This document discusses advances in the medical management of heart failure. It notes that heart failure prevalence is growing globally and in India. Newer drugs like SGLT2 inhibitors (SGLT2i), specifically dapagliflozin, have shown benefits in reducing cardiovascular risks and hospitalizations for heart failure beyond standard therapies. Two major trials, DECLARE and DAPA-HF, found dapagliflozin reduced risks of cardiovascular death or hospitalization for heart failure compared to placebo in patients with and without diabetes. The document concludes that early recognition and effective management of heart failure with newer drugs can help decrease progression and improve outcomes.

1. Advances in
Medical management of
Heart Failure
BUILDING UP THE PILLARS
Dr. Nagula Praveen
MD,DM (Cardiology)
Hyderabad

2. Introduction
 Heart failure is growing in epidemic proportions globally as well as in India.
 Based on disease-specific estimates, the prevalence of heart failure in India due to
coronary heart disease, hypertension, obesity, diabetes and rheumatic heart disease
to range from 1.3 to 4.6 million, with an annual incidence of 0.4–1.8 million.
 The post admission mortality is of 20%-30%.
 Medication adherence ranges from 25% to 50%
 The tolerance of guideline-based medication is low for Indian patients.
Huffman MD, Prabhakaran D. Heart failure: epidemiology and prevention in India. Natl Med J India. 2010;23(5):283-288.
Seth S, Ramakrishnan S, Parekh N, Karthikeyan G, Singh S, Sharma G. Heart failure guidelines for India: Update 2017. J Pract Cardiovasc Sci 2017;3:133-8

8. Diabetes as CVD risk equivalent

9.  From 2013, FDA announce that all Anti diabetic drugs have to evaluated in terms of
CVD risk outcomes – the CVOT trials, prior to FDA approval in view of increasing risk
of CVD in Diabetes.

12. SGLT2I

13. The newer drug in the block for
management of Diabetes

15. Mechanism of Action of SGLT2i

21. DAPAGLIFLOZIN –EXCEEDING THE
EXPECTATION IN HEART FAILURE

22. DECLARE–TIMI 58
22

23. 23
N Engl J Med. 2019 Jan 24;380(4):347-357
Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes
(Dapagliflozin Effect on CardiovasculAR Events - DECLARE–TIMI 58)
Dapagliflozin resulted in a lower rate of cardiovascular death or hospitalization for heart
failure than placebo
PMID: 30415602
Randomized, Double-blind, Multinational, Placebo-controlled Trial
Patients with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for
atherosclerotic cardiovascular disease
17,160 participants – for mean 4.2 years

24. DECLARE
24
Dapagliflozin

25. DECLARE
25
Primary Prevention Secondary Prevention

26. DAPA-HF
26

27. Patient Enrolment and Follow-up.
27
N Engl J Med. 2019 Nov 21;381(21):1995-2008
• All the patients who underwent randomization
were included in the primary analysis
• Patients who did not receive a dose of either
dapagliflozin or placebo were excluded from the
safety analysis

28. Cardiovascular Outcomes
28

29. 29
N Engl J Med. 2019 Nov 21;381(21):1995-2008
Dapagliflozin in Patients with Heart Failure and Reduced Ejection
Fraction
In patients with heart failure and a reduced ejection fraction, dapagliflozin had a lower
risk of worsening heart failure or death from cardiovascular causes and better symptom
scores than placebo, regardless of the presence or absence of diabetes
PMID: 31535829
DAPA-HF - Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure
4744 Participants – Mean 18.2 months

30. 30
N Engl J Med. 2019 Nov 21;381(21):1995-2008
Dapagliflozin in Patients with Heart Failure and Reduced Ejection
Fraction
• In contrast to the CREDENCE trial (Canagliflozin), the present trial examined patients
with chronic kidney disease of whom 32.5% did not have type 2 diabetes and 14.5%
had an estimated GFR below 30 ml per minute per 1.73 m2
• Dapagliflozin had an acceptable safety profile in this population, which included
participants with an estimated GFR as low as 25 ml per minute
PMID: 31535829

34. Take Home Message
 Early recognition of Heart Failure and Effective management is the essence of current
cardiovascular practice.
 Newer drugs in the management of heart failure are effective in decreasing the
progression to end stage heart failure.
 The pleiotropic effects of the newer drugs helps in effective management and
reducing the pill burden of patients, the major concern and reason for non
compliance.
 SGLT2i makes up the fifth pillar in management of HF patients with an effective
mortality benefit over the GDMT.

35. THANK YOU