Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction

John J V McMurray, Scott D Solomon, Silvio E Inzucchi, Lars Køber, Mikhail N Kosiborod, Felipe A Martinez, Piotr Ponikowski, Marc S Sabatine, Inder S Anand, Jan Bělohlávek, Michael Böhm, Chern-En Chiang, Vijay K Chopra, Rudolf A de Boer, Akshay S Desai, Mirta Diez, Jaroslaw Drozdz, Andrej Dukát, Junbo Ge, Jonathan G Howlett, Tzvetana Katova, Masafumi Kitakaze, Charlotta E A Ljungman, Béla Merkely, Jose C Nicolau, Eileen O'Meara, Mark C Petrie, Pham N Vinh, Morten Schou, Sergey Tereshchenko, Subodh Verma, Claes Held, David L DeMets, Kieran F Docherty, Pardeep S Jhund, Olof Bengtsson, Mikaela Sjöstrand, Anna-Maria Langkilde
New England Journal of Medicine 2019 September 19

BACKGROUND: In patients with type 2 diabetes, inhibitors of sodium-glucose cotransporter 2 (SGLT2) reduce the risk of a first hospitalization for heart failure, possibly through glucose-independent mechanisms. More data are needed regarding the effects of SGLT2 inhibitors in patients with established heart failure and a reduced ejection fraction, regardless of the presence or absence of type 2 diabetes.

METHODS: In this phase 3, placebo-controlled trial, we randomly assigned 4744 patients with New York Heart Association class II, III, or IV heart failure and an ejection fraction of 40% or less to receive either dapagliflozin (at a dose of 10 mg once daily) or placebo, in addition to recommended therapy. The primary outcome was a composite of worsening heart failure (hospitalization or an urgent visit resulting in intravenous therapy for heart failure) or cardiovascular death.

RESULTS: Over a median of 18.2 months, the primary outcome occurred in 386 of 2373 patients (16.3%) in the dapagliflozin group and in 502 of 2371 patients (21.2%) in the placebo group (hazard ratio, 0.74; 95% confidence interval [CI], 0.65 to 0.85; P<0.001). A first worsening heart failure event occurred in 237 patients (10.0%) in the dapagliflozin group and in 326 patients (13.7%) in the placebo group (hazard ratio, 0.70; 95% CI, 0.59 to 0.83). Death from cardiovascular causes occurred in 227 patients (9.6%) in the dapagliflozin group and in 273 patients (11.5%) in the placebo group (hazard ratio, 0.82; 95% CI, 0.69 to 0.98); 276 patients (11.6%) and 329 patients (13.9%), respectively, died from any cause (hazard ratio, 0.83; 95% CI, 0.71 to 0.97). Findings in patients with diabetes were similar to those in patients without diabetes. The frequency of adverse events related to volume depletion, renal dysfunction, and hypoglycemia did not differ between treatment groups.

CONCLUSIONS: Among patients with heart failure and a reduced ejection fraction, the risk of worsening heart failure or death from cardiovascular causes was lower among those who received dapagliflozin than among those who received placebo, regardless of the presence or absence of diabetes. (Funded by AstraZeneca; DAPA-HF number, NCT03036124.).

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Bruno Angiulli

Speaking of the depletion volume, does the addition of dapagliflozin require a reduction of the dosage of diuretics? Thank you for your answer. Bruno Angiulli. M.D. Diabetologist


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