After TAVI, dapagliflozin's benefit was concentrated in frail patients

Design

Post hoc subgroup analysis of a randomised trial (DapaTAVI)

Population

1,222 patients after transcatheter aortic valve implantation with baseline frailty assessment

Primary outcome

All-cause death or worsening heart failure at 1 year

Effect

Frail HR 0.53 (95% CI 0.36–0.77); prefrail HR 1.01 (0.66–1.55); robust HR 1.26 (0.42–3.75)

DapaTAVI randomised patients after transcatheter aortic valve implantation to dapagliflozin or standard care. This post hoc analysis looked at 1,222 participants with a baseline FRAIL scale assessment: 47% were frail, 40% prefrail and 12% robust. The primary outcome was death or worsening heart failure at one year.

Frailty itself was a strong predictor: frail patients had more than twice the risk of robust ones. Dapagliflozin was associated with a lower risk of the primary outcome in frail patients, roughly halving it, but not in prefrail or robust patients, and the difference between groups was statistically significant. Frailty did not change the drug's safety profile.

This challenges a common instinct to withhold additional drugs from frail older patients. Here, the frail group was where the benefit appeared.

It is a subgroup analysis that was not the trial's primary question, so it needs confirmation. But it supports not excluding frail patients from dapagliflozin after TAVI on frailty grounds alone, with attention to volume status, kidney function and genital hygiene.

• Consider dapagliflozin for frail patients after TAVI rather than excluding them for frailty.
• Assess frailty before and after TAVI; nearly half of patients were frail.
• Check volume status and kidney function when starting an SGLT2 inhibitor in older adults.
• Advise on genital hygiene and sick-day rules.
• Review the whole medication list to keep the regimen manageable.

Why it matters

It turns frailty from a reason to hold back into a possible reason to treat.

Don't overread it

Post hoc subgroup analysis; it suggests, but does not prove, that frail patients benefit more.

The statistics, in plain English

A hazard ratio of 0.53 (0.36 to 0.77) in frail patients means about half the rate of death or worsening heart failure. In robust patients the interval (0.42 to 3.75) was too wide to say anything. A significant interaction (P = 0.021) suggests the effect differs by frailty, but subgroup results are less reliable than a trial's main finding.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.