Author + information
- Franz H. Messerli, MD∗ (, )
- Stefano F. Rimoldi, MD and
- Sripal Bangalore, MD
- ↵∗Department of Cardiology and Clinical Research, University Hospital, Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
Dr. Pareek and colleagues make several interesting points regarding our paper (1). We agree that SGLT-2 inhibitors have not yet been specifically evaluated for safety and efficacy in HF, including in patients with diabetes. However, the SGLT-2 inhibitor empagliflozin has recently demonstrated an unprecedented 38% reduction in cardiovascular mortality, which might be due at least in part to a reduction in heart failure (HF) (2). These results have gathered strong interest in the scientific community to test the hypothesis of whether SGLT-2 inhibitors should be considered standard HF treatment, even in HF patients without diabetes, and randomized controlled trials are currently underway testing this hypothesis.
The exact sequence of adding antihypertensive agents in HF with hypertension certainly is debatable (we suggested calcium-channel blockers [CCBs], followed by spironolactone and then a thiazide-like diuretic in patients with HF with preserved ejection fraction [HFpEF]). We selected CCBs in HFpEF as initial antihypertensive therapy because CCBs improve left ventricle (LV) filling, and the use of amlodipine was documented to be safe in HF (3,4). As opposed to amlodipine, there are no safety data for thiazides or thiazide-like diuretics (chlorthalidone or indapamide) in HF. There is no question, however, that in hypertension, thiazide-like diuretics are outstanding agents for preventing HF.
Of note, the whole question as to the sequence of adding drugs is somewhat academic. We merely are providing our opinion on how to treat residual hypertension in HF (and not how to treat HF per se); there is no iron-clad evidence or head-to-head comparison of safety and efficacy among various antihypertensive drug classes in HF.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- Messerli F.H.,
- Rimoldi S.F.,
- Bangalore S.
- Packer M.,
- Carson P.,
- Elkayam U.,
- et al.,
- for the PRAISE-2 Study Group