SGLT2 inhibitor reduces total burden of CVD in patients with T2DM and ASCVD
Effects of empagliflozin on first and recurrent clinical events in patients with type 2 diabetes and atherosclerotic cardiovascular disease: a secondary analysis of the EMPA-REG OUTCOME trialLiterature - McGuire DK, Zinman B, Inzucchi SE, et al. - Lancet Diabetes Endocrinol 2020; 8: 949–59, doi.org/10.1016/S2213-8587(20)30344-2
Introduction and methods
In the EMPA-REG OUTCOME trial, treatment with empagliflozin reduced the risk of major adverse CV events (MACE), a composite of time to first event of CV death, non-fatal MI or non-fatal stroke, compared to placebo in patients with type 2 diabetes and established atherosclerotic CVD (RR 0.86, 95%CI: 0.74-0.99,P=0.038) . In addition, secondary analyses showed that empagliflozin reduced risk of CV and all-cause mortality, hospitalization for heart failure and progression of diabetic kidney disease [2,3].
Analyses of total events (first plus recurrent events) are more frequently being used as they reflect the total morbidity burden. This prespecified analysis examined the effects of empagliflozin on total CV events in the EMPA-REG OUTCOME trial.
The EMPA-REG OUTCOME trial was a placebo-controlled randomized trial evaluating the effect of empagliflozin (10 mg and 25 mg) versus placebo in 7020 patients. Eligible patients were ≥18 years, had T2DM, HbA1c of 7-10%, prevalent CVD and eGFR ≥30 mL/min/1.73 m2. Primary outcome of the trial was MACE, a composite of death from CV causes, non-fatal MI or non-fatal stroke. Key secondary outcome was 4-point MACE, including also admission to hospital for unstable angina. Median follow-up was 3.2 (2.2-3.6) years in the pooled empagliflozin group and 3.1 (2.2-3.5) years in the placebo group.
- Risk of total MACE events was reduced by empagliflozin compared to placebo (RR 0.78, 95%CI: 0.67-0.91, P=0.0020). This translates to 12.88(3.74-22.02) total MACE prevented per 1000 patient-years with empagliflozin.
- Empagliflozin reduced the risk of total events of the key secondary outcome of 4-point MACE compared to placebo (RR 0.82, 95%CI: 0.71-0.95, P=0.0081).
- Empagliflozin reduced risk of total MI events (RR 0.79, 95%CI: 0.62-0.998, P=0.049) with an estimated 4.97 (-0.68 to 10.61) events prevented per 1000 patient-years of treatment. No treatment effect was observed for total events of stroke, transient ischemic attack, composite of stroke or transient ischemic attack, admission to hospital for unstable angina, or coronary revascularization.
- Risk of total events of the main coronary outcome was reduced by empagliflozin compared to placebo (RR 0.80, 95%CI: 0.67 to 0.95, P=0.012), translating to an estimated 11.65 (95%CI: 1.25 to 22.05) events prevented per 1000 patient-years of treatment.
- Empagliflozin reduced risk of total events of admission to hospital for heart failure compared to placebo, preventing an estimated 9.67 (3.07-16.28) total events per 1000 patient-years of treatment. Results of the composite of admission to hospital for heart failure or CV death were similar.
- Risk of total events of all-cause admission to hospital were reduced by empagliflozin compared to placebo, preventing an estimated 50.41 (95%CI: 26.20-74.63) total all-cause admission to hospital per 1000 patient-years of treatment.
- Risk reductions were numerically larger for total events than for first events.
In this secondary analysis of the EMPA-REG OUTCOME trial, empagliflozin reduced total outcome events (first plus recurrent events) compared to placebo in patients with T2DM and ASCVD. More specifically, risk of total events of MACE, 4-point MACE, coronary heart disease outcomes, HF outcomes and all-cause admission to hospital were reduced by empagliflozin compared to placebo.