Early initiation of dapagliflozin during hospitalization for AHF
One-Minute Telegram 99-2024-3/3
10-second takeaway
Hospital management of acute heart failure (AHF) includes rapid decongestion and optimization of guideline-directed medical therapy. Previous trials demonstrated improved intermediate and long-term outcomes with the initiation of SGLT2 inhibitors at the end of hospitalization. In the DICTATE-AHF trial, initiation of dapagliflozin within 24 hours of admission for hypervolemic AHF did not improve dose-based diuretic efficiency but was associated with lower cumulative loop diuretic doses, improved diuresis and natriuresis, and a higher likelihood of early hospital discharge compared to usual care. These findings suggest that initiation of dapagliflozin on the first day of hospitalization for AHF is safe and may enhance diuresis.
Study breakdown
• Study population: 240 adults hospitalized with AHF
◦ Mean age, 65 years; 61% male, 68% White
◦ 71% had type 2 diabetes, 60% had LVEF
◦ Inclusion criteria: eGFR ≥ 25 mL/minute/1.73 m2, evidence of hypervolemia, current or planned management with IV loop diuretics
• Methods: multicenter, randomized, open-label study
◦ Randomized 1:1 within 24 hours of hospital presentation to dapagliflozin 10 mg once daily or structured usual care
◦ Both groups received protocolized diuretic titration with IV loop diuretics
◦ Primary outcome: diuretic efficiency, defined as cumulative weight change per cumulative loop diuretic dose
◦ Secondary outcomes: worsening inpatient HF, 30-day HF-related or diabetes-related rehospitalization
◦ Study duration: until discharge or day 5 of hospitalization, whichever occurred first
• Main results
◦ Primary outcome: no significant difference in diuretic efficiency (OR, 0.65; 95% CI, 0.41–1.02)
◦ No significant difference in secondary outcomes
◦ Dapagliflozin was significantly associated with the following exploratory outcomes:
▪ Reduced cumulative loop diuretic doses: 560 mg (IQR, 260–1150 mg) vs. 800 mg (380–1715 mg); P = 0.006
▪ Improved median 24-hour natriuresis (P = 0.025) and increased urine output (P = 0.005)
▪ Higher likelihood of hospital discharge by day 5 (52% vs. 33%)
◦ No significant difference in diabetic, renal, or cardiovascular safety events
• Limitations include:
◦ The open-label design may have introduced bias despite standardized protocols.
◦ Potential sampling bias, as only 10% of screened patients were enrolled in the trial
◦ The trial may have been underpowered to detect a difference in the primary outcome.
• Study funding: AstraZeneca with additional support from NIH grants
• Original study: Efficacy and safety of dapagliflozin in patients with acute heart failure [46]
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