What is the role of Jardiance (empagliflozin) in the treatment of congestive heart failure (CHF)?

Role of Jardiance (Empagliflozin) in Congestive Heart Failure Treatment

Empagliflozin is strongly recommended for patients with heart failure across the spectrum of ejection fractions (both HFrEF and HFpEF), regardless of diabetes status, to reduce the risk of hospitalization for heart failure and cardiovascular death. 1, 2

Efficacy in Different Heart Failure Populations

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Empagliflozin 10 mg daily is part of the first-line quadruple therapy for HFrEF, alongside:
  • ACE inhibitor (or ARB/ARNI)
  • Beta-blocker
  • Mineralocorticoid receptor antagonist (MRA) 1
• In EMPEROR-Reduced trial, empagliflozin demonstrated:
  • 25% reduction in the composite of cardiovascular death or heart failure hospitalization 3
  • Benefits observed as early as 12 days after treatment initiation 3
  • 33% reduction in intensive care admissions for heart failure 3
  • Significant improvement in NYHA functional class 3

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Empagliflozin 10 mg daily is recommended for patients with HFpEF (LVEF >40%) 1, 2
• In EMPEROR-Preserved trial, empagliflozin showed:
  • 21% reduction in the composite of cardiovascular death or hospitalization for heart failure (HR 0.79 [95% CI 0.69–0.90]; P < 0.001) 1, 4
  • Consistent benefits regardless of diabetes status 1, 4
  • Reduction in total heart failure hospitalizations 4

Post-Myocardial Infarction Benefits

• Recent EMPACT-MI trial (2024) showed empagliflozin reduces:
  • Risk of first heart failure hospitalization by 23% (HR 0.77 [95% CI 0.60-0.98]) 5
  • Total heart failure hospitalizations by 33% (rate ratio 0.67 [95% CI 0.51-0.89]) 5
  • Need for new diuretics, renin-angiotensin modulators, or MRAs 5

Mechanism of Action in Heart Failure

Empagliflozin provides cardiovascular benefits through multiple mechanisms:

• Reduction in preload and afterload
• Decreased myocardial oxygen demand
• Improved cardiac metabolism
• Reduced cardiac fibrosis
• Natriuretic and diuretic effects without activating the sympathetic nervous system

Practical Prescribing Considerations

Dosing

• Standard dose: 10 mg orally once daily 2
• No dose adjustment needed based on ejection fraction

Patient Selection

• Appropriate for patients with heart failure regardless of:
  • Ejection fraction (HFrEF, HFmrEF, or HFpEF)
  • Diabetes status
  • NYHA functional class (I-IV)

Renal Function Considerations

• For heart failure treatment: Can be used with eGFR ≥20 mL/min/1.73m² 2
• For diabetes management: Not recommended if eGFR <30 mL/min/1.73m² 2

Monitoring and Safety

• Monitor for:
  • Genital mycotic infections
  • Urinary tract infections
  • Volume depletion/hypotension
  • Rare risk of euglycemic diabetic ketoacidosis (especially with insulin dose reduction, fasting, or carbohydrate restriction) 2
• Discontinue at least 3 days before planned surgery to prevent postoperative ketoacidosis 2

Integration with Other Heart Failure Therapies

• When adding empagliflozin to existing therapy:
  • Consider weaning or stopping sulfonylureas or glinides in patients with well-controlled HbA1c 2
  • Maintain guideline-directed medical therapy for heart failure
  • Monitor for hypotension when combined with diuretics

Conclusion

Empagliflozin has transformed heart failure management by providing significant benefits across the full spectrum of heart failure patients. Its ability to reduce hospitalizations and improve quality of life, combined with its favorable safety profile, makes it a cornerstone therapy for modern heart failure management.