T George
- Boehringer Ingelheim Pharmaceuticals Inc., Ingelheim, Germany.,Warwick Medical School, University of Warwick, UK
| | - Jennifer B Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjay Kaul
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Gregory Y H Lip
- Institute of Cardiovascular Science, University of Birmingham, UK, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nikolaus Marx
- Department of Internal Medicine I, Cardiology, RWTH Aachen University, Aachen, Germany
| | | | | | | | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital Departments of Surgery, and Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital, Wurzburg, Germany
| | | | - Faiez Zannad
- Inserm CIC 1433, U 1116, Université de Lorraine and CHU, Nancy, France
| | - Stefan D Anker
- Department of Cardiology and Pneumology, University Medical Centre Göttingen, Göttingen, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK).,Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Berlin, Germany.,Charité Universitätsmedizin Berlin, Germany
| | | |
Collapse
|
24
|
Butler J, Hamo CE, Udelson JE, O'Connor C, Sabbah HN, Metra M, Shah SJ, Kitzman DW, Teerlink JR, Bernstein HS, Brooks G, Depre C, DeSouza MM, Dinh W, Donovan M, Frische-Danielson R, Frost RJ, Garza D, Gohring UM, Hellawell J, Hsia J, Ishihara S, Kay-Mugford P, Koglin J, Kozinn M, Larson CJ, Mayo M, Gan LM, Mugnier P, Mushonga S, Roessig L, Russo C, Salsali A, Satler C, Shi V, Ticho B, van der Laan M, Yancy C, Stockbridge N, Gheorghiade M. Reassessing Phase II Heart Failure Clinical Trials: Consensus Recommendations. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003800. [PMID: 28356300 DOI: 10.1161/circheartfailure.116.003800] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/22/2017] [Indexed: 01/08/2023]
Abstract
The increasing burden and the continued suboptimal outcomes for patients with heart failure underlines the importance of continued research to develop novel therapeutics for this disorder. This can only be accomplished with successful translation of basic science discoveries into direct human application through effective clinical trial design and execution that results in a substantially improved clinical course and outcomes. In this respect, phase II clinical trials play a pivotal role in determining which of the multitude of potential basic science discoveries should move to the large and expansive registration trials in humans. A critical examination of the phase II trials in heart failure reveals multiple shortcomings in their concept, design, execution, and interpretation. To further a dialogue on the challenges and potential for improvement and the role of phase II trials in patients with heart failure, the Food and Drug Administration facilitated a meeting on October 17, 2016, represented by clinicians, researchers, industry members, and regulators. This document summarizes the discussion from this meeting and provides key recommendations for future directions.
Collapse
Affiliation(s)
- Javed Butler
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.).
| | - Carine E Hamo
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - James E Udelson
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Christopher O'Connor
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Hani N Sabbah
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Marco Metra
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Sanjiv J Shah
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Dalane W Kitzman
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - John R Teerlink
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Harold S Bernstein
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Gabriel Brooks
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Christophe Depre
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Mary M DeSouza
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Wilfried Dinh
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Mark Donovan
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Regina Frische-Danielson
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Robert J Frost
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Dahlia Garza
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Udo-Michael Gohring
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Jennifer Hellawell
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Judith Hsia
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Shiro Ishihara
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Patricia Kay-Mugford
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Joerg Koglin
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Marc Kozinn
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Christopher J Larson
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Martha Mayo
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Li-Ming Gan
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Pierrre Mugnier
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Sekayi Mushonga
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Lothar Roessig
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Cesare Russo
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Afshin Salsali
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Carol Satler
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Victor Shi
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Barry Ticho
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Michael van der Laan
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Clyde Yancy
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Norman Stockbridge
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| | - Mihai Gheorghiade
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Division of Cardiology, Inova Heart & Vascular Institute, Falls Church, VA (C.O'C.); Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (H.N.S.); Division of Cardiology, University of Brescia and Civil Hospital, Italy (M.M.); Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., C.Y.); Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.); Division of Cardiology, University of California San Francisco (J.R.T.); Merck & Co., Kenilworth, NJ (H.S.B., J.K.); Gilead Sciences, Foster City, CA (G.B., J.H., C.S.); Amgen Inc., Thousand Oaks, CA (C.D., M.K.); Bristol-Myers Squibb, Princeton, NJ (M.M.D., M.D., R.J.F., P.M., S.M., C.R.); Bayer, Wuppertal, Germany (W.D., M.v.d.L.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); AstraZeneca, Gaithersburg, MD (R.F.-D., J.H., L.-M.G.); AstraZeneca, Gothenburg, Sweden (R.F.-D., J.H., L.-M.G.); Relypsa Inc., Redwood City, CA (D.G., M.M.); Vifor Pharma, Opfikon, Switzerland (U.-M.G.); Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan (S.I.); Novartis Pharmaceuticals Inc., East Hanover, NJ (P.K.-M., V.S.); Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA (C.J.L.); Bayer Pharma AG, Wuppertal, Germany (L.R.); Cardiology Division, Columbia University Medical Center, New York, NY (C.R.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Moderna Therapeutics, Cambridge, MA (B.T.); Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.); Center for Cardiovascular Innovation, Feinberg School of Medicine, Northwestern University, Chicago, IL (M.G.)
| |
Collapse
|
25
|
Butler J, Hamo CE, Udelson JE, Pitt B, Yancy C, Shah SJ, Desvigne-Nickens P, Bernstein HS, Clark RL, Depre C, Dinh W, Hamer A, Kay-Mugford P, Kramer F, Lefkowitz M, Lewis K, Maya J, Maybaum S, Patel MJ, Pollack PS, Roessig L, Rotman S, Salsali A, Sims JJ, Senni M, Rosano G, Dunnmon P, Stockbridge N, Anker SD, Zile MR, Gheorghiade M. Exploring New Endpoints for Patients With Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003358. [PMID: 27756791 DOI: 10.1161/circheartfailure.116.003358] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The epidemiological, clinical, and societal implications of the heart failure (HF) epidemic cannot be overemphasized. Approximately half of all HF patients have HF with preserved ejection fraction (HFpEF). HFpEF is largely a syndrome of the elderly, and with aging of the population, the proportion of patients with HFpEF is expected to grow. Currently, there is no drug known to improve mortality or hospitalization risk for these patients. Besides mortality and hospitalization, it is imperative to realize that patients with HFpEF have significant impairment in their functional capacity and their quality of life on a daily basis, underscoring the need for these parameters to ideally be incorporated within a regulatory pathway for drug approval. Although attempts should continue to explore therapies to reduce the risk of mortality or hospitalization for these patients, efforts should also be directed to improve other patient-centric concerns, such as functional capacity and quality of life. To initiate a dialogue about the compelling need for and the challenges in developing such alternative endpoints for patients with HFpEF, the US Food and Drug Administration on November 12, 2015, facilitated a meeting represented by clinicians, academia, industry, and regulatory agencies. This document summarizes the discussion from this meeting.
Collapse
Affiliation(s)
- Javed Butler
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.).
| | - Carine E Hamo
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - James E Udelson
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Bertram Pitt
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Clyde Yancy
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Sanjiv J Shah
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Patrice Desvigne-Nickens
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Harold S Bernstein
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Richard L Clark
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Christophe Depre
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Wilfried Dinh
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Andrew Hamer
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Patricia Kay-Mugford
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Frank Kramer
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Martin Lefkowitz
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Kelly Lewis
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Juan Maya
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Simon Maybaum
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Mahesh J Patel
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Pia S Pollack
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Lothar Roessig
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Sarit Rotman
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Afshin Salsali
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - J Jason Sims
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Michele Senni
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Giuseppe Rosano
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Preston Dunnmon
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Norman Stockbridge
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Stefan D Anker
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Michael R Zile
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Mihai Gheorghiade
- From the Department of Medicine, Stony Brook University, NY (J.B., C.E.H.); Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA (J.E.U.); Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.); Division of Cardiology (C.Y., S.J.S.) and Center for Cardiovascular Innovation (M.G.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (P.D.-N); Merck & Co, Kenilworth, NJ (H.S.B.); Medtronic, Mounds View, MN (R.L.C., J.J.S.); Amgen Inc, Thousand Oaks, CA (C.D., A.H., J.M.); Bayer Pharma AG, Wuppertal, Germany (W.D., F.K., K.L., L.R., S.R.); Department of Cardiology, HELIOS Clinic Wuppertal, University Hospital Witten/Herdecke, Germany (W.D.); Novartis Pharmaceuticals Inc, East Hanover, NJ (P.K.-M., M.L., S.M.); Clinical Research in Cardiovascular Disease Division, Merck Research Laboratories, Rahway, NJ (M.J.P.); AstraZeneca Global Medicines Development, Gaithersburg, MD (P.S.P.); Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.); Dipartimento Cardiovascolare, Azienda Ospedaliera Papa Giovannni XXIII, Bergamo, Italy (M.S.); Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy (G.R.); Cardiovascular and Cell Science Institute, St George's University of London, United Kingdom (G.R.); Division of Cardiovascular and Renal Products, the United States Food and Drug Administration, Silver Spring, MD (P.D., N.S.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Germany (S.D.A.); and Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| |
Collapse
|
26
|
Salsali A, Kim G, Woerle HJ, Broedl UC, Hantel S. Cardiovascular safety of empagliflozin in patients with type 2 diabetes: a meta-analysis of data from randomized placebo-controlled trials. Diabetes Obes Metab 2016; 18:1034-40. [PMID: 27376831 PMCID: PMC5096016 DOI: 10.1111/dom.12734] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 01/07/2023]
Abstract
AIM To assess the effect of empagliflozin on cardiovascular (CV) risk in patients with type 2 diabetes (T2DM) through a meta-analysis of data from eight placebo-controlled trials. METHODS Data were analysed from eight randomized placebo-controlled trials undertaken to investigate the efficacy and safety of empagliflozin 10 and 25 mg once daily in patients with T2DM, comprising patients at low/medium and high CV risk. Suspected CV events were prospectively adjudicated. The empagliflozin 10 and 25 mg groups were pooled for the primary analysis. The primary endpoint was a composite of CV death, non-fatal myocardial infarction (MI), non-fatal stroke and hospitalization for unstable angina [4-point major adverse CV events (MACE)]. The secondary endpoint was a composite of CV death, non-fatal MI and non-fatal stroke (3-point MACE). Risk estimates were calculated using Cox regression analysis. RESULTS A total of 3835 patients received placebo and 7457 received empagliflozin. Total exposure was 7448.3 years for placebo and 15482.1 years for empagliflozin. Four-point MACE occurred in 365 (9.5%) patients receiving placebo and 635 (8.5%) patients receiving empagliflozin [hazard ratio for empagliflozin vs. placebo 0.86 (95% CI 0.76, 0.98)]. Three-point MACE occurred in 307 (8.0%) patients receiving placebo and 522 (7.0%) patients receiving empagliflozin [hazard ratio for empagliflozin vs. placebo 0.84 (95% CI 0.73, 0.96)]. CONCLUSIONS In a meta-analysis of data from eight randomized trials involving 11 292 patients with T2DM at low/medium or high CV risk, empagliflozin was associated with a reduced risk of 4-point MACE and 3-point MACE compared with placebo.
Collapse
Affiliation(s)
- A Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA.
| | - G Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - H J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - U C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - S Hantel
- Boehringer Ingelheim Pharma GmbH, Biberach, Germany
| |
Collapse
|
27
|
Yoon KH, Nishimura R, Lee J, Crowe S, Salsali A, Hach T, Woerle HJ. Efficacy and safety of empagliflozin in patients with type 2 diabetes from Asian countries: pooled data from four phase III trials. Diabetes Obes Metab 2016; 18:1045-9. [PMID: 27265507 DOI: 10.1111/dom.12699] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/23/2016] [Accepted: 06/01/2016] [Indexed: 01/04/2023]
Abstract
We investigated the efficacy and safety of empagliflozin over 24 weeks in Asian patients with type 2 diabetes (T2DM) using pooled data from four phase III trials. In these trials, patients were randomized to receive empagliflozin 10 mg, empagliflozin 25 mg or placebo as monotherapy or add-on to metformin, metformin plus sulphonylurea or pioglitazone ± metformin. In total, 1326 patients from Asia received ≥1 dose of study drug. At week 24, adjusted mean differences versus placebo in change from baseline in glycated haemoglobin (HbA1c) were -0.66% [95% confidence interval (CI) -0.76, -0.56] and -0.73% (95% CI -0.83, -0.64) and in weight were -1.6 kg (95% CI -1.9, -1.3) and -1.8 kg (95% CI -2.1, -1.5) with empagliflozin 10 and 25 mg, respectively (all p < 0.001). Empagliflozin significantly reduced systolic and diastolic blood pressure. The proportion of patients reporting ≥1 adverse event was similar across treatment groups, but events consistent with genital infection were more common in patients treated with empagliflozin 10 mg (3.4%) or 25 mg (2.3%) than placebo (0.9%). Thus in Asian patients with T2DM, empagliflozin reduced HbA1c, weight and blood pressure, and was well tolerated.
Collapse
Affiliation(s)
- Kun-Ho Yoon
- Seoul St. Mary's Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea.
| | | | - Jisoo Lee
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Susanne Crowe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | - Thomas Hach
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| |
Collapse
|
28
|
Pratley RE, Salsali A, Matfin G. Review: Inhibition of dipeptidyl peptidase-4 with vildagliptin: a potential new treatment for type 2 diabetes. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/14746514060060040201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Type 2 diabetes mellitus is a growing problem in most parts of the world. There is now good evidence that controlling hyperglycaemia can help prevent many of the serious complications associated with the disease. Despite this evidence and the availability of several classes of oral antidiabetic agents and insulin, many people with diabetes do not achieve adequate glycaemic control (i.e. HbA1C< 6.5 or 7.0%). Thus, there is an urgent unmet medical need to develop new and better treatments for type 2 diabetes. Among the most promising new classes of drugs for type 2 diabetes are those that leverage the incretin hormone glucagon-like peptide-1 (GLP-1). Vildagliptin, an orally available, potent and specific inhibitor of dipeptidyl peptidase-4 (DPP-4), the enzyme that rapidly inactivates GLP-1, augments endogenous active GLP-1 and gastric inhibitory polypeptide/glucose-dependent insulinotropic polypeptide (GIP) and reduces hyperglycaemia in patients with type 2 diabetes. Studies to date in patients exposed for up to one year indicate that vildagliptin produces clinically significant reductions in HbA1C when used as monotherapy and in combination with metformin, glimepiride, or insulin. In general, the drug has proved to be well tolerated with low rates of hypoglycaemia and gastrointestinal side effects (including nausea) and no weight gain or oedema.
Collapse
Affiliation(s)
- Richard E Pratley
- Diabetes and Metabolism Translational Medicine Unit, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Vermont College of Medicine, USA,
| | - Afshin Salsali
- Diabetes and Metabolism Translational Medicine Unit, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Vermont College of Medicine, USA
| | - Glenn Matfin
- Novo Nordisk Inc. 100 College Road West, Princeton, New Jersey 08540, USA, Division of Endocrinology and Diabetes, Department of Medicine, New York University School of Medicine, New York, New York, USA
| |
Collapse
|
29
|
Lund SS, Sattar N, Salsali A, Crowe S, Broedl UC, Ginsberg HN. Potential relevance of changes in haematocrit to changes in lipid parameters with empagliflozin in patients with type 2 diabetes. DIABETOL STOFFWECHS 2016. [DOI: 10.1055/s-0036-1580882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
30
|
Ridderstrale M, Elsasser U, Zeller C, Hantel S, Salsali A, Broedl UC. Influence of baseline HbA1c, BMI, β-cell function and insulin sensitivity on the treatment response of empagliflozin in patients with type 2 diabetes. DIABETOL STOFFWECHS 2016. [DOI: 10.1055/s-0036-1580784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
31
|
Kohler S, Salsali A, Hantel S, Kim G, Woerle HJ, Broedl UC. Safety and tolerability of empagliflozin in patients with type 2 diabetes. DIABETOL STOFFWECHS 2016. [DOI: 10.1055/s-0036-1580888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
32
|
Kohler S, Salsali A, Hantel S, Kaspers S, Woerle HJ, Kim G, Broedl UC. Safety and Tolerability of Empagliflozin in Patients with Type 2 Diabetes. Clin Ther 2016; 38:1299-1313. [PMID: 27085585 DOI: 10.1016/j.clinthera.2016.03.031] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/21/2016] [Accepted: 03/22/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this analysis was to establish the safety profile and tolerability of empagliflozin in patients with type 2 diabetes mellitus (T2DM) according to pooled data from several clinical trials. METHODS Pooled data were analyzed from patients with T2DM treated with placebo (n = 3695), empagliflozin 10 mg (n = 3806), or empagliflozin 25 mg (n = 4782) in 17 randomized, Phase I, II, and III clinical trials plus 6 extension studies. Adverse events (AEs) were assessed descriptively in patients who took ≥1 dose of the study drug. AE incidence rates per 100 patient-years were calculated to adjust for differences in drug exposure across trials. FINDINGS Total exposure was 3254, 3840, and 5649 patient-years in the placebo, empagliflozin 10 mg, and empagliflozin 25 mg groups, respectively. The incidence of any AEs, AEs leading to treatment discontinuation, severe AEs, and serious AEs was no higher in patients treated with empagliflozin than with placebo. Empagliflozin was not associated with an increased risk of hypoglycemia versus placebo, except in patients on background sulfonylurea and/or insulin. The incidence of events consistent with urinary tract infection was similar across treatment groups (9.4-11.3/100 patient-years); 0.4%, 0.2%, and 0.3% of patients in the placebo, empagliflozin 10 mg, and empagliflozin 25 mg groups, respectively, had urinary tract infections that required or prolonged hospitalization. The incidence of events consistent with genital infection was higher in patients treated with empagliflozin (4.7 and 5.0/100 patient-years for empagliflozin 10 and 25 mg, respectively) than placebo (1.3/100 patient-years), but only 0.1%, 0.1%, and <0.1% in the placebo, empagliflozin 10 mg, and empagliflozin 25 mg groups, respectively, had genital infections that required or prolonged hospitalization. The incidence of AEs consistent with volume depletion was similar with placebo, empagliflozin 10 mg, and empagliflozin 25 mg (1.6, 1.5, and 1.3/100 patient-years, respectively) and was higher with empagliflozin 25 mg than placebo or empagliflozin 10 mg in patients aged >75 years (4.4 vs 2.3 and 2.5/100 patient-years, respectively). The incidences of bone fractures, malignancies, decreased renal function, hepatic injury, venous thromboembolic events, and diabetic ketoacidosis were low and similar across the treatment groups. IMPLICATIONS In this predefined analysis that was based on >9000 patient-years' exposure to empagliflozin, empagliflozin 10 mg, and empagliflozin 25 mg were well tolerated in patients with T2DM.
Collapse
Affiliation(s)
- Sven Kohler
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany.
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH, Biberach an der Riss, Germany
| | - Stefan Kaspers
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Gabriel Kim
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| |
Collapse
|
33
|
Fitchett D, Zinman B, Wanner C, Lachin JM, Hantel S, Salsali A, Johansen OE, Woerle HJ, Broedl UC, Inzucchi SE. Heart failure outcomes with empagliflozin in patients with type 2 diabetes at high cardiovascular risk: results of the EMPA-REG OUTCOME® trial. Eur Heart J 2016; 37:1526-34. [PMID: 26819227 PMCID: PMC4872285 DOI: 10.1093/eurheartj/ehv728] [Citation(s) in RCA: 688] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/10/2015] [Indexed: 12/20/2022] Open
Abstract
Aims We previously reported that in the EMPA-REG OUTCOME® trial, empagliflozin added to standard of care reduced the risk of 3-point major adverse cardiovascular events, cardiovascular and all-cause death, and hospitalization for heart failure in patients with type 2 diabetes and high cardiovascular risk. We have now further investigated heart failure outcomes in all patients and in subgroups, including patients with or without baseline heart failure. Methods and results Patients were randomized to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo. Seven thousand and twenty patients were treated; 706 (10.1%) had heart failure at baseline. Heart failure hospitalization or cardiovascular death occurred in a significantly lower percentage of patients treated with empagliflozin [265/4687 patients (5.7%)] than with placebo [198/2333 patients (8.5%)] [hazard ratio, HR: 0.66 (95% confidence interval: 0.55–0.79); P < 0.001], corresponding to a number needed to treat to prevent one heart failure hospitalization or cardiovascular death of 35 over 3 years. Consistent effects of empagliflozin were observed across subgroups defined by baseline characteristics, including patients with vs. without heart failure, and across categories of medications to treat diabetes and/or heart failure. Empagliflozin improved other heart failure outcomes, including hospitalization for or death from heart failure [2.8 vs. 4.5%; HR: 0.61 (0.47–0.79); P < 0.001] and was associated with a reduction in all-cause hospitalization [36.8 vs. 39.6%; HR: 0.89 (0.82–0.96); P = 0.003]. Serious adverse events and adverse events leading to discontinuation were reported by a higher proportion of patients with vs. without heart failure at baseline in both treatment groups, but were no more common with empagliflozin than with placebo. Conclusion In patients with type 2 diabetes and high cardiovascular risk, empagliflozin reduced heart failure hospitalization and cardiovascular death, with a consistent benefit in patients with and without baseline heart failure.
Collapse
Affiliation(s)
- David Fitchett
- St Michael's Hospital, Division of Cardiology, University of Toronto, Toronto, Canada
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Christoph Wanner
- Comprehensive Heart Failure Center and Renal Division, University of Wuerzburg and Hospital, Wuerzburg, Germany
| | - John M Lachin
- The Biostatistics Center, The George Washington University, Rockville, MD, USA
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., 900 Ridgebury Road, Ridgefield, CT 06877, USA
| | | | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | | |
Collapse
|
34
|
Roden M, Merker L, Christiansen AV, Roux F, Salsali A, Kim G, Stella P, Woerle HJ, Broedl UC. Safety, tolerability and effects on cardiometabolic risk factors of empagliflozin monotherapy in drug-naïve patients with type 2 diabetes: a double-blind extension of a Phase III randomized controlled trial. Cardiovasc Diabetol 2015; 14:154. [PMID: 26701110 PMCID: PMC4690334 DOI: 10.1186/s12933-015-0314-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/08/2015] [Indexed: 12/18/2022] Open
Abstract
Background To investigate the long-term efficacy and safety of empagliflozin monotherapy compared with placebo and sitagliptin in drug-naïve patients with type 2 diabetes mellitus. Methods Of 899 patients randomized to receive empagliflozin 10 mg, empagliflozin 25 mg, placebo, or sitagliptin 100 mg once daily for 24 weeks, 615 continued in a double-blind extension trial for ≥52 weeks. Exploratory endpoints included changes from baseline in HbA1c, weight and blood pressure at week 76. Results Compared with placebo, adjusted mean changes from baseline in HbA1c at week 76 were −0.78 % (95 % CI −0.94, −0.63; p < 0.001) and −0.89 % (95 % CI −1.04, −0.73; p < 0.001) for empagliflozin 10 mg and 25 mg, respectively. Compared with placebo, adjusted mean changes from baseline in weight at week 76 were −1.8 kg (95 % CI −2.4, −1.3; p < 0.001) and −2.0 kg (95 % CI −2.6, −1.5; p < 0.001) for empagliflozin 10 mg and 25 mg, respectively. Empagliflozin led to reductions in systolic blood pressure (SBP) compared with placebo in the primary analysis but not in sensitivity analyses. Compared with sitagliptin, empagliflozin 25 mg reduced HbA1c and both empagliflozin doses reduced weight and SBP. Adverse events (AEs) were reported in 76.8, 78.0, 76.4 and 72.2 % of patients on empagliflozin 10 mg, empagliflozin 25 mg, placebo and sitagliptin, respectively. Confirmed hypoglycaemic AEs (glucose ≤3.9 mmol/l and/or requiring assistance) were reported in two patients (0.9 %) per treatment group. Conclusions Empagliflozin monotherapy for ≥76 weeks was well tolerated and led to sustained reductions in HbA1c and weight compared with placebo. Trial registration: clinicaltrials.gov NCT01289990 Electronic supplementary material The online version of this article (doi:10.1186/s12933-015-0314-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany. .,Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Düsseldorf, Germany. .,German Center for Diabetes Research, Partner Düsseldorf, Düsseldorf, Germany.
| | | | | | - Flavien Roux
- Boehringer Ingelheim France S.A.S., Reims, France.
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA.
| | - Gabriel Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Peter Stella
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | | |
Collapse
|
35
|
Merker L, Häring HU, Christiansen AV, Roux F, Salsali A, Kim G, Meinicke T, Woerle HJ, Broedl UC. Empagliflozin as add-on to metformin in people with Type 2 diabetes. Diabet Med 2015; 32:1555-67. [PMID: 26031566 DOI: 10.1111/dme.12814] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 01/01/2023]
Abstract
AIMS To investigate the long-term efficacy and safety of empagliflozin as add-on to metformin in people with Type 2 diabetes. METHODS Of 637 participants treated with empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily for 24 weeks, 463 (72.7%) were treated in a double-blind extension trial for ≥ 52 weeks. Prespecified exploratory endpoints included changes from baseline in HbA1c , weight and blood pressure at week 76. RESULTS Compared with placebo, adjusted mean changes from baseline in HbA1c (overall baseline mean ± sd 63 ± 9 mmol/mol [7.9 ± 0.9%]) were -7 mmol/mol [(-0.6%) 95% CI -8, -5 mmol/mol (-0.8, -0.5%); P < 0.001] and -8 mmol/mol [(-0.7%) 95% CI -10, -6 mmol/mol (-0.9, -0.6%); P < 0.001], for empagliflozin 10 mg and 25 mg, respectively. Compared with placebo, adjusted mean changes from baseline in weight were -1.9 kg (95% CI -2.5, -1.3; P < 0.001) and -2.2 kg (95% CI -2.8, -1.6; P < 0.001) for empagliflozin 10 mg and 25 mg, respectively. Empagliflozin led to sustained reductions in systolic blood pressure vs. placebo. Adverse events were reported in 77.7, 80.2 and 72.0% of participants on placebo, empagliflozin 10 mg and empagliflozin 25 mg, respectively. Confirmed hypoglycaemic adverse events (glucose ≤ 3.9 mmol/l and/or event requiring assistance) were reported in 3.4, 4.1 and 4.2% of participants in these groups, respectively. CONCLUSIONS In people with Type 2 diabetes, empagliflozin 10 mg and 25 mg given as add-on to metformin for 76 weeks were well tolerated and led to sustained reductions in HbA1c , weight and systolic blood pressure.
Collapse
Affiliation(s)
- L Merker
- Diabetes- und Nierenzentrum, Dormagen, Germany
| | - H-U Häring
- University of Tübingen, Tübingen, Germany
| | | | - F Roux
- Boehringer Ingelheim France S.A.S., Reims, France
| | - A Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - G Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - T Meinicke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - H J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - U C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| |
Collapse
|
36
|
Haering HU, Merker L, Christiansen AV, Roux F, Salsali A, Kim G, Meinicke T, Woerle HJ, Broedl UC. Empagliflozin as add-on to metformin plus sulphonylurea in patients with type 2 diabetes. Diabetes Res Clin Pract 2015; 110:82-90. [PMID: 26324220 DOI: 10.1016/j.diabres.2015.05.044] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 05/06/2015] [Accepted: 05/19/2015] [Indexed: 11/27/2022]
Abstract
This study investigated the long-term efficacy and safety of empagliflozin as add-on to metformin plus sulphonylurea in patients with type 2 diabetes mellitus (T2DM). Of 666 patients treated with empagliflozin 10 mg, empagliflozin 25 mg or placebo once daily for 24 weeks, 472 patients (70.9%) were treated in a double-blind extension trial for ≥52 weeks. Pre-specified exploratory endpoints included changes from baseline in HbA(1c), weight and blood pressure at week 76. At week 76, adjusted mean differences versus placebo in change from baseline in HbA(1c) were -0.7% (-8 mmol/mol) with empagliflozin 10 mg or 25 mg (both p<0.001), in weight were -1.8 kg and -1.6 kg with empagliflozin 10 mg and 25 mg, respectively (both p<0.001), and in systolic blood pressure (SBP) were -2.2 mmHg with empagliflozin 10 mg (p=0.021) and -2.1 mmHg with empagliflozin 25 mg (p=0.029). Sensitivity analyses provided consistent results for HbA1c and weight, but showed no significant difference between empagliflozin and placebo in change from baseline in SBP. Adverse events (AEs) were reported in 81.7%, 82.0% and 81.3% of patients on empagliflozin 10 mg, 25 mg and placebo, respectively. Confirmed hypoglycaemic AEs (glucose ≤3.9 mmol/l and/or requiring assistance) were reported in 23.7%, 19.4% and 15.6% of patients on empagliflozin 10 mg, 25 mg and placebo, respectively; one patient each on empagliflozin 10mg and placebo required assistance. In conclusion, empagliflozin as add-on to metformin plus sulphonylurea for 76 weeks was well tolerated and led to sustained reductions in HbA1c and weight versus placebo. CLINICALTRIALS.GOV: NCT01289990.
Collapse
Affiliation(s)
- Hans-Ulrich Haering
- Department of Internal Medicine IV, University of Tübingen, Otfried-Muller-Str. 10, 72076 Tübingen, Germany.
| | - Ludwig Merker
- Diabetes- und Nierenzentrum, Dormagen, Elsa-Brändström-Str. 17, D-41540 Dormagen, Germany.
| | | | - Flavien Roux
- Boehringer Ingelheim Reims S.A.S., 12 Rue André Huet, 51100 Reims, France.
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, Ridgefield, CT 06788, USA.
| | - Gabriel Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Str. 173, 55216 Ingelheim, Germany.
| | - Thomas Meinicke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Str. 65, 88397 Biberach, Germany.
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Str. 173, 55216 Ingelheim, Germany.
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Str. 173, 55216 Ingelheim, Germany.
| |
Collapse
|
37
|
Araki E, Tanizawa Y, Tanaka Y, Taniguchi A, Koiwai K, Kim G, Salsali A, Woerle HJ, Broedl UC. Long-term treatment with empagliflozin as add-on to oral antidiabetes therapy in Japanese patients with type 2 diabetes mellitus. Diabetes Obes Metab 2015; 17:665-74. [PMID: 25772548 DOI: 10.1111/dom.12464] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/06/2015] [Accepted: 03/10/2015] [Indexed: 01/11/2023]
Abstract
AIMS To evaluate the safety and efficacy of empagliflozin for 52 weeks as add-on to one other oral antidiabetes therapy in Japanese patients with type 2 diabetes mellitus (T2DM). METHODS Patients on biguanide (n = 133), thiazolidinedione (n = 273), α-glucosidase inhibitor (n = 139), dipeptidyl-peptidase-4 inhibitor (n = 139) or glinide (n = 140) were randomized 1 : 1 to receive empagliflozin 10 or 25 mg double-blind as add-on therapy for 52 weeks. Patients on sulphonylurea (SU; n = 336) were randomized 2 : 2 : 1 to receive empagliflozin 10 or 25 mg double-blind or open-label metformin as add-on therapy for 52 weeks. The primary objective was to evaluate safety. Change from baseline in glycated haemoglobin (HbA1c) at week 52 was a secondary endpoint. RESULTS Adverse events (AEs) were reported in 67.6-84.6% of patients receiving empagliflozin. Confirmed hypoglycaemic AEs (plasma glucose ≤70 mg/dl and/or requiring assistance) were reported in 4.4 and 6.6%, respectively, of patients receiving empagliflozin 10 and 25 mg as add-on to SU and in 0.0 to 2.9%, respectively, of patients receiving empagliflozin 10 and 25 mg as add-on to other therapies. Baseline mean ± standard deviation HbA1c ranged from 7.51 ± 0.73 to 8.06 ± 0.76% across background therapy groups. At week 52, adjusted mean ± standard error changes from baseline in HbA1c ranged from -0.77 ± 0.06 to -1.00 ± 0.06% in patients receiving empagliflozin. CONCLUSIONS In Japanese patients with T2DM, empagliflozin 10 and 25 mg as add-on to one other oral antidiabetes therapy for 52 weeks were well tolerated and were associated with clinically meaningful reductions in HbA1c.
Collapse
Affiliation(s)
- E Araki
- Department of Metabolic Medicine, Kumamoto University, Kumamoto, Japan
| | - Y Tanizawa
- Division of Endocrinology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Y Tanaka
- Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - A Taniguchi
- Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - K Koiwai
- Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - G Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - A Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - H J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - U C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| |
Collapse
|
38
|
Merker L, Lund SS, Hantel S, Salsali A, Kim G, Broedl UC, Woerle HJ, Hach T. Efficacy and safety of Empagliflozin in younger, overweight/obese patients with Type 2 diabetes with HbA1c ≥8%. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0035-1549618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
39
|
Häring HU, Merker L, Roux F, Salsali A, Kim G, Meinicke T, Woerle HJ, Broedl UC. Empagliflozin as add-on to metformin plus sulfonylurea in patients with type 2 diabetes. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0035-1549551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
40
|
Tikkanen I, Narko K, Zeller C, Green A, Salsali A, Broedl UC, Woerle HJ. Empagliflozin reduces blood pressure in patients with type 2 diabetes and hypertension. Diabetes Care 2015; 38:420-8. [PMID: 25271206 DOI: 10.2337/dc14-1096] [Citation(s) in RCA: 342] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the efficacy, safety, and tolerability of empagliflozin in patients with type 2 diabetes and hypertension. RESEARCH DESIGN AND METHODS Patients (N = 825) with type 2 diabetes and hypertension (mean seated systolic blood pressure [SBP] 130-159 mmHg and diastolic blood pressure [DBP] 80-99 mmHg) were randomized (double blind) to 10 mg or 25 mg empagliflozin or placebo once daily for 12 weeks. RESULTS At week 12, adjusted mean difference versus placebo in change from baseline in mean 24-h SBP (ambulatory blood pressure monitoring [ABPM]) was -3.44 mmHg (95% CI -4.78, -2.09) with 10 mg empagliflozin and -4.16 mmHg (-5.50, -2.83) with 25 mg empagliflozin (both P < 0.001). At week 12, adjusted mean difference versus placebo in change from baseline in mean 24-h DBP (ABPM) was -1.36 mmHg (95% CI -2.15, -0.56) with 10 mg empagliflozin and -1.72 mmHg (95% CI -2.51, -0.93) with 25 mg empagliflozin (both P < 0.001). Changes in office BP were consistent with ABPM. Adjusted mean difference versus placebo in change from baseline in HbA1c at week 12 was -0.62% (95% CI -0.72, -0.52) (-6.8 mmol/mol [95% CI -7.9, -5.7]) with 10 mg empagliflozin and -0.65% (95% CI -0.75, -0.55) (-7.1 mmol/mol [95% CI -8.2, -6.0]) with 25 mg empagliflozin (both P < 0.001). Empagliflozin was well tolerated. One patient on placebo and one patient on 10 mg empagliflozin reported events consistent with volume depletion. CONCLUSIONS Empagliflozin was associated with significant and clinically meaningful reductions in BP and HbA1c versus placebo and was well tolerated in patients with type 2 diabetes and hypertension.
Collapse
Affiliation(s)
- Ilkka Tikkanen
- Department of Medicine, Helsinki University Central Hospital, and Minerva Institute for Medical Research, Helsinki, Finland
| | - Kirsi Narko
- Boehringer Ingelheim Finland Ky, Helsinki, Finland
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Afshin Salsali
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | |
Collapse
|
41
|
Nishimura R, Tanaka Y, Koiwai K, Inoue K, Hach T, Salsali A, Lund SS, Broedl UC. Effect of empagliflozin monotherapy on postprandial glucose and 24-hour glucose variability in Japanese patients with type 2 diabetes mellitus: a randomized, double-blind, placebo-controlled, 4-week study. Cardiovasc Diabetol 2015; 14:11. [PMID: 25633683 PMCID: PMC4339254 DOI: 10.1186/s12933-014-0169-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/28/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND This study evaluated the effect of empagliflozin on postprandial glucose (PPG) and 24-hour glucose variability in Japanese patients with type 2 diabetes mellitus (T2DM). METHODS Patients (N = 60; baseline mean [SD] HbA1c 7.91 [0.80]%; body mass index 24.3 [3.2] kg/m(2)) were randomized to receive empagliflozin 10 mg (n = 20), empagliflozin 25 mg (n = 19) or placebo (n = 21) once daily as monotherapy for 28 days. A meal tolerance test and continuous glucose monitoring (CGM) for 24 hours were performed at baseline and on days 1 and 28. The primary endpoint was change from baseline in area under the glucose concentration-time curve 3 hours after breakfast (AUC1-4h for PPG) at day 28. RESULTS Adjusted mean (95%) differences versus placebo in changes from baseline in AUC1-4h for PPG at day 1 were -97.1 (-126.5, -67.8) mg · h/dl with empagliflozin 10 mg and -91.6 (-120.4, -62.8) mg · h/dl with empagliflozin 25 mg (both p < 0.001 versus placebo) and at day 28 were -85.5 (-126.0, -45.0) mg · h/dl with empagliflozin 10 mg and -104.9 (-144.8, -65.0) mg · h/dl with empagliflozin 25 mg (both p < 0.001 versus placebo). Adjusted mean (95% CI) differences versus placebo in change from baseline in 24-hour mean glucose (CGM) at day 1 were -20.8 (-27.0, -14.7) mg/dl with empagliflozin 10 mg and -23.9 (-30.0, -17.9) mg/dl with empagliflozin 25 mg (both p < 0.001 versus placebo) and at day 28 were -24.5 (-35.4, -13.6) mg/dl with empagliflozin 10 mg and -31.7 (-42.5,-20.9) mg/dl with empagliflozin 25 mg (both p < 0.001 versus placebo). Changes from baseline in mean amplitude of glucose excursions (MAGE; CGM) were not significantly different with either empagliflozin dose versus placebo at either timepoint. Curves of mean glucose (CGM) did not change between baseline and day 1 or 28 with placebo, but shifted downward with empagliflozin. Percentage of time with glucose ≥70 to <180 mg/dl increased from 52.0% at baseline to 77.0% at day 28 with empagliflozin 10 mg and from 55.0% to 81.1% with empagliflozin 25 mg, without increasing time spent with hypoglycemia. CONCLUSION Empagliflozin for 28 days reduced PPG from the first day and improved daily blood glucose control in Japanese patients with T2DM. TRIAL REGISTRATION Clinicaltrials.gov NCT01947855.
Collapse
Affiliation(s)
| | - Yuko Tanaka
- Nippon Boehringer Ingelheim Co. Ltd, Osaki 2-1-1, ThinkPark Tower, Tokyo, 141-6017, Japan.
| | - Kazuki Koiwai
- Nippon Boehringer Ingelheim Co. Ltd, Osaki 2-1-1, ThinkPark Tower, Tokyo, 141-6017, Japan.
| | | | - Thomas Hach
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA.
| | - Søren S Lund
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| |
Collapse
|
42
|
Sarashina A, Ueki K, Sasaki T, Tanaka Y, Koiwai K, Sakamoto W, Woerle HJ, Salsali A, Broedl UC, Macha S. Effect of renal impairment on the pharmacokinetics, pharmacodynamics, and safety of empagliflozin, a sodium glucose cotransporter 2 inhibitor, in Japanese patients with type 2 diabetes mellitus. Clin Ther 2014; 36:1606-15. [PMID: 25199997 DOI: 10.1016/j.clinthera.2014.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 07/11/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to assess the effect of renal impairment on the pharmacokinetic, pharmacodynamic, and safety profiles of empagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, in Japanese patients with type 2 diabetes mellitus (T2DM). METHODS In an open-label, parallel-group study, 32 Japanese patients with T2DM and different degrees of renal function (n = 8 per renal function category: normal renal function, estimated glomerular filtration rate [eGFR; Japanese equation] ≥90 mL/min/1.73 m(2); mild renal impairment, eGFR of 60-<90 mL/min/1.73 m(2); moderate renal impairment, eGFR of 30-<60 mL/min/1.73 m(2); and severe renal impairment, eGFR of 15-<30 mL/min/1.73 m(2)) received a single 25 mg dose of empagliflozin. FINDINGS Empagliflozin exposure increased with increasing renal impairment. Maximum empagliflozin plasma concentrations were similar among all renal function groups. Adjusted geometric mean ratios for extent of exposure (AUC0-∞) to empagliflozin versus normal renal function were 128.8% (95% CI, 106.0-156.6%), 143.8% (95% CI, 118.3-174.8%), and 152.3% (95% CI, 125.3-185.2%) for patients with mild, moderate, and severe renal impairment, respectively. Decreases in renal clearance of empagliflozin correlated with eGFR. Urinary glucose excretion decreased with increasing renal impairment and correlated with eGFR (adjusted mean [SE] change from baseline: 75.0 [4.84] g, 62.6 [5.75] g, 57.9 [4.86] g, and 23.7 [5.24] g for patients with normal renal function and mild, moderate, and severe renal impairment, respectively). Only 2 patients (6%) had adverse events; both were mild. IMPLICATIONS Pharmacokinetic data suggest that no dose adjustment of empagliflozin is necessary in Japanese patients with T2DM and renal impairment because increases in exposure were <2-fold. Urinary glucose excretion decreased with increasing renal impairment. ClinicalTrials.gov identifier: NCT01581658.
Collapse
Affiliation(s)
| | - Kohjiro Ueki
- Department of Molecular Sciences on Diabetes, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Molecular Diabetic Medicine, Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Yuko Tanaka
- Nippon Boehringer Ingelheim Co Ltd, Tokyo, Japan
| | | | | | - Hans J Woerle
- Boehringer Ingelheim GmbH & Co KG, Ingelheim, Germany
| | | | - Uli C Broedl
- Boehringer Ingelheim GmbH & Co KG, Ingelheim, Germany
| | - Sreeraj Macha
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| |
Collapse
|
43
|
Rosenstock J, Jelaska A, Frappin G, Salsali A, Kim G, Woerle HJ, Broedl UC. Improved glucose control with weight loss, lower insulin doses, and no increased hypoglycemia with empagliflozin added to titrated multiple daily injections of insulin in obese inadequately controlled type 2 diabetes. Diabetes Care 2014; 37:1815-23. [PMID: 24929430 DOI: 10.2337/dc13-3055] [Citation(s) in RCA: 283] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We investigated the efficacy and safety of the sodium glucose cotransporter 2 inhibitor, empagliflozin, added to multiple daily injections of insulin (MDI insulin) in obese patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS Patients inadequately controlled on MDI insulin ± metformin (mean HbA1c 8.3% [67 mmol/mol]; BMI 34.8 kg/m(2); insulin dose 92 international units/day) were randomized and treated with once-daily empagliflozin 10 mg (n = 186), empagliflozin 25 mg (n = 189), or placebo (n = 188) for 52 weeks. Insulin dose was to remain stable in weeks 1-18, adjusted to meet glucose targets in weeks 19-40, then stable in weeks 41-52. The primary end point was change from baseline in HbA1c at week 18. Secondary end points were changes from baseline in insulin dose, weight, and HbA1c at week 52. RESULTS Adjusted mean ± SE changes from baseline in HbA1c were -0.50 ± 0.05% (-5.5 ± 0.5 mmol/mol) for placebo versus -0.94 ± 0.05% (-10.3 ± 0.5 mmol/mol) and -1.02 ± 0.05% (-11.1 ± 0.5 mmol/mol) for empagliflozin 10 mg and empagliflozin 25 mg, respectively, at week 18 (both P < 0.001). At week 52, further reductions with insulin titration resulted in changes from baseline in HbA1c of -0.81 ± 0.08% (-8.9 ± 0.9 mmol/mol), -1.18 ± 0.08% (-12.9 ± 0.9 mmol/mol), and -1.27 ± 0.08% (-13.9 ± 0.9 mmol/mol) with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively, and final HbA1c of 7.5% (58 mmol/mol), 7.2% (55 mmol/mol), and 7.1% (54 mmol/mol), respectively. More patients attained HbA1c <7% (<53 mmol/mol) with empagliflozin (31-42%) versus placebo (21%; both P < 0.01). Empagliflozin 10 mg and empagliflozin 25 mg reduced insulin doses (-9 to -11 international units/day) and weight (-2.4 to -2.5 kg) versus placebo (all P < 0.01) at week 52. CONCLUSIONS In obese, difficult-to-treat patients with T2DM inadequately controlled on high MDI insulin doses, empagliflozin improved glycemic control and reduced weight without increasing the risk of hypoglycemia and with lower insulin requirements.
Collapse
Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX
| | - Ante Jelaska
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT
| | | | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT
| | - Gabriel Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | |
Collapse
|
44
|
Hach T, Gerich J, Salsali A, Kim G, Hantel S, Woerle HJ, Broedl UC. Empagliflozin improves glycemic parameters and cardiovascular risk factors in patients with Type 2 Diabetes (T2DM): Pooled data from four pivotal phase III trials. DIABETOL STOFFWECHS 2014. [DOI: 10.1055/s-0034-1374999] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
45
|
Tikkanen I, Narko K, Zeller C, Green A, Salsali A, Broedl UC, Woerle HJ. Empagliflozin improves blood pressure in patients with type 2 diabetes (T2DM) and hypertension. DIABETOL STOFFWECHS 2014. [DOI: 10.1055/s-0034-1374901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
46
|
Kim G, Gerich J, Salsali A, Hach T, Hantel S, Woerle HJ, Broedl UC. Empagliflozin (EMPA) increases genital infections but not Urinary Tract Infections (UTIs) in pooled data from four pivotal phase III trials. DIABETOL STOFFWECHS 2014. [DOI: 10.1055/s-0034-1374997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
47
|
Macha S, Koenen R, Sennewald R, Schöne K, Hummel N, Riedmaier S, Woerle HJ, Salsali A, Broedl UC. Effect of Gemfibrozil, Rifampicin, or Probenecid on the Pharmacokinetics of the SGLT2 Inhibitor Empagliflozin in Healthy Volunteers. Clin Ther 2014; 36:280-90.e1. [DOI: 10.1016/j.clinthera.2014.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 12/20/2013] [Accepted: 01/07/2014] [Indexed: 11/25/2022]
|
48
|
Parikh S, Hardy E, Wei L, Wessman C, Salsali A, Ptaszynska A. Verbesserte Blutzuckerkontrolle und Verringerung des Körpergewichts durch Dapagliflozin bei verschiedenen Patientenpopulationen mit Typ-2-Diabetes mellitus. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
49
|
Rohwedder K, Wygant G, Chalamandaris A, Iloeje U, Salsali A, Grandy S, Sugg J, Parikh S. Dapagliflozin wirksamer als Glipizid in Bezug auf den kombinierten Endpunkt aus Blutzuckerkontrolle, Gewichtsreduktion und keinen Hypoglykämien. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
50
|
Rohwedder K, Langkilde AM, Iqbal N, Ying L, Salsali A. Messung der Betazellfunktion und Insulinsensitivität im Zeitverlauf bei Patienten mit Typ-2-Diabetes, die mit Dapagliflozin im Vergleich zu Glipizid als Zusatztherapie zu Metformin behandelt werden. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|