Jawad H Butt1, Pooja Dewan2, Béla Merkely3, Jan Belohlávek4, Jarosław Drożdż5, Masafumi Kitakaze6, Silvio E Inzucchi7, Mikhail N Kosiborod8, Felipe A Martinez9, Sergey Tereshchenko10, Piotr Ponikowski11, Olof Bengtsson12, Daniel Lindholm12, Anna Maria Langkilde12, Morten Schou13, Mikaela Sjöstrand12, Scott D Solomon14, Marc S Sabatine15, Chern-En Chiang16, Kieran F Docherty2, Pardeep S Jhund2, Lars Køber17, John J V McMurray2. 1. British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom, and Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark (J.H.B.). 2. British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (P.D., K.F.D., P.S.J., J.J.V.M.). 3. Heart and Vascular Centre, Semmelweis University, Budapest, Hungary (B.M.). 4. Second Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic (J.B.). 5. Department of Cardiology, Medical University of Lodz, Lodz, Poland (J.D.). 6. Cardiovascular Division of Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M.K.). 7. Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut (S.E.I.). 8. Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri, and The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia (M.N.K.). 9. Universidad Nacional de Córdoba, Córdoba, Argentina (F.A.M.). 10. Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology of Russia, Moscow, Russia (S.T.). 11. Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wroclaw, Poland (P.P.). 12. Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., D.L., A.M.L., M.Sjöstrand). 13. Department of Cardiology, Herlev-Gentofte University Hospital, Herlev, Denmark (M.Schou). 14. Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts (S.D.S.). 15. Division of Cardiovascular Medicine and TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts (M.S.S.). 16. General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan (C.C.). 17. Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark (L.K.).
Abstract
BACKGROUND: Frailty may modify the risk-benefit profile of certain treatments, and frail patients may have reduced tolerance to treatments. OBJECTIVE: To investigate the efficacy of dapagliflozin according to frailty status, using the Rockwood cumulative deficit approach, in DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure). DESIGN: Post hoc analysis of a phase 3 randomized clinical trial. (ClinicalTrials.gov: NCT03036124). SETTING: 410 sites in 20 countries. PATIENTS: Patients with symptomatic heart failure (HF) with a left ventricular ejection fraction of 40% or less and elevated natriuretic peptide. INTERVENTION: Addition of once-daily 10 mg of dapagliflozin or placebo to guideline-recommended therapy. MEASUREMENTS: The primary outcome was worsening HF or cardiovascular death. RESULTS: Of the 4744 patients randomly assigned in DAPA-HF, a frailty index (FI) was calculable in 4742. In total, 2392 patients (50.4%) were in FI class 1 (FI ≤0.210; not frail), 1606 (33.9%) in FI class 2 (FI 0.211 to 0.310; more frail), and 744 (15.7%) in FI class 3 (FI ≥0.311; most frail). The median follow-up time was 18.2 months. Dapagliflozin reduced the risk for worsening HF or cardiovascular death, regardless of FI class. The differences in event rate per 100 person-years for dapagliflozin versus placebo from lowest to highest FI class were -3.5 (95% CI, -5.7 to -1.2), -3.6 (CI, -6.6 to -0.5), and -7.9 (CI, -13.9 to -1.9). Consistent benefits were observed for other clinical events and health status, but the absolute reductions were generally larger in the most frail patients. Study drug discontinuation and serious adverse events were not more frequent with dapagliflozin than placebo, regardless of FI class. LIMITATION: Enrollment criteria precluded the inclusion of very high-risk patients. CONCLUSION: Dapagliflozin improved all outcomes examined, regardless of frailty status. However, the absolute reductions were larger in more frail patients. PRIMARY FUNDING SOURCE: AstraZeneca.
BACKGROUND: Frailty may modify the risk-benefit profile of certain treatments, and frail patients may have reduced tolerance to treatments. OBJECTIVE: To investigate the efficacy of dapagliflozin according to frailty status, using the Rockwood cumulative deficit approach, in DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure). DESIGN: Post hoc analysis of a phase 3 randomized clinical trial. (ClinicalTrials.gov: NCT03036124). SETTING: 410 sites in 20 countries. PATIENTS: Patients with symptomatic heart failure (HF) with a left ventricular ejection fraction of 40% or less and elevated natriuretic peptide. INTERVENTION: Addition of once-daily 10 mg of dapagliflozin or placebo to guideline-recommended therapy. MEASUREMENTS: The primary outcome was worsening HF or cardiovascular death. RESULTS: Of the 4744 patients randomly assigned in DAPA-HF, a frailty index (FI) was calculable in 4742. In total, 2392 patients (50.4%) were in FI class 1 (FI ≤0.210; not frail), 1606 (33.9%) in FI class 2 (FI 0.211 to 0.310; more frail), and 744 (15.7%) in FI class 3 (FI ≥0.311; most frail). The median follow-up time was 18.2 months. Dapagliflozin reduced the risk for worsening HF or cardiovascular death, regardless of FI class. The differences in event rate per 100 person-years for dapagliflozin versus placebo from lowest to highest FI class were -3.5 (95% CI, -5.7 to -1.2), -3.6 (CI, -6.6 to -0.5), and -7.9 (CI, -13.9 to -1.9). Consistent benefits were observed for other clinical events and health status, but the absolute reductions were generally larger in the most frail patients. Study drug discontinuation and serious adverse events were not more frequent with dapagliflozin than placebo, regardless of FI class. LIMITATION: Enrollment criteria precluded the inclusion of very high-risk patients. CONCLUSION: Dapagliflozin improved all outcomes examined, regardless of frailty status. However, the absolute reductions were larger in more frail patients. PRIMARY FUNDING SOURCE: AstraZeneca.