Part One
2) This program is intended for healthcare professionals and is supported by educational grants from AstraZeneca, Bayer, Boehringer Ingelheim Pharmaceuticals Inc. and Eli Lilly Company, Chiesi, and NovoNordisk. See archived programs at https://t.co/U6Mo1oSwIh.
— cardio-met (@cardiomet_CE) September 7, 2021
4) The #ESCCongress2021 was again an online only event.
— cardio-met (@cardiomet_CE) September 7, 2021
Live between 27th to 30th August 2021
We will be covering what’s new in
✅SGLT2i’s in Heart failure (particularly EMPEROR-Preserved results)
✅Heart Failure Guidelines
✅Finerenone
✅Hypertension
✅Much, much, more pic.twitter.com/413LHBLR7q
6) So what was the population studied?
— cardio-met (@cardiomet_CE) September 7, 2021
📍Approximately 2/3 had an ejection fraction on echo of 40-50% (ESC ‘mildly-reduced’ range)
📍82% NYHA class II
📍45%♀️
📍51% had #atrialfibrillation
📍half had reduced kidney function pic.twitter.com/lClfTjnb9d
8) So let’s do some digging into this data pic.twitter.com/KOpJuvWIIG
— cardio-met (@cardiomet_CE) September 7, 2021
10) Key secondary outcomes
— cardio-met (@cardiomet_CE) September 7, 2021
27%⤵️ Total (1st and recurrent) 🏥💔
⤵️Renal function decline (i.e. some preservation of kidney function)❗️
📍no change in All-Cause☠️
📍although CV☠️ was only half of causes of death in this study pic.twitter.com/1CVgqS7R5L
12) ⚠️ADVERSE EFFECTS⚠️
— cardio-met (@cardiomet_CE) September 7, 2021
✅well tolerated overall
✅No increase in Hypoglycaemia, ketoacidosis, bone fractures and lower limb amputations
⚠️⤴️Hypotension (NNH=55)
⚠️⤴️genital infections (NNH=66) pic.twitter.com/pYZmbAxO2H
14) What SGLT2i (‘flozin’) was used in the EMPEROR Preserved Trial?
— cardio-met (@cardiomet_CE) September 7, 2021
16) Keep Tuned
— cardio-met (@cardiomet_CE) September 7, 2021
More from #ESCCongress #ESCCongress2021 coming very soon.
Next up with be some insights from EMPEROR-Pooled analysis❗️
Do need to change the EF classification of #HeartFailure ❓
How does empalgliflozin outcomes compare to ARNI or spironolactone based therapy❓ pic.twitter.com/8oIy8tEQrY
Part Two
Yesterday we had key messages from the seminal EMPEROR-Preserved trial✅ & EMPEROR-Pooled analysis✅ presented at the #ESCCongress2021
— cardio-met (@cardiomet_CE) September 8, 2021
Today we have key messages from the FIGARO-DKD study & FIDELITY meta-analysis exploring the use of finerenone in T2D & a wide range of CKD pic.twitter.com/ZR2jBWYaTC
Finerenone is a selective non-steroidal mineralocorticoid receptor antagonist (MRA) with different pharmacokinetics & clinical effects to steroidal MRAs such as spironolactone
— cardio-met (@cardiomet_CE) September 8, 2021
Finerenone does not sig lower BP & has fewer steroidal effects such as gynaecomastia but can cause ⬆️K+ pic.twitter.com/Ob02CAExAe
@US_FDA approval was based on results of FIDELIO-DKD which had 1º renal & 2º CV endpoints
— cardio-met (@cardiomet_CE) September 8, 2021
It explored the use of finerenone in people with CKD stage 3 or 4 & severely elevated albuminuria & T2D
Have a look at the earlier tweetorial for a summaryhttps://t.co/9LsHYQBD1X pic.twitter.com/LlVVRglzPl
FIGARO-DKD explored the impact of finerenone in people with T2D & a wider range of CKD
— cardio-met (@cardiomet_CE) September 8, 2021
In contrast to FIDELIO-DKD, FIGARO-DKD had 1º CV & 2º renal endpoints but less advanced CKD
Nearly half had microalbuminuria and the mean eGFR was 68ml/min
Mean follow-up was 3.4 years pic.twitter.com/cMYlogp5d0
Individuals had to have a K ≤4.8mmol/l at screening
— cardio-met (@cardiomet_CE) September 8, 2021
Mean HbA1c 7.7% Mean SBP 136mmHg
Of note, there was 8.4% background SGLT2 inhibitor use & 7.5% background GLP-1 receptor agonist use
These agents have been recommended to reduce cardiorenal risk in many guidelines for T2D pic.twitter.com/K2Aab53T9n
🔵The 1º endpoint of FIGARO-DKD was a composite of death from CV causes, nonfatal MI, nonfatal stroke, or hospitalisation for HF
— cardio-met (@cardiomet_CE) September 8, 2021
🔵The key 2º endpoint was a composite of kidney failure, a sustained decrease from baseline of at least 40% in the eGFR, or renal death pic.twitter.com/EA2VBk8pUv
The 2º composite renal outcome was numerically lower but did not reach statistical significance
— cardio-met (@cardiomet_CE) September 8, 2021
One of the main limitations of FIGARO-DKD was that only around 3.5% of trial participants were of Black ethnic origin
— cardio-met (@cardiomet_CE) September 8, 2021
It is well established that individuals of a Black ethnic background are at increased risk of developing end-stage renal disease pic.twitter.com/D5DnNq6XhD
FIDELITY had 13171 participants of which around 40% had albuminuric CKD with relatively preserved kidney function (mean eGFR 58ml/min)
— cardio-met (@cardiomet_CE) September 8, 2021
So where does finerenone currently fit into our treatment armamentarium for the management of T2D & CKD?
— cardio-met (@cardiomet_CE) September 8, 2021
Recent @goKDIGO 2020 Diabetes in CKD guidance recommends that SGLT2 inhibitors and RAS blockade are used for most patients with T2D & CKD pic.twitter.com/834KQGqzei
Where do you see the positioning of finerenone alongside RAS blockade & SGLT2 inhibitors for the management of T2D & CKD? Please comment below why!
— cardio-met (@cardiomet_CE) September 8, 2021
FIDELIO-DKD, FIGARO-DKD & the FIDELITY meta-analysis also cements the importance of measuring urinary ACR in people living with T2D and preserved kidney function pic.twitter.com/ZgzthYBmQ4
— cardio-met (@cardiomet_CE) September 8, 2021
That’s all for today folks! Join @GoggleDocs again tomorrow for the last day of our @cardiomet_CE takeover for more key take-home messages from #ESCCongress2021 pic.twitter.com/gpbAk6mQX3
— cardio-met (@cardiomet_CE) September 8, 2021
Part Three
First up we’re giving you some SSaSS! pic.twitter.com/GjbEY8Txk4
— cardio-met (@cardiomet_CE) September 9, 2021
What is the recommendation for daily sodium intake according to @American_Heart for healthy individuals?
— cardio-met (@cardiomet_CE) September 9, 2021
So putting that into teaspoons of salt…
— cardio-met (@cardiomet_CE) September 9, 2021
1/4 teaspoon salt = 575 mg sodium
1/2 teaspoon salt = 1,150 mg sodium
3/4 teaspoon salt = 1,725 mg sodium
1 teaspoon salt = 2,300 mg sodium
Salt substitution aims to reduce sodium intake by replacing sodium with potassium salts
— cardio-met (@cardiomet_CE) September 9, 2021
➡️ also has an added benefit (for some) of increasing potassium intake …one issue.. the more the potassium chloride used the more metallic the taste pic.twitter.com/sC2j0Oph0j
In this study, different percentages of KCl were tested to assess acceptability… upto 30% KCl substitution was reasonably acceptable.https://t.co/4MuG4ofugF
— cardio-met (@cardiomet_CE) September 9, 2021
But what about impact on CVD and mortality? Well, not much data… pic.twitter.com/hmtNNQKuzJ
— cardio-met (@cardiomet_CE) September 9, 2021
Stay tuned for a look to see whether this study was worth its salt…
— cardio-met (@cardiomet_CE) September 9, 2021
Stay tuned for a look to see whether this study was worth its salt…
— cardio-met (@cardiomet_CE) September 9, 2021
Primary outcome – stroke 🧠
— cardio-met (@cardiomet_CE) September 9, 2021
Secondary outcome – MACE (non-fatal stroke, non-fatal ACS or CV mortality)🫀 and all cause mortality ☠️
Key safety outcome – hyperkalaemia (and also sudden death)
Interesting to see ⬆️ percentage with uncontrolled hypertension, ⬇️ACEi use, M=F split and relatively ⬇️diabetes population
— cardio-met (@cardiomet_CE) September 9, 2021
But we know this from previous trials and data… what about the important CV results…. pic.twitter.com/NgKLBkPu1m
— cardio-met (@cardiomet_CE) September 9, 2021
Primary Outcome
— cardio-met (@cardiomet_CE) September 9, 2021
🧠⬇️13% rate of fatal or non-fatal stroke p = 0.006 [29.14 vs 33.65 events/1000 patient yrs] – no difference in non-fatal stroke
Secondary Outcomes
13% ⬇️MACE p<0.001
12% ⬇️Death from any cause p<0.001
13% ⬇️Death from vascular causes
30%⬇️Non-fatal ACS
Some impressive findings of reduced stroke and further reductions in all cause mortality, death from vascular causes and non-fatal ACS with no real significant adverse events…. pic.twitter.com/nYIMy4gol1
— cardio-met (@cardiomet_CE) September 9, 2021
Do we need more data?
— cardio-met (@cardiomet_CE) September 9, 2021
Can we generalize this to other areas?
Is this something that we should be advising now?
What does this mean for practical application?
Is this a chance for a population based intervention? pic.twitter.com/75NJx3ugdg
So I ask you again… is this study worth its salt? pic.twitter.com/sG5S33JFsD
— cardio-met (@cardiomet_CE) September 9, 2021
That’s all for now.
— cardio-met (@cardiomet_CE) September 9, 2021
But do return as we continue our journey and STEP further into rural China with another blood pressure trial! pic.twitter.com/IFJVrmDRQ7
Part Four
First…step aside to a different STEP trial – Semaglutide in Obesity – our last tweetorial on this was very popular – have a look! https://t.co/2WXAg5Mvwt
— cardio-met (@cardiomet_CE) September 10, 2021
Blood pressure targets for older adults have always been a balance between appropriate intensification to reduce CV events and complications whilst avoiding the adverse events associated with hypotension (as well as polypharmacy and medication side effects) pic.twitter.com/rMYkRCtb3n
— cardio-met (@cardiomet_CE) September 10, 2021
In the UK recent NICE guidelines suggest in those over 80yrs old a cut off of 150/90 https://t.co/YmjCJo3GEk pic.twitter.com/aDQNOSzZx8
— cardio-met (@cardiomet_CE) September 10, 2021
No discussion on BP targets and thresholds is complete without running into the SPRINT Trial…. pic.twitter.com/HlRiueBCtN
— cardio-met (@cardiomet_CE) September 10, 2021
Just under 10,000 patients randomized to either <120 systolic BP (intensive) or <140 systolic BP
— cardio-met (@cardiomet_CE) September 10, 2021
The primary composite outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes 🫀🧠☠️
Findings were significant even in the population >75yrs old pic.twitter.com/zcmqbmS942
— cardio-met (@cardiomet_CE) September 10, 2021
However… pic.twitter.com/SBtJVtnoi9
— cardio-met (@cardiomet_CE) September 10, 2021
As we see in diabetes, intensive treatment has it’s benefits but at the risk of adverse events….these can be magnified in the older adult
— cardio-met (@cardiomet_CE) September 10, 2021
🇨🇳Chinese patients 60-80yrs old with hypertension
— cardio-met (@cardiomet_CE) September 10, 2021
Intensive treatment ➡️ SBP 110mmHg to <130mmHg
vs
Standard treatment ➡️ SBP 130mmHg to <150mmHg
Another interesting aspect was the use of home BP monitoring and a smartphone app 📱 pic.twitter.com/TEPcQ4zCSK
— cardio-met (@cardiomet_CE) September 10, 2021
Over the trial follow up…
— cardio-met (@cardiomet_CE) September 10, 2021
Mean BP in intensive treatment 126.7mmHg
Mean BP in standard treatment 135.9mmHg pic.twitter.com/r4YmUlx5G0
A 26% reduction in primary composite outcome with intensive treatment with clear CV benefits 🎉 pic.twitter.com/PJUGME7bNA
— cardio-met (@cardiomet_CE) September 10, 2021
33% ⬇️ stroke
— cardio-met (@cardiomet_CE) September 10, 2021
33% ⬇️ ACS
73% ⬇️ HF
28% ⬇️ MACE
28% ⬇️ CV mortality
Increased hypotension… BUT…
— cardio-met (@cardiomet_CE) September 10, 2021
No increased dizziness, syncope, fractures or reductions in eGFR 🥳 pic.twitter.com/FAsz1TqXvE
A few points….
— cardio-met (@cardiomet_CE) September 10, 2021
➡️ specific population and geographical area ?generalisable
➡️ Framingham risk scores used overstimate risk in Chinese adults
➡️ No mention of frailty status
➡️ QOL assessments would also add to this study
A final question:
— cardio-met (@cardiomet_CE) September 10, 2021
In the STEP trial, in older adults, a 26% reduction in primary composite outcome was achieved using what SBP targets?
— cardio-met (@cardiomet_CE) September 10, 2021
Reminders: #physicians #nurses #pharmacists are ALL eligible. The credit-claim is pretty painless and the certificate counts 🇺🇸🇨🇦🇬🇧🇪🇺. Just go to https://t.co/ZbK0kwvlWo. And finally, FOLLOW US for your only source of joint accredited, serialized CE/#CME in this space!
— cardio-met (@cardiomet_CE) September 10, 2021
Again, that link is https://t.co/ZbK0kwvlWo. And it's pic.twitter.com/04Nyehi79Y
— cardio-met (@cardiomet_CE) September 10, 2021