Salty or Sweet: ARNIs, Reduced Salt Intake in HF, and Cardiovascular Safety of Diabetes Medications

Michael Fralick and John Fralick, both general internists in Toronto, kick off The Rounds Table for the New Year.  They cover four articles in a rapid-fire style, including: angiotensin receptor-neprilysin inhibitors (ARNIs) in decompensated heart failure (HF), linagliptin and major cardiovascular events, reduced dietary salt intake in heart failure, and dapagliflozin and cardiovascular outcomes.

Sacubitril/valsartan is an ARNI that has been shown to be superior to enalapril in terms of risk of death from cardiovascular causes or hospitalizations for heart failure, specifically in patients with symptomatic heart failure and reduced ejection fraction.  First, John reviews an article on hospitalized patients with acute decompensated HF and if the use of sacubitril/valsartan compared with enalapril shows a reduction in brain-natriuretic peptide (BNP).

Next, type 2 diabetes mellitus (T2DM) is a major risk factor for cardiovascular and renal disease.  Previous studies have shown cardiovascular safety of three dipeptidyl peptidase 4 (DPP-4) inhibitors but these include a limited number of patients with elevated cardiovascular and renal risk. Mike covers the effect of linagliptin, a selective DPP-4 inhibitor, versus placebo, on cardiovascular and kidney outcomes in patients with T2DM with elevated cardiorenal risk.

Currently, part of HF management includes advising patients to reduce dietary salt intake.  John discusses a systematic review (CARMELINA) that was recently published to delineate whether or not there is high-quality evidence to support this management strategy and what the benefits may be.

Favourable cardiovascular effects have been demonstrated for some of the sodium-glucose cotransporter 2 (SGLT-2) inhibitors for T2DM.  The cardiovascular safety profile for dapagliflozin has yet to be defined.  Mike walks listeners through a study (DECLARE-TIMI 58) assessing the cardiorenal risk profile of dapagliflozin compared to placebo.

Finally, the Good Stuff segment.  John shares an infographic in the British Medical Journal (BMJ) on dual anti-platelet therapy (DAPT) in transient ischemic attacks (TIAs) and minor ischemic strokes.  Mike tells listeners about an article in the Huffington Post on two women who entered and cleaned the wrong home!

Like what you hear?  Rate us on iTunes!  Chat with us on Twitter at @roundstable and tweet at Mike Fralick @fralickmike.

Interested in helping us evaluate our podcast episodes? We’re currently recruiting a panel of residents to serve as regular reviewers for the show. If you’re interested, email wkwong@qmed.ca.

The Papers

1. ARNIs in HF: https://www.nejm.org/doi/full/10.1056/NEJMoa1812851

2. CARMELINA: https://jamanetwork.com/journals/jama/fullarticle/2714646

3. Reduced Salt Intake for HF: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2712563

4. DECLARE-TIMI 58: https://www.nejm.org/doi/full/10.1056/NEJMoa1812389

Good Stuff

1. DAPT in TIA and Minor Ischemic Stroke: https://www.bmj.com/content/363/bmj.k5130

2. Surprise Cleaning: https://www.huffingtonpost.ca/2018/10/18/ns-residents-get-happy-surprise-when-robbers-turn-out-to-be-cleaners_a_23565500/?utm_hp_ref=ca-good-news

Music Credits

The Rounds Table Theme Music by Brendan Quinn, Creative Director and Composer, Vapor RMW

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