ESC Congress 2022 Updates: SGLT2 Inhibitors, Diuretics
Volume 19, Issue 1
It’s that time of year when the fall conferences kick off. And the first of the fall conferences is the European Society of Cardiology meeting this past week. As has become the custom for this column, I will be covering the most relevant clinical trials from this exciting conference.
Point 1: SGLT2 Inhibitors Continue to Deliver
The DELIVER trial is a landmark analysis of dapagliflozin in patients with mildly reduced or preserved ejection fraction heart failure.
Over a median of 2.3 years, cardiovascular death or worsening heart failure occurred in 512 of 3131 patients (16.4%) receiving dapagliflozin as compared to 610 of 3132 patients (19.5%) receiving placebo (hazard ratio, 0.82; 95% confidence interval [CI], 0.73 to 0.92; P < 0.001). These benefits were consistent regardless of the baseline ejection fraction or the presence or absence of diabetes.
These findings bolster the findings of the EMPEROR-Preserved study, which was the first trial to demonstrate a meaningful clinical benefit for SGLT2 inhibitors in this patient population.
Point 2: A New Diuretic for Acute Heart Failure
The ADVOR study investigated the use of acetazolamide as an adjunct diuretic for acute decompensated heart failure. This interesting study was a multicenter, parallel-group, double-blind, randomized, placebo-controlled trial conducted with patients who had acute heart failure. Investigators administered either intravenous acetazolamide at a dose of 500 mg once daily, or placebo plus standardized intravenous loop diuretics.
Researchers assessed the number of patients with successful decongestion, which they defined as “the absence of signs of volume overload, within 3 days after randomization and without an indication for escalation of decongestive therapy.”
Compared to patients in the placebo group, a greater proportion of those in the acetazolamide group experienced successful decongestion (42.2% vs 30.5%) (risk ratio, 1.46; 95% confidence interval [CI], 1.17 to 1.82; P < 0.001). Investigators also reported higher cumulative urine output and natriuresis in the group receiving acetazolamide, suggesting these patients had better diuretic efficiency.
Importantly, adverse events occurred at a similar rate between groups, as did worsening kidney function, hypokalemia, and hypotension. There were also no significant differences in rates of all-cause death or rehospitalization for heart failure between groups.
This study has broad implications for patients with acute heart failure given that acetazolamide is an inexpensive and widely available medication. The one major critique for this study, which the authors could not have avoided, is the lack of up-front SGLT2 inhibitor use as background therapy. This is because the use of SGLT2 inhibitors in acute heart failure has only just recently been studied.
Given the known clinical benefits of SGLT2 inhibitors in the setting of acute heart failure, I would likely prefer them over acetazolamide as a second agent for decongestion in patients with acute heart failure.
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