Yes, Jardiance (empagliflozin) is strongly recommended for patients with HFrEF
Empagliflozin is a cornerstone therapy for HFrEF and should be initiated in all eligible patients with heart failure and reduced ejection fraction (LVEF ≤40%), regardless of diabetes status. 1
Evidence-Based Recommendation
The most recent Canadian guidelines (2021) provide a Strong Recommendation with High-Quality Evidence that SGLT2 inhibitors like empagliflozin should be used in patients with HFrEF, with or without type 2 diabetes, to improve symptoms, quality of life, and reduce the risk of heart failure hospitalization and cardiovascular mortality 1.
Key Clinical Trial Evidence
The EMPEROR-Reduced trial (2020) definitively established empagliflozin's benefit in HFrEF 2:
- 3,730 patients with LVEF ≤40% randomized to empagliflozin 10 mg daily vs placebo
- 25% risk reduction in the primary composite endpoint of cardiovascular death or heart failure hospitalization (HR 0.75,95% CI 0.65-0.86, p<0.0001)
- 31% reduction in heart failure hospitalizations (HR 0.69,95% CI 0.59-0.81)
- Benefits seen regardless of diabetes status (50% had type 2 diabetes at baseline)
- Benefits apparent as early as 12 days after initiation 3
Practical Implementation
Starting dose: Empagliflozin 10 mg once daily 4
Target dose: 10-25 mg daily (though 10 mg is the FDA-approved dose for HFrEF) 4
When to initiate:
- Start early in the disease course alongside other guideline-directed medical therapy (GDMT)
- Can be initiated even if patient is not yet on maximally tolerated doses of other HF medications
- Benefits accrue rapidly (within 30 days) 1
Eligibility Criteria
Include patients with:
- LVEF ≤40%
- NYHA Class II-IV symptoms
- eGFR ≥20 mL/min/1.73 m² 1
Key considerations:
- Diabetes NOT required - benefits are consistent with or without diabetes 1
- Safe to use with other HF medications including ACE inhibitors/ARBs/ARNI (88% on these agents in trials), beta-blockers (95%), and MRAs (71%) 2
- No treatment interactions with baseline HF therapies 1
Renal Function Guidance
- Can initiate if eGFR ≥20 mL/min/1.73 m² 1
- EMPEROR-Reduced included patients down to eGFR 20 mL/min/1.73 m²
- Continue therapy even if eGFR falls below initiation threshold during treatment (unless dialysis initiated) 5
- Empagliflozin actually slows eGFR decline compared to placebo (0.55 vs 2.28 mL/min/1.73 m²/year) 1
Safety Profile
Empagliflozin was well-tolerated in trials with no excess in 1:
- Hypovolemia (5.7% empagliflozin vs 5.5% placebo)
- Hypoglycemia
- Renal side effects
Common but manageable adverse events:
- Genital mycotic infections (counsel on hygiene)
- Volume depletion (monitor, consider proactive diuretic reduction in high-risk patients)
- Diabetic ketoacidosis (rare, educate on sick day protocol)
Critical Pitfalls to Avoid
- Don't wait for "optimal" GDMT - Empagliflozin can be started early; waiting delays benefit
- Don't exclude non-diabetic patients - 55% of DAPA-HF and 50% of EMPEROR-Reduced patients had no diabetes
- Don't stop if eGFR declines - Initial eGFR dip is expected and reversible; continue unless dialysis needed
- Don't avoid in lower blood pressure - Patients with baseline SBP 100-110 mmHg showed minimal BP decrease (<1 mmHg after 4 months) and may even experience BP increase due to improved cardiac function 6
Additional Benefits Beyond Hospitalization Reduction
- Reduces total number of heart failure hospitalizations (not just first event) 2
- Decreases need for ICU admissions (HR 0.67) and vasopressor/inotrope use (HR 0.64) 3
- Reduces diuretic intensification needs (HR 0.67) 3
- Improves NYHA functional class (20-40% more likely to improve, 20-40% less likely to worsen) 3
- Improves quality of life scores 1
- Benefits consistent in both ischemic and non-ischemic cardiomyopathy 7
The evidence is unequivocal: empagliflozin should be considered foundational therapy for all patients with HFrEF (LVEF ≤40%) and eGFR ≥20 mL/min/1.73 m², initiated early alongside other GDMT to maximize morbidity and mortality benefits. 1