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ACC House Call: Dapagliflozin for Heart Failure

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How new DAPA-HF findings continue to build the SGLT2 inhibitors’ cardiovascular portfolio.

Hello everyone and welcome back to our final round of acc twenty20 virtual house-call interviews that me and my team are conducting i’m kevin khan’s man managing editor hcp live i’m joined today by dr. sanjeev gulati md facs c chief of cardiology at the sanger heart & vascular institute and dr. gulati is going to be joining us to discuss and break down some of

These final findings that we disseminated and reported on in our acc coverage on our site this week both pertaining to some fairly well-known trials with some fairly well known drugs that by hf and paragon hf so first and foremost we’re going to break down some subgroup analysis that was taking place in def hf but first and foremost article id do you want to just

Take a moment to introduce yourself well kevin yeah thank you very much for allowing me to speak with you today as you mentioned i’m the chief of cardiology at the sanger heart vascular institute which is part of atrium health in charlotte north carolina i’m actually also the medical director for the heart fair and transplant service so kind of a dual role and been

In the heart fair field for well over 20 years so really both these trials today that we talk about are kind of in our wheelhouse of what we’re looking at and how it can take care of our fair patients better so again thank you for the time yeah absolutely and i can’t agree with you more these are seems like certainly pertinent and very relevant data discussion

Points that we now have from deb hf in paragon ehs and something then next for said to me actually even before the meeting began was the emphasis of now that we have these sglt2 inhibitors that are making rounds and sort of to some extent competing with one another to you know advance capability and known efficacy he highlighted their potential role in heart failure

And our understanding of how it benefits patients so that bigelow’s in these new findings show that they significantly reduced time to first and recurrent hospitalizations for heart failure related events and in patients do you want to break down what really stood out to you in terms of these findings and yes so i think you know to your point with def hf we know

That the primary employment was cardiovascular death heart fair hospitalization and urgent heart ferry visits and to your point in the treatment arm there was significant reduction in the primary endpoint 16.3% versus placebo which was 21.2% and really showed similar benefit from in terms of cardiovascular death and her clear hospitalization so overall kind of

The primary endpoint was very positive for depo glass closin in terms of treatment now when you break the trial down you had about 2300 patients in both arms so the treatment arm the placebo arm about 18-month follow-up the average age was about 66 a quarter of them were female so majority male and about 42 percent of the recall correctly was was or diabetic so

Over half or not so symptomatic low ejection fraction and just as we just remind everybody we mean less than 40 percent typically elevated pro bmp we’re all kind of the main criteria and – leading to that primary endpoint so we know overall the trial was was positive across the board now when we heard to break it down i think there’s a couple of things that were

Very interesting from that standpoint so number one when you looked at the diabetics versus the non diabetics there was a very similar reduction in terms of positive effects of the job the drug compared to the placebo so almost a 25 percent relative reduction for but diabetics and non diabetics and that’s again gets to the whole concept of what you brought up this

Is not just a therapy for diabetes this is really a tear of therapy now we’re in concern for heart fair patients and the sub context to that is really now a heart fair specialist general cardiologist whoever takes care of heart failure and definitely the primary care doctors who manage diabetes we have to start thinking of these patients in a very different way

You know like everything else in life you get so sub specialized that you silo your care and so is a cardiologist or a doctor i always tell them your diabetes taken care of but i’m not the one jumping in to manage that i defer that to their endocrinologist their primary care doctor and now as a cardiologist really gonna make that effort to say we really need to

Be treating you but now it clearly also has effects in a positive way for patients who are i’m diabetic so we’re going to really rethink of how we use these drugs in the heart fare clinic or cardiology clinic for even the non diabetics so really important thing there other important kind of sub context or sub endpoints are sorry secondary endpoints is the quality

Of life and we saw an improvement in quality of life in the treatment arm and so again the reason i bring that up is we talk about symptoms we talk about quality of life and more and more again in heart failure world we recognize that quality of life is as important if not more important to the patient compared to like mortality and hospitalizations those are hard

Endpoints that cardiologists are used to for years taking care of and looking at when we look at data but really when we talk about a patient with a chronic deadly disease that really limits their everyday when we look at quality of life is as important for those patients if not more important depending on that age group so i think that’s really important that

There’s a benefit in terms of quality of life and that was using the kansas city a cardiomyopathy questionnaire and showed a significant improvement and that question it’s a very standard questionnaire that we used and then when you looked at cross the baseline of medications really there was a benefit across the treatment arm compared to with all the medications

That were used so again really kind of independent of the baseline medications again benefit for for dapa in terms of treatment and outcomes what was also kind of interesting in this trial was that there was a relatively low use of tsukuba trial valsartan or entrust oh as the branded name and then over to talk about that in a few minutes but again that was not used

As heavily as more other contemporary trials are starting to use this given trial valsartan combination so really kind of in summary from this trial overall improvement in hard endpoints of cardiovascular death and heart fair hospitalization improvements in quality of life and then really a similar improvement in the diabetic and the non diabetic patient as we

Looked across this yeah it certainly seems to hit all those notes of assuring patient quality of life like you said less the burden of treatment and care overall in reducing events and that’s really what you’re looking for generally speaking in these heart failure trials speaking from a clinical perspective in conducting of the trial i thought it was particularly

Interesting how the investigators emphasized the need for understanding encompassing event risk instead of time to first even as they pointed out in in layman’s terms essentially this is a slippery slope most patients are at an extreme risk of hospitalization and once that happens the risk is greater and greater and greater and you see that in the patient population

Of those who maybe were on placebo or just previously had their current events over and over again can you speak about assessing these therapies as we continue to assess them more and more greatly for heart failure and emphasize their utility there to consider the role of first and recurrent events and i think that’s really an important concept that is becoming more

Delight and you know a lot of this has been driven to be honest with you like through the kind of quality improvements that hospitals have been under scrutiny for you know readmissions length of stay mortality that are becoming more public reported but that’s actually fallen in line with what we in cardiology have looked at and realized that there are two things one

We want to prevent you know goes back to what level of prevention you’re talking about so really true primary prevention is try to control your diabetes control your high blood pressure your cholesterol so and then exercise don’t smoke don’t use vaping products all those things are kind of really true primary prevention to reduce the risk of ever developing heart

Failure say for example and as we look at these medications we’re really in that kind of either secondary or i would almost called tertiary prevention so secondary prevention would be you have heart failure how do we prevent a high risk event from occurring so ie how do we end up preventing you from ending up in the hospital or dying from your heart failure and

That’s that kind of that first event or that we’re talking about it’s once you get into that and you’ve got into the hospital for example you know we know that repeated hospitalizations actually predict mortality in heart fair patients so that gets that your your kind of recurrent events that we’re talking about so once we’ve identified even a higher-risk patient

How do we prevent that from cascading even worse down the road and that’s why these trials are actually becoming more and more important as not only time to first hospitalization as we’ve seen with this trial as other trials but then also the repeated do they get possible do we prevent the recurrent hospitalization or readmission and again what we do know across

The board is by starting medications earlier in the course of heart failure is critically important to reduce that rapid progression to recurrent events so really we are trying to in the carfare community remind people that even with newer drugs like this that the key is to identify heart failure patients early educate them start them on medications maximize their

Doses and that really leads to kind of what you’re asked because how do we reduce that first event and then rear current events

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ACC House Call: Dapagliflozin for Heart Failure By HCPLive