Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy? Expectations and realities of a new standard of care
Abstract
This editorial refers to ‘Effects of dapagliflozin in DAPA-HF according to background heart failure therapy’†, by K.F. Docherty et al., on page 2379. Many drugs that antagonize endogenous neurohormonal systems reduce the risk of death in patients with heart failure and a reduced ejection fraction. Importantly, the magnitude of the survival benefit with each agent has not been influenced by concomitant treatment with other life-prolonging drugs. In the post-infarction patient, angiotensin-converting enzyme (ACE) inhibitors decreased the mortality rate in patients already receiving beta-blockers. Conversely, in patients with established heart failure due to systolic dysfunction, beta-blockers reduced the risk of death in patients already receiving ACE inhibitors. The mortality reduction with mineralocorticoid receptor antagonists in an early trial where few patients were treated with a beta-blocker was similar to that seen in a later trial where most patients were receiving a beta-blocker. In subgroup analyses of clinical trials, the survival benefits of a neurohormonal antagonist have not been meaningfully affected by the intensity of use of other important treatments for heart failure. The concept that each neurohormonal antagonist exerts favourable effects that are independent of the benefits of other treatments is critically important to physicians. In clinical practice, most patients with heart failure and a reduced ejection fraction are treated with only a conventional…
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