Daily Cardiology Research Analysis
Three impactful cardiology studies stood out today: a randomized trial showing perioperative empagliflozin reduced acute kidney injury after on-pump CABG in patients with type 2 diabetes; a prespecified analysis from FINEARTS-HF demonstrating finerenone benefits across NYHA functional classes in HF with mildly reduced or preserved EF; and an EHJ cohort revealing persistent ventricular arrhythmic risk in mitral valve prolapse patients with mitral annular disjunction even after surgical correction
Summary
Three impactful cardiology studies stood out today: a randomized trial showing perioperative empagliflozin reduced acute kidney injury after on-pump CABG in patients with type 2 diabetes; a prespecified analysis from FINEARTS-HF demonstrating finerenone benefits across NYHA functional classes in HF with mildly reduced or preserved EF; and an EHJ cohort revealing persistent ventricular arrhythmic risk in mitral valve prolapse patients with mitral annular disjunction even after surgical correction.
Research Themes
- Perioperative cardiorenal protection using SGLT2 inhibitors
- Mineralocorticoid receptor modulation in HFpEF/HFmrEF
- Arrhythmic risk stratification in mitral valve prolapse and mitral annular disjunction
Selected Articles
1. Empagliflozin in Patients With Type 2 Diabetes Undergoing On-Pump CABG: The POST-CABGDM Randomized Clinical Trial.
In a pragmatic randomized trial of 145 T2DM patients undergoing on-pump CABG, perioperative empagliflozin reduced postoperative AKI (22.5% vs 39.1%; RR 0.57) without increasing adverse events. Atrial fibrillation and type 5 MI rates were similar, and all three deaths occurred in the control group.
Impact: This is the first randomized evidence suggesting SGLT2 inhibitor preoperative use can reduce AKI after on-pump CABG, potentially shifting perioperative renal protection strategies.
Clinical Implications: Consider perioperative empagliflozin in T2DM patients scheduled for on-pump CABG to lower AKI risk, with attention to stopping 72 hours pre-op and monitoring standard safety parameters.
Key Findings
- Postoperative AKI reduced with empagliflozin: 22.5% vs 39.1% (RR 0.57; 95% CI 0.34-0.96; P=0.03).
- No excess in postoperative atrial fibrillation (15.4% vs 13.5%) or type 5 MI (1.4% vs 4.1%).
- No significant differences in safety events; all three deaths occurred in the control arm.
Methodological Strengths
- Randomized, pragmatic design with blinded outcome adjudication.
- Clear, clinically relevant primary endpoint (AKI within 7 days) with established criteria.
Limitations
- Single-center, open-label design with modest sample size (N=145).
- Short follow-up focused on AKI; longer-term renal and cardiovascular outcomes not assessed.
Future Directions: Multicenter, double-blind RCTs powered for renal and cardiovascular outcomes should validate perioperative SGLT2 strategies and define optimal timing and patient selection.
OBJECTIVE: To evaluate the efficacy and safety of empagliflozin in patients with type 2 diabetes mellitus (T2DM) undergoing elective on-pump coronary artery bypass grafting (CABG). RESEARCH DESIGN AND METHODS: Investigator-initiated, pragmatic, single-center, randomized, open-label trial with blinded outcome adjudication conducted in Brazil. A total of 145 patients with T2DM scheduled for elective on-pump CABG were randomized to receive empagliflozin 25 mg daily plus standard care (n = 71) for at least 3 months, which was discontinued 72 h before surgery, or to received standard care alone (n = 74). The primary outcome was postoperative acute kidney injury (AKI) within 7 days of surgery, defined by creatinine-based criteria (namely, Acute Kidney Injury Network; Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease; or Kidney Disease: Improving Global Outcomes). Secondary outcomes included 30-day postoperative atrial fibrillation and type 5 myocardial infarction (MI). Safety outcomes were ketoacidosis, urinary tract infection, hospital-acquired pneumonia, and wound infection within 30 days after CABG. RESULTS: AKI occurred in 22.5% of the empagliflozin group vs. 39.1% in the control group (relative risk [RR] 0.57 [95% CI 0.34-0.96]; P = 0.03). Rates of atrial fibrillation (15.4% vs. 13.5%; RR 1.15 [95% CI 0.52-2.53]; P = 0.73) and type 5 MI (1.4% vs. 4.1%; RR 0.35 [95% CI 0.04-3.26]; P = 0.62) were similar between groups. No statistically significant differences between groups were observed for safety events. Three deaths occurred, all in the control group. CONCLUSIONS: Empagliflozin use before on-pump CABG in patients with T2DM was associated with a reduced incidence of postoperative AKI without an increase in safety events. These findings warrant confirmation in larger clinical trials.
2. Finerenone and New York Heart Association Functional Class in Heart Failure: The FINEARTS-HF Trial.
In this prespecified analysis of FINEARTS-HF including 6,000 patients with HFmrEF/HFpEF, finerenone reduced cardiovascular death and total HF events and improved health status irrespective of baseline NYHA functional class. Patients with NYHA III/IV had higher event rates than NYHA II.
Impact: Supports broad applicability of finerenone across symptom severity in HFmrEF/HFpEF, informing clinical decision-making and guideline adoption.
Clinical Implications: Finerenone can be considered across NYHA II–IV in HFmrEF/HFpEF to reduce HF events and improve health status, with risk stratification acknowledging higher baseline risk in NYHA III/IV.
Key Findings
- Baseline NYHA III/IV vs II was associated with higher cardiovascular death and total HF events (adjusted rate ratio 1.28; 95% CI 1.11–1.46).
- Finerenone reduced the primary composite outcome irrespective of baseline NYHA functional class.
- Finerenone improved patient-reported health status across NYHA strata.
Methodological Strengths
- Prespecified subgroup analysis within a large randomized, placebo-controlled trial.
- Robust assessment including both clinical outcomes and patient-reported health status.
Limitations
- Subgroup analysis; the trial was not primarily powered for interactions across NYHA classes.
- Follow-up duration not specified in the abstract; details required from the main trial for temporal context.
Future Directions: Examine finerenone’s efficacy across other clinically relevant strata (e.g., etiology, comorbid CKD) and assess long-term mortality and hospitalization benefits in pragmatic settings.
BACKGROUND: The NYHA functional classification remains an important and widely used metric in heart failure (HF)-oriented clinical care and research. OBJECTIVES: This study aims to evaluate whether the effect of finerenone varies according to NYHA functional class in HF with mildly reduced or preserved ejection fraction. METHODS: In this prespecified analysis of the FINEARTS-HF trial, treatment effects of finerenone according to baseline NYHA functional class (II or III/IV) were examined on the primary endpoint (cardiovascular death and total HF events) and key secondary endpoints. Effects of finerenone on change in NYHA functional class were evaluated using ordinal logistic regression. RESULTS: At baseline, 4,146 (69%) and 1,854 (31%) participants were NYHA functional class II and III/IV, respectively. Participants with baseline NYHA functional class III/IV vs II experienced a significantly higher rate of cardiovascular death and total HF events (adjusted rate ratio: 1.28 [95% CI: 1.11-1.46]; P < 0.001). Finerenone consistently reduced the primary endpoint irrespective of baseline NYHA functional class (P CONCLUSIONS: In this FINEARTS-HF analysis, finerenone reduced clinical outcomes and improved patient-reported health status in HF with mildly reduced or preserved ejection fraction irrespective of baseline NYHA functional class. (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure [FINEARTS-HF]; NCT04435626).
3. Mitral annular disjunction and mitral valve prolapse: long-term risk of ventricular arrhythmias after surgery.
Among 599 MVP patients undergoing mitral surgery, 16% had preoperative MAD (median 8 mm). Despite surgical correction of MAD, these patients had a threefold higher long-term risk of ventricular arrhythmias (adjusted HR 3.33) over a median 5.4-year follow-up.
Impact: Defines persistent arrhythmic risk in MVP with MAD after surgical correction, informing long-term surveillance and risk stratification strategies.
Clinical Implications: Patients with MVP and preoperative MAD warrant intensified long-term rhythm surveillance and consideration of arrhythmic risk mitigation (e.g., ambulatory monitoring, EP evaluation) even after successful mitral surgery.
Key Findings
- Preoperative MAD present in 16% of surgical MVP cohort; median MAD length 8.0 mm (IQR 5.0–10.0).
- MAD associated with younger age, female sex, and Barlow’s disease.
- Adjusted hazard ratio for long-term ventricular arrhythmias was 3.33 (95% CI 1.37–8.08) despite surgical correction.
Methodological Strengths
- Relatively large surgical cohort with systematic echocardiographic measurement of true MAD pre- and post-operatively.
- Long median follow-up (5.4 years) with clinically adjudicated arrhythmic outcomes from records.
Limitations
- Single-center, retrospective observational design with potential residual confounding.
- Arrhythmia ascertainment relies on clinical encounters and records, possibly underdetecting asymptomatic events.
Future Directions: Prospective, multicenter studies integrating continuous rhythm monitoring and tissue/strain imaging may refine arrhythmic risk models and guide preventive strategies (e.g., ICD consideration) in MVP with MAD.
BACKGROUND AND AIMS: Mitral valve prolapse (MVP) is associated with progressive mitral regurgitation (MR) requiring surgical correction. A subset of patients with MVP experience ventricular arrhythmias (VA), and mitral annular disjunction (MAD) has been reported as a risk factor. This study aimed to assess the long-term risk of VA in patients with MAD and MVP undergoing mitral valve surgery for MR. METHODS: Patients with MVP with moderate or severe degenerative MR undergoing mitral valve surgery (repair or replacement) in 2010-22 at Karolinska University Hospital were included. Mitral annular disjunction length, referring to true MAD, was measured at end systole on pre- and post-operative transthoracic echocardiography. The primary outcome consisted of VA including hospitalizations, outpatient visits or ablation for confirmed sustained or non-sustained ventricular tachycardia, or high burden of premature ventricular complexes and assessed from medical records. RESULTS: Of 599 patients undergoing mitral valve surgery, 96 (16%) had pre-operative MAD. The median MAD length was 8.0 [inter-quartile range (IQR) 5.0-10.0] mm. Compared with patients without MAD, patients with MAD were younger (55 ± 15 vs 63 ± 11 years), were more often women (31% vs 17%), and had more Barlow's disease (70% vs 27%). Mitral annular disjunction was surgically corrected in all patients. During a median follow-up time of 5.4 (IQR 2.8-7.5) years, patients with pre-operative MAD had a higher risk of VA (hazard ratio adjusted for age and sex 3.33, 95% confidence interval 1.37-8.08) regardless of repair/replacement (Pinteraction = .18). CONCLUSIONS: Mitral annular disjunction in patients with MVP and MR was associated with a three-fold increased long-term risk of VA post-mitral valve surgery, despite anatomical correction of MAD.