Ryan Caputo, PharmD, BCCP

@iamcrsmith 1) It’s questionable to pool the results of trials with totally different pt populations 2) all cause mortality reduction doesn’t make sense when CV death and renal failure were not different if the proposed benefit is for HFpEF/CKD 3) Still need outcomes vs alt MRA IMO

@RyanCaputo1 The pooled analyses showing mortality benefit were FINE-HEART and FIDELITY. Another meta analysis was released earlier this year showing reduction in all cause mortality linked below. link.springer.com/article/10.100…

A surrogate outcome does not mean a new age. This type of study leads to over prescribing based on a soft endpoint with financial detriment to the patient with no proven benefit in hard outcomes. Does the next drug that reduces BNP create a new age for heart failure?

@iamcrsmith Finerenone has not shown mortality benefit in any of these trials or any of these disease states. Spironolactone is the only drug for HFpEF with data to suggest possible mortality benefit. It’s already been established that MRA + SGLT2i is safe in the 4 landmark SGLT2i HF trials.

Here's my overall take. For HFpEF and CKD, the evidence is overwhelmingly positive for finerenone and SGLT2s. Sure, you can argue we still need an RCT w/ clinical outcomes, but the standalone mortality benefit and reduction of progression to ESRD from previous trials is hard to overlook. And I think this trial points in the direction that they likely do have an additive effect. Though, my greatest takeaway is we can now discern that the two can be safely utilized together. This was my question previously; if adverse effects are greater when used concomitantly. We've had patients come through the ED after starting both due to overdiuresis issues (dizziness, weakness, hypotension) where they had previously tolerated either alone. I had developed a bit of a bias against using both together. In this trial, rates of discontinuation were equal. Thus, my perspective is changed. Sometimes I have to step back and remind myself we only see the worst cases coming thru the ED. I'm not too keen on the argument that finerenone may have no benefit over other MRAs. Other MRAs have never shown a mortality benefit for the aforementioned diseases.

@iamcrsmith Yes, but the premise is not that finerenone improves outcomes. It’s that finerenone + SGLT2i is superior to either agent alone based on a surrogate marker. Not to mention finerenone has only shown benefit against placebo but not against existing (cost effective) MRAs.

@RyanCaputo1 Typically I'd agree. Biomarkers aren't desirable outcomes. Fortunately, we have FINEARTS-HF, FIDELIO-DKD, and FIGARO-DKD which did prove morbidity and mortality benefit with finerenone.

@IsgittJohn Both

@RyanCaputo1 What’s your opinion of statins? What is more important for CAD, statins or controlling blood glucose?

So that statistically significant ~1.5% reduction of a composite endpoint driven by the weakest of the endpoints in COLCOT was actually just noise? Who would have thought? #colchicine acc.org/Latest-in-Card…

@StevenMathern TAVR is an important and amazing option in the correct patient. But Early TAVR was nothing more than industry marketing disguised as a trial

@RyanCaputo1 i am not sure what to think about these percutaneous valves yet, tavr/tavi, ttvr, tmvr

@blais_danielle 2.5 years ago and I remember it like yesterday 🥺

@RyanCaputo1 @RyanCaputo1 I remember sitting in the cafeteria discussing these with you and Kushal. Who would have guessed 😂

@IsgittJohn Yes, why wouldn’t I want to know if a drug is effective or ineffective?

@RyanCaputo1 You say this gleefully?

If you think finerenone is good, just wait until you hear about this drug called spironolactone.

🚨When it is a YES ✅ and not 🚫in DOACS 💊 👉🏻 J Am Coll Cardiol 2024;83:444-465.

New: Either ACEi or ARB therapy protect against kidney failure in those with advanced CKD. Neither therapy provided a death benefit for those with late-stage CKD: ecs.page.link/SWNAD

Hence my Antibiotic Stewardship for the 21st Century Lecture: slides

Analogous to LVAD ramp studies, a trial assessing RHC to guide optimal pacing rates for HFpEF may allow for further individualization of pacer settings beyond the algorithm used in MyPace jamanetwork.com/journals/jamac…

If there was half as much enthusiasm about initiating spironolactone as there is about sacubitril/valsartan, the world would be a better place 😌

Clinical strategies for mitigating adverse events with GLP-1 medicines @BevTchangMD #ADA2024 pubmed.ncbi.nlm.nih.gov/34775881/

@Dokutah_Vyew Ostensibly to reduce bleeding risk with concomitant anti platelet therapy

@RyanCaputo1 What was the reason?

Patient with ACS found to have new AF. Something commonly overlooked is in Pioneer AF-PCI, rivaroxaban was reduced to 15 mg daily in pts otherwise indicated for 20 mg daily. Make things simple and use apixaban which was studied at the same dose as used in its landmark AF trial.

@STL_Biotech It is fascinating in principle, but we need RCT data assessing hard outcomes with genotype guided therapy. Oncology has been the most proactive field.

@RyanCaputo1 I get atleast one student per year telling me how fascinating pharmacogenomics is and how it's the future. They're always suprised when I tell them I've been hearing that for over a decade.

A scientific statement on CYP2C19 testing to guide anti platelet therapy that I have to respectfully disagree with. A 🧵 on why genomic testing a misguided solution to a complicated problem ahajournals.org/doi/abs/10.116…

When to suspect cardiac amyloidosis? Echo features: 🔹Nondilated LV with thickened walls 🔹E/A > 2 and E/e’ > 14 🔹Biatrial enlargement 🔹Valvular thickening 🔹Apical sparing strain pattern …and the following clinical features, 🖼️ via British Society of Echocardiography: