Guideline-direct medical therapy (GDMT) optimization is partially and safely met with early dapagliflozin treatment in hospitalized patients with acute heart failure (AHF), a new open-label study shows. Weight-based diuretic efficiency was not significantly reduced with dapagliflozin, but the drug was associated with evidence for improved diuresis in patients with AHF, according to the DICTATE-AHF study. These data were reported by Zachary L. Cox, PharmD, of Lipscomb University College of Pharmacy and Vanderbilt University Medical Center, both in Nashville, Tennessee, and colleagues, in a manuscript published Monday online and in the April 9 issue of the Journal of the American College of Cardiology. When patients are hospitalized for AHF, decongestion and GMDT optimization are the primary goals of the care team. Loop diuretics prescribed in combination with acetazolamide or hydrochlorothiazide have been shown to improve decongestion, but these combinations are not optimal, and they have not been shown to improve outcomes after discharge. Early dapagliflozin treatment may dually achieve goals for patients during AHF hospitalization. The diuretic efficacy and safety of early dapagliflozin treatment was examined in hospitalized patients with AHF. The primary outcome of this study was diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose. This outcome was compared across assignments to treatment and adjusted for baseline weight using a proportional odds model. A total of 240 patients were randomized within 24 hours of hospitalization for hypervolemic AHF. Patients were either assigned 10 mg of dapagliflozin once per day or structured usual care, consisting of protocolized diuretic titration until 5 days or discharge from the hospital. The difference between dapagliflozin and usual care for diuretic efficiency failed to reach statistical significance (odds ratio [OR]=0.65; 95% confidence interval [CI]=0.41-1.02; p=0.06). The dapagliflozin treatment was associated with decreased loop diuretic doses (median 560 mg [interquartile range [IQR]=260-1,150 mg] versus 800 mg [IQR=380-1,715 mg]; p=0.006) and fewer intravenous diuretic up-titrations (p≤0.05) for equivalent weight loss per usual care. Diabetic, renal and cardiovascular safety events were not increased by early dapagliflozin treatment, but dapagliflozin was associated with better median 24-hour natriuresis (p=0.03) and urine yield (p=0.005), and these expedited hospital discharge throughout the study period. Overall, dapagliflozin as early treatment during hospitalization for AHF was found to be safe and not associated with decreased weight-based diuretic efficiency, but diuresis may be enhanced with dapagliflozin treatment. In an accompanying editorial, Maria Rosa Costanzo, MD, of the Midwest Cardiovascular Institute, Naperville, Illinois, and James L. Januzzi, MD, of Massachusetts General Hospital, Boston, wrote about the changing landscape in HF treatment and how this study enhances knowledge of AHF management. “Initiation of SGLT2is [sodium glucose cotransporter 2 inhibitors] amid AHF decompensation is safe, may promote decongestion with lower loop diuretics doses, and facilitates optimization of GDMT,” the editorialists wrote about the present study. “At this stage, clinicians should now understand both when to start proven treatments for AHF and what treatments, such as SGLT2is, can be initiated early. Now we know why: SGLT2is improve decongestion and ensure long-term favorable outpatient use,” the editorialists concluded. Sources: Cox ZL, Collins SP, Hernandez GA, et al. Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure. J Am Coll Cardiol. 2024;83:1295-1306. Costanzo MR, Januzzi JL. Early SGLT2 Inhibitors in Acute Heart Failure: Safe Diuretic-Sparing Strategy. J Am Coll Cardiol. 2024;83:1307-1309. Image Credit: luchschenF – stock.adobe.com