The EMPATICC-trial—should location shape therapy?

This commentary refers to ‘Heart Failure Therapy in Patients with Advanced Cancer Receiving Specialized Palliative Care (EMPATICC trial)’, by M. S. Anker et al., https://doi.org/10.1093/eurheartj/ehaf705 and the discussion piece ‘Revisiting the EMPATICC Trial in Low- and Middle-Income Countries, by N. Adnan et al., https://doi.org/10.1093/eurheartj/ehag006. The multicentre, double blind, randomized controlled EMPATICC trial1–3 tested provision of an optimized heart failure (HF) therapy in patients with advanced cancer in a specialized palliative care setting. Patients had an estimated life expectancy of 1–6 months at baseline as well as cardiovascular (CV) risk factors and functional limitation at baseline. The tested HF therapy consisted of empagliflozin, sacubitril/valsartan, ivabradine, and i.v. ferric carboxymaltose. While the self-care ability of patients was not improved at 30 days, those patients who survived 30 days showed significantly better self-reported overall quality of life (i.e. improved patient global assessment, odds ratio 0.22), reduced cardiac biomarkers (N-terminal prohormone of brain natriuretic peptide, NTproBNP −41%), and increased left ventricular ejection fraction (LVEF, absolute change +2.9%). These results encourage further testing of HF drug therapies in patients with advanced cancer, especially when expected survival times are at >6 months—since the mortality in the EMPATICC was high with on average 32% at 30 days and 47% at 60 days.