Selected in The New England Journal of Medicine by Jolie Bruno
References
Authors: S. Raposeiras‑Roubin, I. J. Amat‑Santos, X. Rossello, R. Gonzalez Ferreiro, I. Gonzalez Bermudez, D. Lopez Otero, L. Nombela‑Franco, L. Gheorghe, J.L. Diez, C. Baladron Zorita, J. A. Baz, A. J. Munoz Garcia, V. Vilalta, S. Ojeda‑Pineda, J. M. de la Torre Hernandez, J. G. Cordoba Soriano, A. Regueiro, P. Bordes Siscar, J. Salgado Fernandez, B. Garcia del Blanco, R. Martin‑Reyes, R. Romaguera, C. Moris, S. Garcia Blas, J. A. Franco‑Pelaez, I. Cruz‑Gonzalez, D. Arzamendi, N. Romero Rodriguez, F. Diez‑del Hoyo, S. Camacho Freire, F. Bosa Ojeda, J. C. Astorga Burgo, E. Molina Navarro, J. Caballero Borrego, V. Ruiz Quevedo, A. Sanchez‑Recalde, V. Peral Disdier, E. Alegria‑Barrero, J. Torres‑Llergo, G. Feltes, J. A. Fernandez Diaz, C. Cuellas, G. Jimenez Britez, J. Sanchez‑Rubio Lezcano, C. Barreiro‑Pardal, I. Nunez‑Gil, E. Abu‑Assi, A. Iniguez‑Romo, V. Fuster and B. Ibanez.
Reference: N Engl J Med. 2025 Mar 29. doi: 10.1056/NEJMoa2500366
Read the abstract
Why this study – the rationale/objective?
Severe aortic stenosis is the leading valvular disorder affecting older adults, with transcatheter aortic valve implantation (TAVI) now widely adopted as the preferred treatment. Although effective therapeutic measures, patients undergoing TAVI remain at high risk of heart failure (HF) events and adverse outcomes. The DapaTAVI trial represents the first clinical evaluation of a sodium–glucose cotransporter 2 inhibitor (SGLT2i), dapagliflozin, in this high-risk population.
How was it executed – the methodology?
This investigator-initiated, multicenter trial was conducted in Spain and supported by public institutions, including the Instituto de Salud Carlos III, the Regional Health Management of the Junta de Castilla y León, the Spanish Society of Cardiology, and the Galician Society of Cardiology. The study employed a randomized, open-label design with blinded endpoint adjudication to evaluate the efficacy and safety of dapagliflozin, 10 mg once daily, in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Eligible participants had a documented history of heart failure and met at least one of the following criteria: moderate renal impairment (eGFR 25–75 mL/min/1.73 m²), type 2 diabetes mellitus, or reduced left ventricular ejection fraction (LVEF ≤ 40%).
What is the main result?
A total of 1,222 patients with a mean age of 82 years were randomized to receive dapagliflozin or standard of care. At 12-month follow-up, the primary composite endpoint—all-cause death or worsening HF—was significantly lower with dapagliflozin (15.0% vs. 20.1%; HR 0.72; p = 0.02), mainly driven by fewer worsening HF events. This effect was consistent across prespecified subgroups (age, sex, renal function and LVEF). Importantly, no major safety concerns emerged: the most frequent adverse events were genital infections (1.8%) and hypotension (6.6%), both occurring more commonly in the dapagliflozin group. Approximately 20% of patients in this group discontinued treatment (mainly due to infections), while 7% of those in the control arm initiated dapagliflozin for indications unrelated to HF. Nevertheless, overall adherence rates remained high—82% in the dapagliflozin group and 90% in the control group—with minimal loss to follow-up, supporting the robustness of the observed clinical benefit.
Critical reading and the relevance for clinical practice
The traditional view of aortic stenosis as a purely mechanical valvular disease is no longer sufficient. Emerging evidence indicates that myocardial involvement—such as extracellular volume, fibrosis and microvascular dysfunction—plays a key role in its pathophysiology. Importantly, HF remains the most common cause of rehospitalization after TAVI, highlighting that valve relief alone does not fully reverse the underlying cardiac injury, which continues to impact prognosis. The therapeutic goal should therefore extend beyond relieving the obstruction to include strategies that promote favourable cardiac remodelling. SGLT2i have been shown to improve left ventricular volumes, systolic function, and pulmonary pressures—effects that likely contribute to the prognostic benefit observed in this study. Their effects may be mediated by reductions in oxidative stress and inflammation—key mechanisms linking heart failure, frailty, and disease progression in older adults.
The DapaTAVI trial offers a pragmatic and timely contribution with clear implications for clinical practice by evaluating dapagliflozin in older adults undergoing TAVI—a population largely excluded from prior SGLT2i trials. Broad inclusion criteria yielded a representative real-world population, with a balanced sex distribution (about 49% of women), enhancing generalizability. The observed 28% relative reduction in the composite outcome of death or worsening HF, achieved with good safety, supports expanding HF therapy beyond traditional boundaries. These findings also provide a strong rationale to overcome therapeutic inertia in older patients. Age and the associated frailty should not represent a barrier to treatment, but rather a compelling reason for timely initiation of guideline-directed medical therapy, as already emphasized in trials such as STRONG-HF, PARAGON-HF and DELIVER.
In conclusion, DapaTAVI provides the first high-quality evidence supporting dapagliflozin—and likely any SGLT2i—in older patients with severe aortic stenosis undergoing TAVI. Clinicians should consider its use to reduce post-procedural HF events in this vulnerable and growing population.
Alexandre Mebazaa on DAPA-TAVI trial results
Alexandre Mebazaa takes a closer look at the results of the DAPA-TAVI trial, presented by Sergio Raposeiras Roubín at ACC 2025.
