Researchers presented new evidence that SGLT2 inhibitors may benefit a wide range of patients with heart failure (HF). At the ESC Congress 2022 in Barcelona, and in simultaneous publications in The New England Journal of Medicine and The Lancet, physician-scientists presented late-breaking research from the largest trial to date of heart failure patients with mildly reduced or preserved ejection fraction (EF).
They showed that dapagliflozin, which had previously been shown to benefit patients with heart failure with reduced ejection fraction (HFrEF), is likely to also reduce cardiovascular death and hospitalisation for patients with mildly reduced or preserved EF, for whom therapeutic options are limited. A meta-analysis that included two clinical trials further strengthened the evidence that this class of drugs may provide protection for a wide range of heart failure patients.
Scott Solomon, MD, at the Brigham, presented results from the AstraZeneca-funded DELIVER trial, a randomised, placebo-controlled trial of dapagliflozin among patients with heart failure with mildly reduced or preserved EF.
“In the largest and most inclusive trial of heart failure with mildly reduced or preserved ejection fraction, we found that treatment with the SGLT2 inhibitor dapagliflozin can benefit patients across the full spectrum of heart failure,” explained Dr Solomon. “These findings establish SGLT2 inhibitors as foundational treatment for patients living with heart failure, regardless of ejection fraction, to help prevent hospitalisation and morbidity and to extend meaningful survival and improve health-related quality of life. These are the outcomes that matter most to patients and to clinicians – to keep patients feeling well and living longer.”
Muthiah Vaduganathan, MD MPH, also at the Brigham, presented results from a pre-specified meta-analysis of DELIVER and EMPEROR-Preserved, a large-scale clinical trial of empagliflozin, funded by Boehringer Ingelheim and Eli Lilly.
“Our meta-analysis, encompassing more than 12 000 patients, provides a summary of the totality of the evidence and drives home the message that, when it comes to heart failure, this is a therapy for all,” said Dr Vaduganathan. “These trials included patients across a broad range of ages, race, functional class, sex and medical histories, but regardless of individual characteristics, they benefited consistently from this treatment.”
Dapagliflozin is a sodium-glucose co-transporter-2 (SGLT2) inhibitor, which causes the body to excrete sugar in urine. As well as blood glucose control in diabetes, SGLT-2 inhibitors have been shown to provide significant cardiovascular and kidney disease benefits. The DELIVER trial was designed to determine whether dapagliflozin would decrease cardiovascular morbidity and mortality in patients with heart failure with mildly reduced or preserved EF.
The international trial enrolled patients aged 40 or older and had symptomatic HF with an EF of greater than 40%, including mildly reduced ejection fraction and preserved EF, as well as patients who had previously had reduced EF that had improved to greater than 40%, and in both the outpatient and inpatient setting. More than 6000 participants were randomised to receive dapagliflozin or placebo and followed for a median of 2.3 years. The primary endpoint was a composite of cardiovascular death or worsening heart failure.
Dapagliflozin significantly reduced the primary composite endpoint by 18 percent. In the dapagliflozin group, 11.8% experienced worsening heart failure compared to 14.5% of the placebo group. Cardiovascular death in these groups occurred in 7.4 % and 8.3% of participants, respectively. Key secondary outcomes were also significantly reduced, including total heart failure hospitalisations and total symptom burden.
The meta-analysis used data from DELIVER and EMPEROR-Preserved, with a composite of cardiovascular death or first hospitalisation for heart failure. SGLT2 inhibitors were found to reduce primary outcome risk by 20%. Effects were consistent across subgroups by age, sex, race, body mass index, systolic blood pressure, history of various medical conditions and more.
The team further incorporated data from additional clinical trials with SGLT2 inhibitors, including those performed with dapagliflozin and empagliflozin in patients with HFrEF, and in patients from a clinical trial of the SGLT1/2 inhibitor sotagliflozin. Taken together, the evidence with all these data suggest that patients across the full spectrum of HF benefit from this class of drugs, regardless of EF or care setting.
Limitations were noted by the authors. Black patients made up less than 5% of the patients enrolled in DELIVER; the COVID pandemic limited symptom assessment after March 2020; and subgroups in the trial were underpowered. However, findings were consistent across prespecified subgroups.
“There are more than 64 million people worldwide affected by heart failure, half of whom have mildly reduced or preserved ejection fraction,” said Dr Solomon. “Our goal is to rigorously and scientifically evaluate potential treatments so that we can provide the best evidence-based care to help them lead longer, healthier lives.”
Source: Brigham and Women’s Hospital
