Background: Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been demonstrated to promote reverse cardiac remodeling in people with diabetes or heart failure. While it has been theorized that SGLT2 inhibitors might afford similar benefits in people without diabetes or prevalent heart failure, this has not been evaluated. We sought to determine if SGLT2 inhibition with empagliflozin leads to a decrease in left ventricular (LV) mass in people without type 2 diabetes or significant heart failure. Methods: Between April 2021 and January 2022, 169 individuals, 40-80 years of age, without diabetes but with risk factors for adverse cardiac remodeling were randomized to empagliflozin (10 mg/day; n=85) or placebo (n=84) for 6 months. The primary outcome was the 6-month change in LV mass indexed (LVMi) to baseline body surface area (BSA) as measured by cardiac magnetic resonance imaging. Other measures included 6-month changes in LV end-diastolic and -systolic volumes indexed to baseline BSA and LV ejection fraction. Results: Among the 169 participants (141 men [83%], mean age 59.3 ± 10.5 years), baseline LVMi was 63.2 ± 17.9 g/m 2 and 63.8 ± 14.0 g/m 2 for the empagliflozin- and placebo-assigned groups, respectively. The difference (95% CI) in LVMi at 6 months in the empagliflozin group vs. placebo group adjusted for baseline LVMi was -0.30 g/m2 (-2.1,1.5 g/m 2 ) (P=0.74). Median baseline (IQR) NT-proBNP was 51 pg/mL (20, 105 pg/mL) and 55 pg/mL (21, 132 pg/mL) for the empagliflozin- and placebo-assigned groups, respectively. The 6-month treatment effect of empagliflozin vs. placebo (95% CI) on blood pressure and NT-proBNP (adjusted for baseline values) were -1.3 mmHg (-5.2, 2.6 mmHg) (P=0.52), 0.69 mmHg (-1.9, 3.3 mmHg) (P=0.60) and -6.1 pg/mL (-37.0, 24.8 pg/mL) (P=0.70) for systolic blood pressure, diastolic blood pressure and NT-proBNP, respectively. No clinically meaningful between group differences in LV volumes (diastolic and systolic indexed to baseline BSA) or ejection fraction were observed. No difference in adverse events was noted between the groups. Conclusions: Among people with neither diabetes nor significant heart failure but with risk factors for adverse cardiac remodeling, SGLT2 inhibition with empagliflozin did not result in a meaningful reduction in LVMi after 6 months. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04461041clinicaltrials.gov Identifier: NCT04461041
CV outcome trials have established that long-term use of GLP-1 receptor agonists (GLP-1RAs) yields important CV benefits in people with T2D. Similar to SGLT2i, GLP-1RAs are recommended for people with T2D who have established CVD and heart failure regardless of their A1C. In a randomized trial of people with T2D and coronary artery disease, use of the SGLT2i empagliflozin for 6 months increased the frequency of vascular regenerative (VR) cells in the circulation. To determine if GLP-1RA therapy has a similar impact on the same VR cell populations, we retrospectively analyzed data from an ongoing research program with adults >40 years of age with T2D. Peripheral blood mononuclear cells were isolated and profiled with an established flow cytometry assay that was founded on the activity of the anti-oxidative enzyme aldehyde dehydrogenase (ALDH) that is highly expressed in progenitor (ALDHhi) versus mature (ALDHlow) cells. At baseline, 17 participants were on a GLP-1RA (9 of whom were also on an SGLT2i), 33 were on an SGLT2i but not a GLP-1RA, and 28 were on neither drug class. Mean age, weight, BMI, A1C, and duration of T2D was balanced across the groups. The frequency of ALDHhiSSClow cells (primitive hematopoietic and endothelial progenitor cells that coordinate angiogenesis) was higher in participants who were on a GLP-1RA (0.064%) or an SGLT2i (0.048%) relative to those not on either drug class (0.037%; P<0.05 for both). The frequencies of VR ALDHhiSSCmid monocytes in the three groups were comparable. The frequency of pro-inflammatory ALDHhiSSChi granulocyte precursor cells in participants on a GLP-1RA (2.9%) was lower than that in individuals on an SGLT2i (4.3%; P=0.05) or not on either drug class (5.2%; P<0.01). GLP-1RA therapy in people with T2D was associated with greater VR cell content and lower inflammatory burden. Augmented vessel repair mediated by higher VR cell content may account in part for the CV benefits observed with GLP-1RA in the setting of T2D. Disclosure A.Krishnaraj: None. B.Park: None. E.Bakbak: None. Y.Pan: None. A.Quan: None. H.Teoh: None. S.Verma: Advisory Panel; Amgen Canada, AstraZeneca, Bayer Inc., Boehringer Ingelheim and Eli Lilly Alliance, HLS Therapeutics Inc., Janssen Pharmaceuticals, Inc., Novartis Canada, Novartis, Novo Nordisk, Novo Nordisk Canada Inc., Consultant; AstraZeneca, Other Relationship; Amarin Corporation, AstraZeneca, Bayer Inc., Boehringer Ingelheim and Eli Lilly Alliance, Boehringer Ingelheim International GmbH, Canadian Medical and Surgical Knowledge Translation Research Group, EOCI Pharmacomm, HLS Therapeutics Inc., Janssen Pharmaceuticals, Inc., Novartis Canada, Novo Nordisk, Novo Nordisk Canada Inc., Pfizer Inc., PhaseBio Pharmaceuticals, Inc., S & L Solutions Event Management Inc, Sanofi, Sun Pharmaceutical Industries Ltd., Toronto Knowledge Translation Working Group, Research Support; Amarin Corporation, Amgen Canada, AstraZeneca, Bayer Inc., Boehringer Ingelheim International GmbH, HLS Therapeutics Inc., Novartis, Novo Nordisk, Pfizer Inc., PhaseBio Pharmaceuticals, Inc. D.A.Hess: None.
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