SGLT2 Inhibitors in Heart Failure Management
SGLT2 inhibitors should be given to heart failure patients regardless of ejection fraction or diabetes status, as they significantly reduce hospitalization for heart failure and cardiovascular death across the spectrum of heart failure. 1
Benefits of SGLT2 Inhibitors in Heart Failure
SGLT2 inhibitors have demonstrated robust benefits in heart failure management:
- Reduced hospitalization for heart failure: Multiple large trials show 27-39% reduction in heart failure hospitalizations 1
- Decreased cardiovascular mortality: Particularly evident in heart failure with reduced ejection fraction (HFrEF) 1
- Improved quality of life: Benefits seen across heart failure types 1
- Early clinical benefits: Effects begin within days to weeks of initiation 1
Evidence in Heart Failure with Reduced Ejection Fraction (HFrEF)
The evidence for SGLT2 inhibitors in HFrEF is particularly strong:
DAPA-HF trial: Dapagliflozin reduced the composite of worsening heart failure or cardiovascular death by 26% (HR 0.74 [95% CI 0.65-0.85]) in patients with NYHA class II-IV heart failure and ejection fraction ≤40%, regardless of diabetes status 1
EMPEROR-Reduced trial: Empagliflozin reduced the composite of cardiovascular death or hospitalization for heart failure by 25% (HR 0.75 [95% CI 0.65-0.86]) in patients with heart failure and ejection fraction ≤40% 2
Evidence in Heart Failure with Preserved Ejection Fraction (HFpEF)
SGLT2 inhibitors have also shown benefits in HFpEF:
EMPEROR-Preserved trial: Empagliflozin reduced the composite of cardiovascular death or hospitalization for heart failure by 21% (HR 0.79 [95% CI 0.69-0.90]) in patients with heart failure and ejection fraction >40% 1
DELIVER trial: Dapagliflozin reduced the composite of worsening heart failure or cardiovascular death by 18% (HR 0.82 [95% CI 0.73-0.92]) in patients with heart failure and ejection fraction >40% 1
Implementation in Clinical Practice
When to Initiate SGLT2 Inhibitors
- In-hospital initiation: Recommended for eligible patients before discharge from heart failure hospitalization 1
- Outpatient setting: Should be part of standard therapy for all eligible heart failure patients 1
Patient Selection
SGLT2 inhibitors should be considered for:
- All patients with HFrEF (ejection fraction ≤40%) 1
- All patients with HFpEF (ejection fraction >40%) 1
- Patients with or without diabetes 1
- Patients with chronic kidney disease (eGFR ≥20-30 mL/min/1.73m²) 1
Practical Considerations
- Dosing: Standard doses (empagliflozin 10mg daily, dapagliflozin 10mg daily) 1
- Monitoring: Watch for volume depletion, especially when combined with diuretics
- Combination therapy: SGLT2 inhibitors can facilitate use of other heart failure medications by decreasing risk of hyperkalemia and slowing progression of kidney dysfunction 1
Potential Pitfalls and Caveats
- Genital infections: More common with SGLT2 inhibitors; educate patients on hygiene 2
- Volume depletion: May require adjustment of diuretic therapy
- Diabetic ketoacidosis: Rare but serious risk, especially in insulin-dependent patients
- Renal function: Most agents require eGFR ≥20-30 mL/min/1.73m²
Meta-analysis Evidence
A comprehensive meta-analysis of 21,947 patients from five major trials (EMPEROR-Reduced, EMPEROR-Preserved, DAPA-HF, DELIVER, and SOLOIST-WHF) demonstrated consistent benefits of SGLT2 inhibitors across the heart failure spectrum 3:
- 23% reduction in the composite of cardiovascular death or hospitalization for heart failure
- 13% reduction in cardiovascular death
- 28% reduction in first hospitalization for heart failure
- 8% reduction in all-cause mortality
These benefits were consistent regardless of ejection fraction, diabetes status, or care setting 3, 4.