Empagliflozin in Heart Failure with a Preserved Ejection Fraction

Empagliflozin in Heart Failure with a Preserved Ejection FractionTo the Editor: Anker et al. (Oct.14 issue) 1 report that in EMPEROR-Preserved (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction), empagliflozin reduced the incidence of primary outcome events among patients with heart failure and a preserved ejection fraction, and they contrast their results with those with spironolactone in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. 2 However, the incidences of cardiovascular death, death from any cause, and hospitalization for heart failure were higher in the empagliflozin group of EMPEROR-Preserved than in the spironolactone group of the TOPCAT trial.Although 82% of the patients were receiving diuretics at randomization in the TOPCAT trial, data on the use of diuretics were not shown in EMPEROR-Preserved. 1 A low overall use of diuretics in EMPEROR-Preserved would have created a bias in favor of empagliflozin, which acts as an osmotic diuretic.Concomitantly, the possible lack of an adequately dosed loop diuretic could have contributed to a higher overall mortality in EMPEROR-Preserved than in the TOPCAT trial.Can the authors provide data on the baseline diuretic use and comment on the apparently in-