From the Guidelines
Dapagliflozin (Farxiga) would be the most appropriate additional medication to reduce this patient's risk for worsening heart failure. This recommendation is based on the most recent and highest quality evidence from the DAPA-HF trial 1 and further supported by the EMPEROR-Reduced trial 1, which demonstrated that dapagliflozin reduces the risk of cardiovascular death and hospitalization for heart failure in patients with heart failure with reduced ejection fraction (HFrEF), regardless of diabetes status. The patient's current medications, including an ACE inhibitor (lisinopril), beta-blocker (metoprolol succinate), and mineralocorticoid receptor antagonist (spironolactone), are optimized according to guideline-directed medical therapy, but the addition of dapagliflozin would provide further benefits. Key points to consider include:
- Dapagliflozin's mechanism of action, which includes improved cardiac energetics, reduced cardiac fibrosis, decreased cardiac preload and afterload, and beneficial effects on renal function.
- The typical dosing of dapagliflozin is 10 mg once daily, as indicated in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1.
- Potential side effects to monitor include genital mycotic infections, urinary tract infections, and volume depletion, though the medication is generally well-tolerated. Given the patient's stable blood pressure and lack of current symptoms, dapagliflozin would be a valuable addition to further reduce his risk of heart failure progression, as supported by the findings from the DAPA-HF and EMPEROR-Reduced trials 1.
From the Research
Heart Failure Treatment Options
The patient in question has heart failure with an ejection fraction of 40% and is currently asymptomatic. To reduce the risk of worsening heart failure, the following treatment options are considered:
- Dapagliflozin (Farxiga)
- Digoxin
- Isosorbide dinitrate/hydralazine (BiDil)
- Ivabradine (Corlanor)
- Liraglutide (Victoza)
Dapagliflozin as a Treatment Option
Dapagliflozin has been shown to be effective in reducing the risk of worsening heart failure and cardiovascular death in patients with heart failure and reduced ejection fraction, regardless of the presence or absence of type 2 diabetes 2, 3. The DAPA-HF trial demonstrated that dapagliflozin reduced the risk of worsening heart failure or cardiovascular death by 26% compared to placebo 3. Additionally, the DELIVER trial showed that dapagliflozin improved heart failure outcomes in patients with mildly reduced or preserved ejection fraction, regardless of glycaemic status 4.
Age Considerations
The efficacy and safety of dapagliflozin have been evaluated in patients of different age groups, and the results suggest that dapagliflozin reduces the risk of death and worsening heart failure across the broad spectrum of age studied in DAPA-HF, with no significant imbalance in tolerability or safety events between dapagliflozin and placebo, even in elderly individuals 5.
Current Treatment Guidelines
Current treatment guidelines for heart failure with reduced ejection fraction recommend pharmacotherapy based on neurohumoral inhibition of the renin-angiotensin-aldosterone system and the adrenergic system, as well as the use of implantable devices such as defibrillators and pacemakers for cardiac resynchronization 6.
Recommended Treatment
Based on the available evidence, dapagliflozin (Farxiga) would be the most appropriate additional medication to reduce the risk of worsening heart failure in this patient, as it has been shown to be effective in reducing the risk of worsening heart failure and cardiovascular death in patients with heart failure and reduced ejection fraction 2, 3.