How Jardiance (Empagliflozin) Helps in Heart Failure
Empagliflozin significantly reduces the risk of heart failure hospitalization and cardiovascular death in patients with heart failure, regardless of ejection fraction or diabetes status, through multiple mechanisms that improve cardiac function and reduce cardiac workload. 1
Efficacy in Different Types of Heart Failure
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Empagliflozin demonstrates a 21% reduction in the composite of cardiovascular death or hospitalization for heart failure in patients with HFrEF (HR 0.79 [95% CI 0.69–0.90]; P < 0.001) 1
- Benefits appear early, with statistically significant effects observed as soon as 12 days after treatment initiation 2
- Reduces total number of heart failure hospitalizations requiring intensive care (HR 0.67 [95% CI 0.50-0.90]) and those requiring vasopressors or inotropic support (HR 0.64 [95% CI 0.47-0.87]) 2
Heart Failure with Preserved Ejection Fraction (HFpEF)
- Empagliflozin shows a 21% reduction in the primary outcome of cardiovascular death or hospitalization for heart failure in patients with HFpEF (LVEF >40%) 3, 1
- Benefits are similar in patients with mildly reduced ejection fraction (40-50%) and mid-range (50-60%), but may be attenuated at higher ejection fractions 4
Mechanisms of Action in Heart Failure
Empagliflozin works through several complementary mechanisms:
Hemodynamic effects:
- Promotes osmotic diuresis and natriuresis, reducing preload
- Decreases blood pressure and vascular stiffness, reducing afterload
- Reduces cardiac workload without activating neurohormonal systems
Metabolic effects:
- Shifts cardiac metabolism from glucose to ketone bodies, improving cardiac energetics
- Reduces epicardial fat and systemic inflammation
- Improves insulin sensitivity
Direct cardiac effects:
- Inhibits sodium-hydrogen exchange in cardiomyocytes, reducing intracellular sodium and calcium
- Improves mitochondrial function
- Reduces cardiac fibrosis and remodeling
Clinical Benefits Beyond Hospitalization Reduction
- Symptom improvement: Patients on empagliflozin are 20-40% more likely to experience improvement in NYHA functional class 2
- Reduced need for diuretic intensification: 33% reduction in outpatient diuretic intensification compared to placebo (HR 0.67 [95% CI 0.56-0.78]) 2
- Quality of life improvement: Significantly improves health-related quality of life measures 5
- Renal protection: Reduces risk of serious kidney problems by 50% compared to placebo (1.6% vs 3.1%) 6
Guideline Recommendations
The European Society of Cardiology and American Diabetes Association strongly recommend SGLT2 inhibitors including empagliflozin for:
- Heart failure patients with reduced ejection fraction (HFrEF) to reduce risk of hospitalization and death (Class I, Level A) 3
- Heart failure patients with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) to reduce risk of hospitalization and cardiovascular death (Class I, Level A) 3
- These recommendations apply regardless of diabetes status 1
Important Clinical Considerations
- Dosing: The recommended dose is 10 mg once daily 1
- Renal function: Can be used in patients with eGFR ≥30 mL/min/1.73m² 1
- Side effects: Most common is genital mycotic infections (1.7% vs 0.6% with placebo) 6
- Efficacy across etiologies: Benefits are consistent regardless of whether heart failure is ischemic or non-ischemic in origin 7
Practical Implementation
- Add empagliflozin to standard heart failure therapy including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists
- Monitor for volume depletion, especially when initiating therapy
- No dose adjustment needed for patients with diabetes, but monitor for hypoglycemia if on insulin or sulfonylureas 1
- Benefits are seen early (within 12-18 days) and sustained throughout treatment 2, 4
Empagliflozin represents a significant advance in heart failure management, offering substantial benefits across the spectrum of heart failure with minimal side effects.