Cardiac and Metabolic Effects of Dapagliflozin in Heart Failure With Preserved Ejection Fraction - CAMEO-DAPA
Contribution To Literature:
The CAMEO-DAPA trial showed that in patients with HFpEF, dapagliflozin 10 mg daily reduces both resting and exercise PCWP compared with placebo.
The goal of this trial was to assess whether dapagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT2i), affects rest and exercise pulmonary capillary wedge pressure (PCWP) in patients with heart failure with preserved ejection fraction (HFpEF).
Patients with HFpEF and documented elevation in exercise PCWP were randomized to receive dapagliflozin 10 mg daily (n = 21) or matching placebo (n = 17). Rest and exercise PCWP were obtained at baseline and follow-up visits. Exercise PCWP was obtained at peak exercise tolerance on a supine ergometer. Workload was increased at 20-W increments at 3-minute intervals until volitional exhaustion.
- Total number of enrollees: 38
- Duration of follow-up: 24 weeks
- Median patient age: 68 years
- Percentage female: 66%
- Obese: 71%
- Age ≥18 years
- New York Heart Association (NYHA) class II-III dyspnea
- Left ventricular ejection fraction (LVEF) ≥50%
- Elevated baseline exercise PCWP ≥25 mm Hg
- Type 1 diabetes mellitus (DM)
- Poorly controlled type 2 DM
- Hospitalization <30 days or revascularization <90 days
- Suspected alternate cause of dyspnea, including constrictive pericarditis or a primary cardiomyopathy
- Hemoglobin <9 g/dL
- Greater than moderate left-sided valvular disease
- Estimated glomerular filtration rate <30 mL/min/1.73 m2
Other salient features/characteristics:
- Percentage body mass index ≥30 kg/m2: 71%
- Percentage NYHA functional class III: 68%
- Baseline mean exercise PCWP, dapagliflozin vs. placebo: 33.5 vs. 32.0 mm Hg
Primary outcome, change in PCWP at 24 weeks, for dapagliflozin vs. placebo:
- At rest: -6.6 vs. -0.4 mm Hg (p = 0.027)
- With exercise: -2.5 vs. +1.1 mm Hg (p = 0.029)
Secondary outcomes for dapagliflozin vs. placebo, change in:
- Exercise right atrial pressure: -3.4 vs. +0.8 mm Hg (p = 0.011)
- Exercise mean pulmonary arterial pressure: -5.2 vs. +0.7 mm Hg (p = 0.024)
- Body weight: -3.7 vs. -0.2 kg (p = 0.006)
- Plasma volume: -170 vs. +115 mL (p = 0.014)
- Peak oxygen consumption: -0.1 vs. -0.8 mL/(kg·min) (p = 0.37)
- Peak workload: -4 vs. -4 W (p = 0.99)
The CAMEO-DAPA trial demonstrates that dapagliflozin is associated with decreased rest and exercise PCWP compared with placebo in HFpEF patients. Although peak exercise capacity and oxygen consumption did not improve, reduction in PCWP particularly with exercise may explain the improvement in patient-reported symptoms and submaximal exercise tolerance associated with SGLT2i in the DELIVER and PRESERVED-HF trials. This single-center study of a small population nevertheless provides granular, invasive hemodynamic data to support larger established data of patient symptoms and functional status.
The authors note that the exact mechanism by which dapagliflozin is associated with reduced PCWP is not clear. They observed only a weak correlation (r = 0.29) with change in plasma volume, suggesting pleiotropic effects beyond simply increased diuresis. Further, dapagliflozin was associated with greater weight loss in this primarily obese population. This may suggest the effect of SGLT2i on elevated PCWP, and associated exertional dyspnea may extend to the extracardiac and metabolic dysfunction that plays a key role in HFpEF.
Keywords: Body Mass Index, Body Weight, Diabetes Mellitus, Dyspnea, Exercise, Heart Failure, Metabolic Syndrome, Obesity, Secondary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Stroke Volume, Ventricular Function, Left, Weight Loss, Workload
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