[Skip to Navigation]
Views 2,243
Citations 0
May 26, 2021

Dapagliflozin—Does Cost Make 4-Pillar Heart Failure Therapy Too Herculean a Labor for Medicine?

Author Affiliations
  • 1Duke Clinical Research Institute, Duke University, Durham, North Carolina
  • 2Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
JAMA Cardiol. 2021;6(8):875-876. doi:10.1001/jamacardio.2021.1448

Legend states that as penance for an act of homicidal madness, Hercules, the mythological Greek demigod, agreed to perform 12 labors, feats that are now metaphors for accomplishments of prodigious difficulty. After completion of the 10th labor, he created the Pillars of Hercules, which the modern world knows as the Straits of Gibraltar. Ancient commentators were undecided about his motives, but one theory was that he intended the pillars to mark the end of the world, a warning that beyond that point nothing exists. Heart failure provides clinicians a modern-day Herculean labor: its prognosis is often described as cancerlike, its clinical manifestations are often progressive and sometimes refractory, and the number of affected patients is expected to grow by a staggering amount in the next few decades as the population ages. Evidence to extend life expectancy of reasonable quality past the “nothing further beyond” pillars that a diagnosis of heart failure has historically conveyed has developed slowly over the past 30 years. Starting with trials showing the prognosis-modifying potential for angiotensin-converting enzyme (ACE) inhibitors, followed by β-blockers, angiotensin II receptor blockers (ARBs), and then mineralocorticoid receptor antagonists, clinical science has developed an impressive portfolio of what works in heart failure. However, clinical practice has consistently underperformed in the use of these agents relative to what both pivotal trial results and clinical practice guidelines would have us do.1

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words