Secondary Logo

Journal Logo


Does dipeptidyl peptidase IV inhibitor increase the risk of heart failure? A cardiologist’s paradox

Kanakia, Rushita; Martinho, Shaunc; Patel, Tejasa; Arain, Faisal A.a; Panday, Manoj M.b; Le Saux, Claude J.b; Pham, Son V.b; Bailey, Steven R.a; Chilton, Roberta

Author Information
doi: 10.1097/XCE.0000000000000036
  • Free



Historically, observational studies and meta-analyses have suggested an association between reduction of hyperglycemia with a reduction in microvascular and macrovascular complications in patients with type 2 diabetes 1–3. Moreover, previous studies have found that traditional oral diabetes medications, despite lowering blood glucose levels, generally do not improve cardiovascular outcomes. In contrast, several randomized trials have reported a reduction in microvascular events, primarily renal and retinal complications with the use of the new dipeptidyl peptidase IV (DPP-4) inhibitors 4. Recently, Patil et al.4 completed a meta-analysis of 18 randomized trials including 4998 patients treated with the new oral DPP-4 inhibitors compared with 3546 patients on other oral agents with a median follow-up of 46 weeks. They reported a 60% reduction in risk of nonfatal myocardial infarction (MI) or acute coronary syndrome (ACS) in diabetes patients treated with oral DPP-4 inhibitors [relative risk (RR) 0.40 (95% confidence interval (CI) 0.18–0.88)]. The RR of any adverse cardiovascular event with a DPP-4 inhibitor in this pooled analysis was 0.48 (95% CI 0.31–0.75), again in favor of DPP-4 agents. They concluded that the use of DPP-4 inhibitors was safe and resulted in a significant reduction in cardiovascular events. However, other recent large prospective trials found reduced microvascular complications but a higher incidence of hypoglycemia with intensive glycemic control without a reduction in macrovascular events 5. Lately, new concerns have emerged on the safety of DPP-4 inhibitors with the release of two large prospective trials, Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus (SAVOR) 6 and Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care (EXAMINE) 7. Newer oral DPP-4 inhibitors have also failed to show improvement in cardiovascular outcomes. In the SAVOR trial, there was an increase in heart failure hospitalizations but not an increase in mortality 6.

There have been encouraging results with the treatment of diabetes in the National Health Interview Survey, the National Hospital Discharge Survey, the US Renal Data System, and the US National Vital Statistics. A study compiling information from these databases showed that there is a significant reduction in the incidences of acute MI, stroke, lower-extremity amputation, end-stage renal disease, and death from hyperglycemic crisis between 1990 and 2010 8. Even though there is a marked reduction in ACS, there are still twice as many cardiovascular events in diabetes patients than in nondiabetic patients with an almost 10-fold increase in lower-extremity amputations in the diabetes subset. Unfortunately, with an escalating prevalence of obesity and diabetes, there still remains excess morbidity and mortality associated with this disease (Fig. 1).

Fig. 1
Fig. 1:
The improvement in diabetes risk for vascular events. Age-standardized rates of diabetes complications and the relative risk of complications, according to the presence or absence of diabetes, 1990, 2000, and 2010. In 2010, there is still a doubling of risk for myocardial infarction in the diabetes patients 8. DM, diabetes mellitus.

The trials

The SAVOR trial 6 (TIMI-53) was a superiority trial. It was designed to evaluate the safety and efficacy of saxagliptin when added to existing type 2 diabetes treatments on cardiovascular outcomes in patients at risk for future cardiovascular events. In addition, a closed testing hierarchy was used to preserve the α-level and prespecified that a test for noninferiority for the primary composite endpoint should be completed first and a test for superiority performed afterwards. A total of 16 492 diabetes patients were prospectively randomized with a mean follow-up of 2.1 years. Patients were randomized to saxagliptin 5 mg daily (2.5 mg if glomerular filtration rate is below 50 ml/min) or placebo. The primary endpoint was a composite of cardiovascular death, MI, or ischemic stroke. The primary endpoint occurred in 613 patients in the saxagliptin group and in 609 patients in the placebo group (7.3 and 7.2%). The 2-year Kaplan–Meier estimates for superiority were not achieved; hazard ratio (HR) 1.00 (95% CI 0.89–1.12); however, noninferiority was significant at P less than 0.001. The major secondary endpoints included a composite of cardiovascular death, MI, stroke, hospitalization for unstable angina, coronary revascularization, or heart failure was 12.8% in the treatment arm and 12.4% in the placebo arm [2-year Kaplan–Meier estimates; HR 1.02 (95% CI 0.94–1.11)]. It also reduced the progression and development of microalbuminuria; however, it is unclear if it translates to decreased renal complications. Specifically, hospitalizations for heart failure were significantly increased in the saxagliptin arm by 27% [HR 1.27 (95% CI 1.07–1.51)]. The study result addressing whether the DPP-4 inhibitor saxagliptin can reduce cardiovascular events in diabetes patients was negative. However, the apparent off-target effect with increased hospitalizations for heart failure (best predicted by a history of heart failure) was not associated with an increase in mortality. This will remain a question for future trials (Figs 2 and 3, Tables 1 and 2).

Fig. 2
Fig. 2:
Selected cardiovascular events in the SAVOR trial. The primary endpoint was a composite of CV death, nonfatal MI or nonfatal stroke. The secondary endpoint was a composite of death from cardiovascular causes, myocardial infarction, ischemic stroke, hospitalization for unstable angina, coronary revascularization, or heart failure. CI, confidence interval; CV, cardiovascular; HR, hazard ratio; ITT, intention to treat; MI, myocardial infarction.
Table 1
Table 1:
Comparison of type of patients and entry criteria 9,10

The EXAMINE trial 7 was a double-blind noninferiority trial. It evaluated the impact of adding alogliptin to standard diabetes therapy on major cardiovascular events in patients with type 2 diabetes with ACS within 15–90 days before randomization. The primary cardiovascular endpoint was a composite of death from cardiovascular causes, nonfatal MI, or nonfatal stroke. A total of 5380 patients underwent randomization and were followed for up to 40 months (median 18 months). The primary endpoint was achieved in 305 patients assigned to alogliptin (11.3%) and in 316 patients assigned to placebo (11.8%) [HR 0.96 (P<0.32)] at 36-month follow-up. Figure 3 and Table 2 shows the components of the primary endpoint in addition to the exploratory adjudicated components. The EXAMINE trial did not find increased hospitalizations for heart failure. The principal secondary endpoint of death from cardiovascular causes, nonfatal MI, nonfatal stroke, or urgent revascularization due to unstable angina found no significant difference between placebo (n=359, 13.4%) versus alogliptin (n=344, 12.7%), P less than 0.26. Hospitalization for heart failure in the alogliptin treatment arm was 106/2701 events versus 89/2679 which was not significant [odds ratio 1.19 (95% CI 0.89–1.58)] (Figs 4 and 5).

Fig. 3
Fig. 3:
The EXAMINE trial evaluated patient with acute coronary syndrome 15–90 days after event. The 1-year cardiovascular (CV) event rate was 6–7%. These study populations were a much high-risk group than seen in SAVOR. MI, myocardial infarction.
Table 2
Table 2:
Patient demographics of SAVOR and EXAMINE
Fig. 4
Fig. 4:
A new information presented at the American College of Cardiology meeting found no significant difference in cardiovascular mortality in the EXAMINE trial. The most common cardiovascular (CV) death was due to sudden death 11. HR, hazard ratio.
Fig. 5
Fig. 5:
Special groups that received improved risk reduction 11. CV, cardiovascular; DM, diabetes mellitus; GFR, glomerular filtration rate;HR, hazard ration.

Diabetes and heart failure considerations

Over the past three decades, we have seen a marked increase in prevalence of type 2 diabetes. What are the potential etiologies of this increase? Are they dietary or food density changes, changes in exercise, increased obesity, microbiome changes, or epigenetic changes 12? It is apparent that the vascular bed is clearly centered in the insulin-resistant complex. Unfortunately, cardiovascular disease continues to cause death in over 50% of type 2 diabetes patients. In addition, heart failure syndrome with preserved left ventricular function accounts for almost 50% of diabetes patient developing heart failure 13. At a more basic level, translational information in diabetes finds microRNAs as important regulators of hypoxia and growth factor pathways 14. Abnormalities of increased oxidative stress in diabetes, advanced glycosylation end products, reduced stem cells, vascular endothelial growth factor, and metabolic inflexibility at a cardiomyocyte level are among the targets for future research 15.

Heart failure in diabetes patients with preserved left ventricular function is complex 16. It is important to recognize that over 80% of the patients in SAVOR-TIMI and EXAMINE trials had hypertension, which itself is associated with increased left ventricular matrix changes that reduce ventricular compliance. Clinical conditions associated with diastolic dysfunction include left ventricular hypertrophy by echocardiography or ECG, enlarged left atrium, and a fourth heart sound. Type 2 diabetes patients have insulin resistance that can shift the metabolic pathways away from glucose as the major energy source, thus leading to an increased loss of ATPs (Fig. 6). The combination of both matrix changes and reduced energy production decreases power in the insulin-resistant heart and together increases the potential risk for heart failure. Moreover, the insulin-resistant heart is comprised of molecular and cellular disharmony. Translational research and prospective trials will be required to answer many of these questions.

Fig. 6
Fig. 6:
Potential heart failure changes over the last two decades. In the current two trials (EXAMINE and SAVOR), the incidence of hypertension is greater than 80% and with the new onset over the last 20 years of type 2 diabetes with impaired metabolic ability to utilize glucose as the major energy source in the heart due to insulin resistance. DM, diabetes mellitus; HTN, hypertension; LV, left ventricular.

In summary, both trials of the new DPP-4 inhibitors have failed to show a reduction in cardiovascular events in type 2 diabetes patients. There was a significant increase in hospitalization for heart failure with saxagliptin but not alogliptin, a paradigm previously observed with the thiazolidinedione class of drugs. The reasons for increased heart failure admissions with DPP-4 inhibitors remain unclear. Could this be a play of chance or actually be an increase in heart failure due to DPP-4 inhibitor? Consideration of translational findings in animals have ranged from improvement in cardiac function 17 to a possible increased circulating blood volume from increased neuropeptide Y due to vasoconstriction of microcirculation 18. Further studies are needed to determine whether this is a problem with the drug characteristics or the drug class. Various studies on oral diabetes agents have similarly failed to consistently show a decrease in macrovascular outcomes. Current research studies in animals have not demonstrated structural cardiovascular harm, and neither the SAVOR nor EXAMINE trials showed an increase in cardiac mortality. Early diagnosis and initiation of treatment for type 2 diabetes patients may be a better strategy for reducing cardiovascular outcomes.


Conflicts of interest

There are no conflicts of interest.


1. Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998; 317:703–713[Erratum in BMJ 1999; 318:29].
2. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonyl ureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998; 352:837–853.
3. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003; 348:383–393.
4. Patil H, Al Badarin F, Al Shami H, Bhatti H, Lavie CJ, Bell DS, O’Keefe JH. Meta-analysis of effect of dipeptidyl peptidase-4 inhibitors on cardiovascular risk in type 2 diabetes mellitus. Am J Cardiol. 2012; 110:826–833.
5. Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal TP, Hemmingsen C, Wetterslev J. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2013; 11:CD008143.
6. Scirica B, Bhatt D, Braunwald E, Steg PG, Davidson J, Hirshberg B, et al.. SAVOR-TIMI 53 Steering Committee and Investigators. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med. 2013; 369:1317–1326.
7. White W, Cannon C, Heller S, Nissen SE, Bergenstal RM, Bakris GL, et al.. EXAMINE Investigators. Alogliptin after acute coronary syndrome in patients with type 2 diabetes. N Engl J Med. 2013; 369:1327–1335.
8. Gregg E, Li Y, Wang J, Burrows N, Ali M, Rolka, et al.. Changes in diabetes-related complications in the United States, 1990–2010. N Engl J Med. 2014; 370:1514–1523.
9. White WB, Bakris GL, Bergenstal RM, Cannon CP, Cushman WC, Fleck P, et al.. EXamination of cArdiovascular outcoMes with alogliptIN versus standard of carE in patients with type 2 diabetes mellitus and acute coronary syndrome (EXAMINE): a cardiovascular safety study of the dipeptidyl peptidase 4 inhibitor alogliptin in patients with type 2 diabetes with acute coronary syndrome. Am Heart J. 2011; 162:620–626.
    10. Scirica BM, Bhatt DL, Braunwald E, Steg PG, Davidson J, Hirshberg B, et al.. The design and rationale of the saxagliptin assessment of vascular outcomes recorded in patients with diabetes mellitus-thrombolysis in myocardial infarction (SAVOR-TIMI) 53 study. Am Heart J. 2011; 162:818–825.e6.
      11. White WB, Kupher K, Nissen S, Cushman W, Bakris G, Heller S, et al.. Cardiovascular mortality in patients with type 2 diabetes and recent acute coronary syndromes from the EXAMINE trial. J Am Coll Cardiol. 2014; 6312_Sdoi: 10.1016/S0735-1097(14)60116-9.
        12. Musso G, Gambino R, Cassader M. Obesity, diabetes, and gut microbiota: the hygiene hypothesis expanded? Diabetes Care. 2010; 33:2277–2284.
        13. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA. 2002; 287:2570–2581.
        14. Wang XH, Qian RZ, Zhang W, Chen SF, Jin HM, Hu RM. MicroRNA-320 expression in myocardial microvascular endothelial cells and its relationship with insulin-like growth factor-1 in type 2 diabetic rats. Clin Exp Pharmacol Physiol. 2009; 36:181–188.
        15. Howangyin KY, Silvestre JS. Diabetes mellitus and ischemic diseases molecular mechanisms of vascular repair dysfunction. Arterioscler Thromb Vasc Biol. 2014; 34:1126–1135.
        16. Aurigemma GP, Gaasch WH. Diastolic heart failure. N Engl J Med. 2004; 351:1097–1105.
        17. Aroor AR, Sowers JR, Bender SB, Nistala R, Garro M, Mugerfeld I, et al.. Dipeptidylpeptidase inhibition is associated with improvement in blood pressure and diastolic function in insulin resistant male zucker obese rats. Endocrinology. 2013; 154:2501–2513.
        18. Marney A, Kunchakarra S, Byrne L, Brown NJ. Interactive hemodynamic effects of dipeptidyl peptidase-IV inhibition and angiotensin-converting enzyme inhibition in humans. Hypertension. 2010; 56:728–733.

        diastolic dysfunction; cardiovascular outcomes; dipeptidyl peptidase IV inhibitors; heart failure

        Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.