Safety and efficacy of SGLT2i in acute heart failure

ESC Congress 2023 In the DICTATE-AHF trial, early initiation of dapagliflozin in patients hospitalized with acute HF did not lead to a significantly higher diuretic efficiency compared with usual care, but all diuretic measures together indicated dapagliflozin increased fluid removal with fewer IV loop diuretic doses.

Presented at the ESC Congress 2023 by: Zachary Cox - Nashville, TN, USA

Introduction and methods

Hospitalization of patients with acute HF (AHF) serves 2 main goals: excess fluid removal and optimization of guideline-directed medical therapy (GDMT). The DICTATE-AHF trial was designed to examine the efficacy and safety of early in-hospital initiation of dapagliflozin when added to intravenous (IV) loop diuretics.

In this multicenter, randomized, investigator-initiated, parallel group, open-label, phase 3 trial, 240 T2D patients hospitalized with AHF were randomized within 24 hours of admission to oral dapagliflozin 10 mg once daily or usual care until day 5 or hospital discharge (if earlier), in addition to structured IV loop diuretic titration.

The primary endpoint was the diuretic efficiency, measured as the cumulative change in weight (in kg) per cumulative loop diuretic dose (IV plus oral) from enrollment to day 5 or discharge. Additional measurements included urine volume, urine sodium levels, and time necessary for excess fluid removal. Additionally, safety was assessed up to 30 days after discharge.

Main results

• Patients treated with dapagliflozin showed a nonsignificant trend towards a higher diuretic efficiency (adjusted for baseline body weight) compared with those receiving usual care (OR: 0.65; 95%CI: 0.41–1.01; P=0.06).
• Although the weight change was identical in both groups, the cumulative loop diuretic dose was significantly lower in the dapagliflozin group.
• Compared with the usual-care group, the dapagliflozin group showed significantly improved urine volume and urine sodium excretion (measured as 24-hour natriuresis), significantly faster completion of IV diuresis, and a significantly shorter hospital stay.
• Frequencies of diabetic, CV, and renal safety outcomes were similar in both study arms.

Conclusion

Initiation of dapagliflozin treatment within 24 hours of AHF hospitalization did not lead to a significant improvement of diuretic efficiency compared with usual care. Still, the researchers believe that all diuretic measures together indicated dapagliflozin increased fluid removal with fewer IV loop diuretic doses. Furthermore, the results showed dapagliflozin can be safely started to optimize GDMT in this population.

- Our reporting is based on the information provided at the ESC Congress -