Cardiovascular Trials Need Better Characterization of Heart Failure in Diabetics Interview with:

Stephen J. Greene, MD Division of Cardiology Duke University Medical Center Durham, NC

Dr. Greene

Stephen J. Greene, MD
Division of Cardiology
Duke University Medical Center
Durham, NC What is the background for this study? What are the main findings?

Response: In 2008, the United States FDA issued an industry guidance specifying that diabetes drugs should routinely be tested in large cardiovascular outcome trials to confirm cardiovascular safety. The guidance specifically mentioned cardiovascular safety in terms of MACE, or major adverse cardiac events, including cardiovascular death, myocardial infarction, and stroke.  Largely because of this, these trials have traditionally had a focus on cardiovascular disease in terms of atherosclerotic events. Heart failure was not mentioned in the FDA document and these trials have had a lesser focus on it.

As the years have gone by, we have learned more and more about the connection between diabetes and heart failure. There is tremendous overlap between the two patient populations. Also, as more and more of the large cardiovascular outcome trials have been completed, we have seen multiple examples of various glucose lowering therapies either increasing or decreasing risk of heart failure events. Given all these data on heart failure/ diabetes interactions, the goal of our research was to carefully examine all of the completed large cardiovascular outcome trials of diabetes therapies to systematically describe the type of heart failure-related data they capture. As an initial step in improving heart failure characterization in these trials, we wanted to first describe what trials have already been doing and where the gaps in understanding heart failure in these trials exist.

Overall, we found major gaps in the amount and quality of the heart failure data capture in these trials. We looked at 21 large trials, including over 150,000 patients. Rates of patients with baseline heart failure were inconsistently provided, and among those trials that did provide it, heart failure patients tended to be underrepresented compared to the general population. Patients with baseline heart failure were also poorly characterized, with minimal data on functional status, ejection fraction, or heart failure medications. Only 6 trials reported rates of new-onset heart failure and the definitions used were non-specific. Most trials tended to report rates of heart failure hospitalization, but did not include data on fatal or other types of heart failure events. Only 2 trials included heart failure events within the primary study endpoint. More details are included in our full manuscript, which was published in the Journal of the American College of Cardiology to coincide with our presentation at the ACC conference. What should readers take away from your report?

Response: It is important that cardiovascular outcome trials of diabetes therapies work to improve heart failure characterization going forward. This applies to baseline heart failure, new-onset heart failure, and all heart failure-related events that occur during follow-up. This is important for many reasons.  First, there is so much overlap in routine practice between diabetes and heart failure. Cardiovascular safety does not just apply to atherosclerotic events. A comprehensive cardiovascular safety evaluation needs to pay close attention to heart failure.

Second, better characterization of new-onset heart failure has the potential to inform which diabetes therapies have the potential to actually prevent heart failure. Finding evidence-based drugs that can do this is a huge need, especially among diabetic patients who are at high risk of developing heart failure. Third, better characterization of the baseline heart failure population in these trials and types of heart failure events they experience may allow us to better evaluate for potential heart failure efficacy signals. This would better inform the utility of testing these drugs in dedicated heart failure trials as a drug specifically for heart failure, irrespective of whether the patient has diabetes. What recommendations do you have for future research as a result of this work?

Response: In our published manuscript, we detail multiple strategies for how future cardiovascular outcome trials can improve heart failure characterization.
Some suggestions include:

  • Separately reporting the impact of therapy on heart failure risk among patients with and without baseline heart failure
  • Improved characterization at baseline for patients with existing heart failure
  • Capturing heart failure data from the actual time of new-onset heart failure diagnosis, and
  • Enrolling a proportion of patients with baseline heart failure similar to the prevalence of heart failure in the general type 2 diabetes population.We think these strategies could pay major dividends in confirming both the cardiovascular safety of these various diabetes therapies, but also in finding better ways to prevent and treat heart failure. 


ACC 2018 abstract:

Prevalent and Incident Heart Failure in Cardiovascular Outcome Trials of Patients with Type 2 Diabetes
Stephen GreeneMuthiah VaduganathanMuhammad KhanGeorge BakrisMatthew WeirJonathan SeltzerNaveed SattarDarren McGuireJames JanuzziNorman Stockbridge and Javed Butler

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