Heart failure - Enter the Emperor
Channel: York Cardiology
Date: 2022-12-03

Heart failure is a clinical syndrome where the heart fails to pump out enough blood to meet the body’s requirements and in particular when the body’s requirements are heightened. This may then manifest with symptoms of breathlessness, tiredness, and exercise intolerance. Virtually all forms of heart disease if left unchecked will eventually lead to heart failure. So if you have high blood pressure for a prolonged period of time and it remains unchecked, then eventually the patient will develop heart failure. Similarly heart attacks damage the heart and therefore affect the ability of the heart to pump blood put and this leads to heart failure. 
Patients with heart failure will not have as good a quality of life as patients without heart failure and in general not live as long as patients with strong hearts.

SGLT-2 inhibitors are anti-diabetic drugs which have only over the past 5-10 years gained prominence because they were shown to reduce the development of heart failure in patients with Diabetes. Subsequently, further studies suggested that they reduced progression and improved prognosis in patients with heart failure (HEFREF) irrespective of whether the patient even had diabetes or not. 2 such agents (Dapagliflozin and Empaglifloxin) are now routinely given to all HEFREF patients as standard therapy because of the prognostic benefits that have been documented. So anyone watching this who has heart failure with a reduced ejection fraction who is not on an SGLT-2 inhibitor then I would very much recommend seeing your doctor and asking why you are not on it. 

Given the benefits seen in HEFREF, the next step was to see whether these agents could help patients with HEFPEF and this led to the EMPEROR-Preserved study the results of which were published in the New England Journal of Medicine last year. In this double blind placebo controlled study, the investigators randomly assigned 5988 patients with symptomatic heart failure and patients with ejection fraction of more than 40% to receive wither placebo or an SGLT-2 inhibitor called Empagliflozin at a dose of 10 mg once daily in addition to usual therapy and they wanted to study whether there was a reduction in hospitalisations for heart failure or death to cardiovascular causes.

Over a median period of 26.2 months, an outcome vent occurred in 415 of 2997 patients on Empa and 511 of 2991 patients on placebo.  13.8 percent of the Empa population had to be hospitalised or died due to cardiovascular causes in comparison with 17.1% in patients on placebo. The NNT was 31. Much of the benefit was driven by reduced hospitalisations rather than mortality but even reduced hospitalisations is benefit very much worth considering. 
The study was published in NEJM on the 14th October 2021 and the lead author is prof Stefan Anker.


So the main points that I wanted to make are:

1. The diagnosis of heart failure is a clinical diagnosis. ECHO can tell you if you have a significantly reduced ejection fraction but even if your EF is preserved, you can still have heart failure
2. SGLT-2 inhibitors are an exceptionally interesting new class of agent which may help in terms of improving prognosis in patients with heart failure regardless of ejection fraction.