Black patients with HF undertreated with SGLT2 inhibitors
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PHILADELPHIA — Black patients are highly likely to benefit from prescription of SGLT2 inhibitors for HF, but they are less commonly prescribed them compared with other patients, according to a speaker.
Because Black patients have high prevalence of HF, diabetes and chronic kidney disease and high risk for adverse outcomes, “the potential therapeutic benefit of SGLT2 inhibitors in this population is very high,” Alanna A. Morris, MD, MSc, associate professor of medicine and director of heart failure research at Emory Clinical Cardiovascular Research Institute, said during a presentation at the Heart in Diabetes CME conference.
The new American College of Cardiology/American Heart Association/Heart Failure Society of America guideline for the management of HF gives a class I, level of evidence A recommendation for SGLT2 inhibitors to reduce risk for CV death and HF hospitalization in patients with symptomatic chronic HF with reduced ejection fraction, regardless of the presence of diabetes, based on results from the EMPEROR-Reduced trial of empagliflozin (Jardiance, Boehringer Ingelheim/Eli Lilly) and the DAPA-HF trial of dapagliflozin (Farxiga, AstraZeneca), she said.
The guideline also gives a class 2, level of evidence A recommendation for SGLT2 inhibitors for patients with HF with mildly reduced EF and HF with preserved EF, she said.
“These drugs have benefit across the spectrum of EF,” she said.
Unfortunately, she said, Black patients were underrepresented in EMPEROR-Reduced and DAPA-HF.
“Unfortunately, the patients who have these conditions epidemiologically are often the least likely to be enrolled in these trials,” she said, noting Black Americans have the highest rates of HF-related hospitalization.
However, she said, a meta-analysis pooling results from both trials showed that SGLT2 inhibitors reduced risk for CV death and HF hospitalization by almost 50% in Black patients compared with placebo (HR = 0.53; 95% CI, 0.37-0.76), a greater benefit than that seen in white and Asian patients.
Prior studies document multiple mechanisms that suggest Black patients may have higher renal reabsorption of sodium than other race/ethnic groups, which may predispose to more hypertension and HF, she said.
For example, data from the Dallas Heart Study, the MESA cohorts and others have shown that Black individuals have lower levels of natriuretic peptides than white individuals, and such deficiency is associated with phenotypes such as elevated heart rate and BP, hypertrophy, diastolic dysfunction, hypertension, salt retention and fluid retention. The pleiotropic effects of SGLT2 inhibitors may be able to combat those mechanisms, Morris said.
Moreover, she said that diabetes, HF and CKD are common comorbid conditions, and Black patients more commonly have overlap of these comorbidities.
Compared with white patients, Black and Hispanic patients report higher rates of medication cost-related delays and lower access to higher-quality medications, so steps to achieve “pharmacoequity” are necessary, Morris said.
These steps include, among others, addressing differential prescribing practices, increasing the numbers of underrepresented groups in clinical trials, reducing drug prices, conducting equity impact analyses on new drug therapies, systematically identifying prescribing inequities and prioritizing “pharmacoequity” in quality improvement programs, she said.
Data show that rates of SGLT2 inhibitor prescription are lower in Black patients than in white patients — in one study, the difference was 17% — and that the disparity has been consistent over time, Morris said.
“Much work remains to achieve health equity in heart failure as well as diabetes and CKD,” she said. “Achieving ‘pharmacoequity’ is one mechanism to reduce health care disparities that we know exist and are so pervasive.”
References:
- Eberly LA, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.6139.
- Essien UR, et al. JAMA. 2021;doi:10.1001/jama.2021.17764.
- Heidenreich PA, et al. J Card Fail. 2022;doi:10.1016/j.cardfail.2022.02.010.
- McMurray JJV, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa1911303.
- Morris AA, et al. Circulation. 2021;doi:10.1161/120.052821.
- Packer M, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa2022190.
- Zannad F, et al. Lancet. 2020;doi:10.1016/S0140-6736(20)31824-9.
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Morris AA. Session 1: Joint Symposium with Circulation. Presented at: Heart in Diabetes; June 24-26, 2022; Philadelphia (hybrid meeting).
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