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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 < 50%
◦ 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]

🛸Early initiation of SGLT2i therapy in patients hospitalized with acute heart failure decreases major cardiovascular events and congestion, and reduces the length of hospital stay.

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✅ BMJ OnExamination 2024_2025
MRCP

Correct answer:IC











In this woman with prior episodes of self-limited jaundice
associated with illnesses, Gilbert syndrome is the most likely
diagnosis. In this patient, checking serum concentrations of
aspartate aminotransferase (AST), alanine aminotransferase
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serologies would be reasonable although not mandatory given
the lack of alarm features other than low-grade fever, which
can be attributed to her upper respiratory illness. Gilbert syn￾drome is the most common form of hereditary jaundice. It is an autosomal dominant disorder linked to a mutation in the gene
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stress. It is important to make the diagnosis because if these
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Biliary colic is unlikely in the absence of pain. Porphyrias are
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in older adults with progressive hepatomegaly and elevated
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jaundice starting in childhood would be unusual.

A 20-year-old college student presents to student health clinic
with 3 days of fevers, runny nose, sore throat, and malaise.
She has no abdominal pain, nausea, or vomiting, and she
denies taking any medications, alcohol, supplements, or illicit
drugs. On examination, she has a temperature of 100.3°F. She
has pharyngeal erythema without exudates, and there is mild
bilateral anterior cervical lymphadenopathy. Her sclerae are
icteric and her abdomen is nontender without hepatospleno￾megaly. On further questioning, she recalls having similar
episodes of her eyes turning yellow when she was sick ever
since she was a child; in those instances, her eye color always
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