Management of Acute and Residual Congestion in Patients with Acute Heart Failure by Adding Dapaglifozin to Intravenous Loop Diuretic Therapy - ENDORSE­ – HF

Published Congress: ESC HFA  2024

Link: The full text of the study hasn’t been published yet.  

Dr. İrem Dilara Can

Background:
Congestion is strongly associated with heart failure prognosis. After an acute heart failure episode only half of the patients experience efficient decongestion leaving the other half prone to future decompensation events due to residual congestion. There is a strong need for more efficient ways to tackle residual congestion.

Objective:
The goal of this prospective study was to evaluate the efficacy of adding sodium­glucose transporter­-2 (SGLT2i) inhibitor dapaglifozin to intravenous loop diuretic therapy for the management of acute and residual congestion in patients with acute heart failure.

Methods:
In this study we have prospectively evaluated 100 consecutive patients admitted to our regional clinical county hospital, with a primary diagnosis of acute heart failure with reduced ejection fraction during 2023. Patients were randomized to receive either iv loop diuretic with the addition of 10 mg dapaglifozin (n = 50) or iv loop diuretic therapy only (n=50) in the first 24 h from hospital admission. Patients were evaluated for congestion at admission, at discharge and after one month. For statistical analysis we used independent t test for comparison of continuous values, Pearson X2 test for comparison of categorical values, multivariate logistic regression for predictors of congestion remission.

Results:
The mean age of the cohort was 63 years, 80% were male and 20% female, with a mean left ventricular ejection fraction of 30% and a mean NT­proBNP of 10670 pg/mL. Patients assigned to SGLT2 inhibitors had a higher degree of congestion assessed by CA125 biomarker (2649 U/mL vs 1466 U/mL, p = 0.05). The addition of SGLT2i to iv loop diuretics was associated with shorther in­hospital length of stay (6 days vs 8 days, p=0.02), increased 24 h natriuresis (565 mmol/L3 vs 208 mmol/L3, p= 0.03), greater weight loss at discharge (8kg vs 6kg, p=0.02). At one month, patients who received SGLT2i experienced a decrease in B lines assessed by lung ultrasound (12 vs 21, p=0.002), a greater reduction of NTproBNP levels (69 % vs 18%, p=0.02), respectively an increase in ejection fraction (39% vs 30%, p=0.05). In a regression model, adding SGLTi to diuretic therapy in the first 24 hours of an acute heart failure episode was predictive of a shorter time to hospital discharge (p=0.03, OR=0.8) and fewer measured B lines at lung ultrasound at one month visit (p=0.008, OR = 0.8) while diuretic therapy without SGLT2i was predictive of higher NTproBNP levels at one month visit (p=0.04, OR=1). No serious adverse events were reported.
Conclusion:

• Early initiation of SGLT2i (dapaglifozin) in additionto IV furosemide facilitates decongestion in AHF patients expressed by measurement of B lines through lung ultrasound.
• Early initiation of SGLT2i (dapaglifozin) in addition to IV furosemide reduces in-hospital length of stay.
• Early initiation of SGLT2i (dapaglifozin) in addition to IV furosemide increases natriuresis.
• Early initiation of SGLT2i (dapaglifozin) in addition to IV furosemide improves LVEF at 1 month and further decreases NTproBNP.
• Early initiation of SGLT2i (dapaglifozin) in addition to IV furosemide was proven to be safe with no severe adverse effects.

Interpretations:
This study demonstrates that the addition of SGLT2i (dapaglifozin) to diuretic therapy in the first 24 h in patients admitted for acute heart failure is well tolerated resulting in an increase of 24 h natriuresis with a more rapid decongestion, earlier hospital discharge and sustained congestion relief at one month.