Dr John McMurray Compares EMPEROR-Reduced Findings With DAPA-HF

Having 2 trials that both show benefits of SGLT2 inhibitors in heart failure hospitalizations can only encourage the use of these drugs, said John McMurray, MD, FRCP, FESC, professor of medical cardiology in the Institute of Cardiovascular and Medical Sciences at the University of Glasgow.

The American Journal of Managed Care® (AJMC®): EMPEROR-Reduced met its primary end point in patients with and without diabetes, similar to DAPA-HF. How likely is it that the results represent a class effect in heart failure regardless of diabetes status, similar to what we have seen for cardiovascular (CV) outcomes in diabetes?

Dr. McMurray:It was great to see the results of EMPEROR-Reduced and to see that it met its primary composite outcome. I suppose the only thing that's come up and some of my colleagues have sort of contacted me to say that they're disappointed that it didn't show the same reduction in mortality that was observed in DAPA-HF. However, I think having 2 trials that both show benefits in heart failure hospitalization that are otherwise completely consistent in terms of symptoms, improvement in kidney function, I think 2 positive trials can only encourage the use of these drugs in patients with heart failure. A key finding in EMPEROR-Reduced was that the benefit was seen in the large subgroup of patients who were already on sacubitril/valsartan (Entresto), in addition to other standard therapies. We now know that, we're certain that in both trials that SGLT 2 inhibitors have incremental benefit over and about our best available therapy. So this is really an incredible breakthrough.

AJMC®:In the United States, we have heard that despite the evidence, some cardiologists are still reluctant to prescribe SGLT 2 inhibitors for their patients with diabetes. What is the experience in the United Kingdom?

Dr. McMurray: We've been using these drugs for a long time. They're very easy to use. Patients like taking them and as we've just discussed, they're extremely effective. So personally, I cannot understand why there is any hesitation. They are actually much easier to use than almost all the other effective therapies we have. They don't reduce blood pressure substantially. They don't cause hypertension. They don't cause worsening renal function. They actually improve renal function contrary to the experience with almost all the other drugs that we use. So these are very easy to use, very well tolerated, and very effective treatments.

AJMC®:As the outcomes of EMPEROR-Reduced are comparable to those in DAPA-HF, do you anticipate that cardiologists will gain more comfort using empagliflozin, or the SGLT 2 inhibitor class generally, to treat heart failure?

Dr. McMurray:I think it's up to individual doctors to decide which agent in a class they use, and normally we choose those based on the results of trials. But the 2 trials did show a reduction in the composite outcome of cardiovascular death or heart failure hospitalization. That reduction was proportionally identical in the 2 trials. There may be little differences in terms of mortality reduction. That may be the play of chance, that may be differences in the patient population. But if you put the 2 trials together, the bottom line is people either feel better or are less likely to deteriorate symptomatically, less likely to be admitted to hospital, and less likely to die. That's a sort of triple whammy of wins in terms of your goals for treating patients with heart failure. So I would anticipate a huge increase in the uptake of this therapy.

AJMC®:What points of comparison between EMPEROR-Reduced and DAPA-HF most interest you?

Dr. McMurray:I would say that what I've heard most discussion about, people have been contacting me about of course, as I said, is the mortality difference. I'm probably going to make less of that and some people might. I think the interesting difference really, is that EMPEROR-Reduced had a larger proportion of patients on sacubitril/valsartan at baseline than DAPA-HF. It was great to see that within that subset of patients on sacubitril/valsartan, there was a significant benefit of SGLT 2 inhibition. So that on top of the similar findings in DAPA-HF to me, is probably the single most important finding in this study. Now we can be sure that these 2 new life saving therapies can be used and should be used in combination. And more importantly, both trials tell us that they can be used safely in combination, that are well tolerated when used together.