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TOPLINE:

Empagliflozin improved clinical outcomes in patients with acute heart failure (AHF), regardless of blood pressure (BP) levels, with particularly strong benefits observed in those with diastolic BP (DBP) < 70 mm Hg. Contrary to the common perception, empagliflozin did not further reduce the BP.

METHODOLOGY:

• Low BP in AHF may limit the initiation of sodium-glucose cotransporter 2 inhibitors because of the perceived risk of worsening hypotension.
• Researchers conducted a post hoc analysis of a randomized, double-blind, placebo-controlled trial (EMPULSE) to assess the effect of empagliflozin on clinical outcomes in patients hospitalized with AHF who could be categorized as those having low BP.
• Patients were considered to have low BP if their systolic BP (SBP) was < 110 mm Hg (n = 131; mean age, 70 years; 34.4% women) or DBP was < 70 mm Hg (n = 190; mean age, 74 years; 41.6% women) at the time they were randomly assigned to receive either placebo or 10 mg empagliflozin once daily.
• The effect of empagliflozin on the primary outcome of EMPULSE, a hierarchical composite endpoint of time to all-cause death, number of HF events, time to first HF event, and an improvement in the health status after 90 days of treatment was evaluated.

TAKEAWAY:

• In the placebo group, low BP was associated with an increased proportion of clinical events over 90 days, with low DBP showing stronger associations than low SBP; however, the associations were largely attenuated in the empagliflozin group.
• Changes in SBP with empagliflozin vs placebo were minimal (−2 to 2 mm Hg) and did not reach statistical significance, with no further decrease in SBP noted in patients with low BP. Similar findings were observed for changes in DBP with empagliflozin.
• Compared with placebo, empagliflozin treatment improved the hierarchical composite outcome regardless of BP at randomization, with the effect being more pronounced in patients with DBP < 70 mm Hg than in those with DBP ≥ 70 mm Hg (win ratio, 2.11 vs 1.23; P interaction = .02).

IN PRACTICE:

"Patients with AHF [acute HF] presenting with low BP have very few therapeutic options, and the observation that such patients may experience a greater benefit from treatment with empagliflozin is clinically important," the authors wrote.

"The consistent benefit of empagliflozin irrespective of SBP [systolic BP] or DBP [diastolic BP] is reassuring regarding its clinical use in AHF patients presenting with a low BP," they added.

SOURCE:

This study was led by João Pedro Ferreira, MD, PhD, of the Université de Lorraine in Nancy, France. It was published online on February 20, 2025, in the European Journal of Heart Failure.

LIMITATIONS:

Patients with SBP < 100 mm Hg and symptomatic hypotension were not included in the trial and limited the generalizability of the findings to this population. No lower thresholds for inclusion with respect to DBP values were considered, which might have contributed to the observed associations. This post hoc exploratory analysis had a small subgroup sample size, few clinical events, and test multiplicity.

DISCLOSURES:

EMPULSE was funded by Boehringer Ingelheim and Eli Lilly and Company Diabetes Alliance. Several authors reported receiving research support, consultancy fees, or honoraria from various pharmaceutical, medical device, and biotechnology companies and other sources such as the German Federal Ministry of Education and Research.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.