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2yr
Cardiovascular death and hospitalization in patients with heart failure

The incidence and prevalence of heart failure (HF) has increased in recent years. Experts suggest that this increase in frequency may be due to the growing elderly population with comorbidities such as hypertension and T2DM. Another reason why the number of HF patients has risen could be due to longer survival in those individuals with the condition. HF is a leading cause of hospitalizations, and recurrent HF hospitalization (hFH) predicts cardiovascular (CV) and all-cause mortality. 

In a recent meta-analysis, investigators mined data from various trials, which are grouped by HF presentation as follows:

•Patients with HF with mid-range ejection fraction (HFmrEF) or HF with preserved ejection fraction (HFpEF)

-DELIVER trial (dapagliflozin)

-EMPEROR-Preserved trial (empagliflozin)

•Patients with HF with reduced ejection fraction (HFrEF)

-DAPA-HF trial (dapagliflozin)

-EMPEROR-Reduced trial (empagliflozin)

•Patients with worsening HF regardless of ejection fraction

-SOLOIST-WHF trial (sotagliflozin)

The aim of this meta-analysis was to gauge the effects of SGLT2 inhibitors on different clinical outcomes of heart failure. 

In the trials assessed (n=21,947), SGLT2 inhibitors decreased the risk of composite cardiovascular death or hospitalization for heart failure (HR: 0.77); cardiovascular death (HR: 0.87); first hospitalization for heart failure (HR: 0.72); and all-cause mortality (HR: 0.92) Overall, this meta-analysis demonstrated that SGLT2 inhibitors decreased the risk of cardiovascular death and hospitalizations for heart failure in a broad gamut of heart-failure presentations, thus bolstering their role as foundational therapy for heart failure—regardless of ejection fraction.

What have you found to be effective in reducing the risk of heart-failure hospitalization in your HF patients?

  • 2yr
    SGLT2 Inhibitors now play an important role in reducing the risk of hospitalization in heart failure patients. Optimal guideline-directed medical therapy is also essential utilizing ACE/ARB/ARNI, diuretics, beta-blockers, mineralocorticoid receptor antagonists, etc.
  • 2yr
    Both systolic and diastolic heart failure have unacceptably high mortality. The introduction of drugs like empa, dapa may well improve these high rates. If one considers soloist, rugs like Impefa may support the notions of a sgkt2i class effect.
  • 2yr
    I think following guideline therapy improves patients prognosis and decreases hospital admissions. Patients need to be on toprol or coreg, loop diuretics, aldactone, ACE/ARB or Entresto and a SGLT2 agent. I also think patient education in terms of exercise, and low Na diets is essential. Also compliance with medications and daily weigh ins are essential. Diuretic therapy needs to be altered based on diet and weight.
  • 2yr
    Indeed , for both the systolic and diastolic Heart failure - SGLT2 inhibitors have shown their value. I have observed a marked reduction. In CHF episodes. There is probably a class effect .ARNI is necessary for systolic CHF and really has become the standard of care . Personally, I believe we need to see more data before we use GLP1 agonists broadly .
  • 2yr
    agree with many of above posts that SGLT2 has rightly deserved its place as one of the four " horseman" of rx for CHF-- in this case regardless of ef
    It is easier to use and less adverse reactions than the other modalities
    I also feel another effective " treatment" to reduce deaths and hospitalizations is remote monitoring as wellas increased visits ( often virtual} to chf patients ( especially post discharge to assess how they are doing and ensure compliance with meds
  • 2yr
    I have been adding SGLT2 INH earlier in the course of diagnosis with each passing month of experience that I have gained as I have seen exceptional results both from patient self reporting regarding symptoms as well as objective improvements in EF very quickly after adding SGLT 2 inh to beta blockers / with either ace /arb/ or arni.
    The percentage of patients covered by insurance has been very reasonable.
  • 2yr
    RAAS inhibition as well as SGLT2 inhibitors, mineralocorticoids and Beta blockers all have been shown to decrease recurrent hospitalizations for CHF. The one caution is that all beta blockers and all SGLT2 inhibitors are not created equal and all in class do not carry the same risk reduction benefits. Increased incidence of CHF particularly diastolic CHF is probably due to aging population and increased incidence of diastolic dysfunction as patients/people age. CLinically it is feasible to initiate triple therapy for CHF once the diagnosis of CHF is made, dependent upon blood pressure. A fourth medication can then be added at next outpatient office visit. For patients with marginal BP could initiated dual therapy and the add further medications dependent upon blood pressure and clinical symptoms
  • 2yr
    SGLT2 inhibitors help reduce risk of heart failure hospitalizations regardless of EF. If EF is low, then Entresto, beta-blockers, and spironolactone help decrease CHF hospitalizations. Also, if QRS is wide with low EF, biV pacing decreases hospitalization for CHF.
  • 2yr
    in addition to Entresto, beta blockers the use os SGLT2 agents clearly helps to reduce hospitalization and mortality
  • 2yr
    I am interested in CHF management since my cardiology fellowship at NIH,HOPKINS AND TUFTS.I have an active practice and try to use all groups.
  • 2yr
    Trying to get patients on the 4 “pillars “ of medications ( including ace/arb/arni, diuretics, stlg2 inhibitors , bblockers and mineralocorticoids. We have some devices like cardio mem that can help predict when meds need to be uptitrated so hopefully can avoid HF hospitalization
  • 2yr
    There are 4 classes of medicines that should be used, barring medical or financial contraindications. These apply to the entire spectrum of EFs from HFrEF to HFmEF to HFpEF. I usually try to start an ARNI (entresto) and SGLT2 in the hospital f the patient is already admitted because I can get a price check and find out if it is affordable for the patient. I usually will start carvedilol or toprol xl as well. After several weeks, after arni or arb titration, I will add an MRA if renal function and potassium are stable. Cost is a big barrier to two of the four classes of medications.
  • 2yr
    My understanding is that addition of SGLT2 inhibitor to other GDMT for HFpEF significantly reduces heart failure hospitalization and composite endpoint (due to inclusion of HF hospitalization in the composite). The reduction in mortality is marginally or not significant. Also, the patients studied in the trials are not the frail patients in their 80s which is many of the CHF patients I see. Simplifying treatment is most important in such elderly, less active patients to assure compliance, avoid side effects, and provide affordability of the medical treatment. In the majority of my HFpEF and HFmEF patients, aiming for euvolemia with diuretic and diet, spironolactone, and possibly Entresto if still symptomatic is a reasonable goal.
  • 2yr
    Although all of the medications have shown benefit, and are additive to each other, I hesitate to start 4 new medications at once for new diagnosis of CHF. For systolic CHF, I still start with Coreg and ARB and titrate to max doses. If still symptomatic, I will start adding the expensive drugs, initially and ARNI (changing ARB to Entresto) and then Jardiance. I worry that starting all of them at once will lead to some ill defined side effect or too much cost all at once and the patient will decide not to take anything.
  • 2yr
    As always instruction re dietary compliance and lifestyle, and maintenance of euvolemia.
    I believe we are seeing real improvements with Entresto (HFREF) and now SGLT2I (HF with essentially all EFs).
  • 2yr
    For HFrEF starting ARNI is very useful provided the renal function is normal. If patient has CKD would prefer SGLT-2 inhibitors. SGLT 2 inhibitors are useful for HF either reduced, midrange or prefered. Don't have experience with newly approved Sotaglifozin.
  • 2yr
    Have had to teach hospitalists NOT to start ACE on their patients admitted with no CHF, particularly if EF reduced.
    Once on an ACE, it has to be discontinued and waith 36 hrs before starting Entresto. Ideally, skip the ACE step and start Entresto immediately.
    If BP is borderline, can start low dose Valsartan which makes for a very easy transition to Entresto
  • 2yr
    Adding entresto early on the front line before going thru ACE-I or ARBS. Next, based on a multitude of SGLT2 data, adding them independent of LVF. I always thought that this will be available in patients with HFpEF.
  • 2yr
    Adding Entresto early on frontline before going through ACE inhibitors or ARB's. Next based on a multitude of the SGLT2 data, adding them independent of LV EF. always thought that this would be valuable in patients with HFpEF!
  • 2yr
    The primary methods in which we can reduce heart failure hospitalization for our patients is education, getting patients on all 4 pillars of medical therapy as quickly and efficiently as possible, and the provision of home health with nursing and pill counts to monitor patients' blood pressures and weights to prevent readmissions.
  • 2yr
    Agree with above comments. Start as combination with other medications and uptitratr
  • 2yr
    Works great.
  • 2yr
    Epidemiologically, no matter which of the aforementioned RCT results we evaluate, the concordance of impact in reducing CV mortality is impressive (HR ). These RCTs are pretty recent and have similar patient population so the meta analysis holds water.
    In patients with CHF, GDMT with ACE/ARB/ARNI/aldactone should be initiated, with addition of a SGLT2 inhibitor (in particular patients with diabetes or HFpEF). Patient education is of utmost importance and there needs to be a buy-in regarding the aim of therapy and compliance.
  • 2yr
    Important to use goal directed medical treatment. When possible, I prefer ARNI over ACE and ARB’s.
  • 2yr
    Trying to make sure treatment is optimized
    Adjusting meds as tolerated to target dosages
  • 2yr
    Education! I believe this is the most important tool with helping our heart failure patients stay out of the hospital. Explaining the heart failure diagnosis and the importance of GDMT, especially SGLT2 inhibitors. If they don’t understand their diagnosis and treatment, they will be less likely to have an active role in their health, including watching for signs and symptoms or worsening heart failure.
  • 2yr
    As mentioned above SGLT 2 inh are very effective as well as ACE / ARB / ARNI and Aldactone. Long active beta blocker is effective in those with reduced EF. The challenges with meds such as ARNI or SGLT2 inh is that they can be still expensive as outpatient.

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