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SGLT2 inhibitors offer hope for managing heart failure in diabetes

Cardiovascular Rehabilitation
Risk Factors and Prevention

Issei-Komuro.jpgThere is a strong connection between heart failure (HF) and diabetes, as 25—44% of patients with HF also have diabetes. A new class of drugs may be the solution to treatment in these high-risk patients.

Patients with type 2 diabetes are most likely to develop HF with preserved ejection fraction (HFPEF) rather than valve disease or left ventricular systolic dysfunction. Additionally, compared with HF patients who do not have diabetes, they have an increased risk of cardiovascular (CV) death or HF hospitalisation, are more likely to develop CV disease at a younger age, and may have less success with treatments such as coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI).

Professor Issei Komuro (Department of Cardiology, University of Tokyo, Japan) is chairing a session, alongside Professor Francesco Cosentino (Karolinska Institutet, Stockholm, Sweden), today on the prevention and management of HF in diabetes. He says that the key issues to consider when managing these patients are which diabetes drugs to use and whether glycaemic control should be lenient or strict. He adds: “SGLT2 inhibitors (gliflozins), sodium-glucose co-transporter- 2 inhibitors, are a new group of oral medications that work by helping the kidneys to lower blood glucose levels. They have been proposed as a new treatment option for patients with HF and diabetes. The evidence for this drug is based on the results from two trials—EMPA-REG OUTCOME and CANVAS.”

Both studies reviewed the use of an SGLT2 inhibitor in patients with type 2 diabetes at elevated risk of CV events. EMPA-REG OUTCOME showed that patients receiving empagliflozin had a significantly lower risk of death from CV causes, non-fatal myocardial infarction, or non-fatal stroke (the primary outcome) while CANVAS found that canagliflozin significantly lowers the risk of CV events. The trials, both of which were published in the New England Journal of Medicine, also suggested that the gliflozins reduced the risk of HF hospitalisation. However, with CANVAS, the observed lower risk of HF hospitalisation was not statistically significant. Furthermore, canagliflozin was associated with a significantly higher risk of amputation.

Data presented yesterday at the Late-Breaking Science in Heart Failure session have provided further insights into the efficacy of SGLT2 inhibitors in the context of HF and diabetes. Reporting “Insights” from the EMPA-REG OUTCOME, Doctor Javed Butler (Atlanta, USA) said: “Empagliflozin reduced the risk for HF hospitalisation and CV mortality in patients with type 2 diabetes with or without HF. In patients without HF at baseline, empagliflozin reduced HF hospitalisation and CV mortality across a spectrum of HF risk.”

Also at this session, Doctor Anna Norhammar (Stockholm, Sweden) outlined the CVD-REAL study. This study compared the use of SGLT2 inhibitors with other glucose-lowering drugs and indicated that the first use of SGLT2 inhibitors was consistently associated with a lower risk of HF events in men, women, patients under 65 years, and those older than 65. She commented: “We observed no effect modification by any of the key demographic factors, suggesting that the CV benefits associated with SGLT2 inhibitors may extend to a broad population of patients with type 2 diabetes.”

The Heart Failure in Diabetes: Prevention and Management session today examines treatment with these novel agents in further detail. It will also review exercise and diabetes prevention, the pathophysiological mechanisms of heart failure in diabetes, and the optimal weight for HF patients with and without diabetes. Prof. Komuro says: “With increasing patient numbers and death from heart failure all over the world, heart failure is becoming more and more important for cardiologists to identify and treat. Additionally, diabetes is one of the most important risk factors for heart failure, making this is a crucial session to attend.”

Resources of the session: Heart failure in diabetes: prevention and management

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