Dapagliflozin Effects on Biomarkers, Symptoms, and Functional Status in Patients With Heart Failure With Reduced Ejection Fraction: The DEFINE-HF Trial

• Published in: Circulation (New York, N.Y.) N.Y.), 2019-10, Vol.140 (18), p.1463-1476
• Main Authors: Nassif, Michael E, Windsor, Sheryl L, Tang, Fengming, Khariton, Yevgeniy, Husain, Mansoor, Inzucchi, Silvio E, Mc-Guire, Darren K, Pitt, Bertram, Scirica, Benjamin M, Austin, Bethany, Drazner, Mark H, Fong, Michael W, Givertz, Michael M, Gordon, Robert A, Jermyn, Rita, Katz, Stuart D, Lamba, Sumant, Lanfear, David E, LaRue, Shane J, Lindenfeld, JoAnn, Malone, Michael, Margulies, Kenneth, Mentz, Robert J, Mutharasan, R Kannan, Pursley, Michael, Umpierrez, Guillermo, Kosiborod, Mikhail, Malik, Ali O, Wenger, Nannette, Ogunniyi, Modele, Vellanki, Priyathama, Murphy, Brenda, Newman, Jonathan, Hartupee, Justin, Gupta, Charu, Goldsmith, Marcela, Baweja, Paramdeep, Montero, Manuel, Gottlieb, Stephen S, Costanzo, Maria Rosa, Hoang, Thanh, Warnock, Alicia, Allen, Larry, Tang, Wilson, Chen, Horng H, Cox, John M
• Format: Article
• Language: English
• Subjects: Aged; Benzhydryl Compounds - pharmacology; Biomarkers - analysis; Diabetes Mellitus, Type 2 - complications; Diabetes Mellitus, Type 2 - drug therapy; Female; Glucosides - pharmacology; Heart Failure - drug therapy; Heart Failure - physiopathology; Humans; Male; Middle Aged; Stroke Volume - drug effects; Ventricular Dysfunction, Left - drug therapy; Ventricular Function, Left - drug effects
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.119.042929

BACKGROUND:Outcome trials in patients with type 2 diabetes mellitus have demonstrated reduced hospitalizations for heart failure (HF) with sodium-glucose co-transporter-2 inhibitors. However, few of these patients had HF, and those that did were not well-characterized. Thus, the effects of sodium-glucose co-transporter-2 inhibitors in patients with established HF with reduced ejection fraction, including those with and without type 2 diabetes mellitus, remain unknown. METHODS:DEFINE-HF (Dapagliflozin Effects on Biomarkers, Symptoms and Functional Status in Patients with HF with Reduced Ejection Fraction) was an investigator-initiated, multi-center, randomized controlled trial of HF patients with left ventricular ejection fraction ≤40%, New York Heart Association (NYHA) class II-III, estimated glomerular filtration rate ≥30 mL/min/1.73m, and elevated natriuretic peptides. In total, 263 patients were randomized to dapagliflozin 10 mg daily or placebo for 12 weeks. Dual primary outcomes were (1) mean NT-proBNP (N-terminal pro b-type natriuretic peptide) and (2) proportion of patients with ≥5-point increase in HF disease-specific health status on the Kansas City Cardiomyopathy Questionnaire overall summary score, or a ≥20% decrease in NT-proBNP. RESULTS:Patient characteristics reflected stable, chronic HF with reduced ejection fraction with high use of optimal medical therapy. There was no significant difference in average 6- and 12-week adjusted NT-proBNP with dapagliflozin versus placebo (1133 pg/dL (95% CI 1036–1238) vs 1191 pg/dL (95% CI 1089–1304), P=0.43). For the second dual-primary outcome of a meaningful improvement in Kansas City Cardiomyopathy Questionnaire overall summary score or NT-proBNP, 61.5% of dapagliflozin-treated patients met this end point versus 50.4% with placebo (adjusted OR 1.8, 95% CI 1.03-3.06, nominal P=0.039). This was attributable to both higher proportions of patients with ≥5-point improvement in Kansas City Cardiomyopathy Questionnaire overall summary score (42.9 vs 32.5%, adjusted OR 1.73, 95% CI 0.98–3.05), and ≥20% reduction in NT-proBNP (44.0 vs 29.4%, adjusted OR 1.9, 95% CI 1.1–3.3) by 12 weeks. Results were consistent among patients with or without type 2 diabetes mellitus, and other prespecified subgroups (all P values for interaction=NS). CONCLUSIONS:In patients with heart failure and reduced ejection fraction, use of dapagliflozin over 12 weeks did not affect mean NT-proBNP but increased the proportion of patients exp