Yes, empagliflozin can and should be used in this 80-year-old woman with grade III diastolic dysfunction.
Empagliflozin is specifically indicated for heart failure with preserved ejection fraction (HFpEF), which is the clinical manifestation of severe diastolic dysfunction, and age alone is not a contraindication. 1, 2
Guideline-Based Recommendation
The 2022 AHA/ACC/HFSA guidelines give empagliflozin a Class 1 (Strong) recommendation for patients with HFpEF (LVEF ≥50%), which encompasses grade III diastolic dysfunction 1. The 2025 Canadian guidelines similarly recommend SGLT2 inhibitors as first-line therapy for heart failure with nonreduced ejection fraction, with empagliflozin dosed at 10 mg daily 2.
Evidence in Elderly Patients
The FDA label explicitly states that no dosage adjustment is needed based on age alone 3. While the label notes increased risks of volume depletion (4.4% vs 2.1% placebo) and urinary tract infections (15.1% vs 10.5% placebo) in patients ≥75 years, these risks are manageable and do not preclude use 3.
Real-world evidence strongly supports use in octogenarians:
- A 2025 Belgian study of 577 HFpEF patients (median age 82 years, 58% female) showed empagliflozin was well-tolerated with only 2.8% discontinuation rate, primarily due to genitourinary infections 4
- The same study demonstrated significant improvements in NYHA functional class and reduction in peripheral edema 4
- A 2022 study in patients ≥80 years hospitalized for acute heart failure showed empagliflozin reduced NT-proBNP levels and increased diuretic response with good safety profile 5
Mechanism Relevant to Diastolic Dysfunction
Empagliflozin directly improves diastolic function through SGLT2-independent mechanisms 6. Laboratory studies demonstrate it reduces myofilament passive stiffness and improves diastolic tension in human heart failure tissue, with confirmed benefits in HFpEF animal models 6. This makes it particularly appropriate for grade III diastolic dysfunction.
Practical Implementation
Start with empagliflozin 10 mg once daily 2. Before initiating:
- Check renal function: The drug can be used with eGFR ≥20 mL/min/1.73 m², though benefits diminish below 45 mL/min/1.73 m² 3
- Assess volume status: Monitor for orthostatic hypotension, especially if on diuretics
- Screen for genitourinary infection history: Counsel on genital hygiene
Key Monitoring Points
Monitor closely for:
- Volume depletion: Risk increases to 4.4% in patients ≥75 years (vs 2.1% placebo) 3
- Urinary tract infections: Risk increases to 15.1% in elderly (vs 10.5% placebo) 3
- Renal function: Expect modest decline without clinical sequelae 4
The cardiovascular mortality benefit (38% reduction) and heart failure hospitalization reduction (29%) from the EMPEROR-Preserved trial were consistent across all age subgroups, including those ≥75 years 1, 7.
Common Pitfalls to Avoid
- Do not withhold due to age alone: The evidence shows consistent benefit and acceptable safety in octogenarians
- Do not stop if modest eGFR decline occurs: Small decreases in renal function are expected and not harmful 4
- Do not use if eGFR <20 mL/min/1.73 m² or on dialysis: Drug is contraindicated in severe renal impairment 3
The all-cause mortality rate in real-world elderly HFpEF patients on empagliflozin was only 6.9% over 16 months of follow-up 4, supporting both safety and effectiveness in this exact population.