Dapagliflozin (Farxiga) for Diastolic Heart Failure
Dapagliflozin is highly effective for treating diastolic heart failure (heart failure with preserved ejection fraction, HFpEF) and should be prescribed for patients with this condition regardless of diabetes status. 1
Efficacy of Dapagliflozin in Diastolic Heart Failure
Evidence from Clinical Trials
- The DELIVER trial demonstrated that dapagliflozin reduced the composite endpoint of cardiovascular death or worsening heart failure by 18% in patients with heart failure with preserved ejection fraction (HFpEF) 2
- In a comprehensive analysis of the DAPA-HF and DELIVER trials, dapagliflozin showed consistent benefits across the entire ejection fraction spectrum, including patients with diastolic heart failure 1
- Benefits were observed regardless of diabetes status, making dapagliflozin appropriate for all patients with diastolic heart failure 3, 1
Mechanism of Action in Heart Failure
Dapagliflozin works through multiple mechanisms that specifically benefit heart failure patients:
- Promotes osmotic diuresis and natriuresis
- Reduces cardiac preload and afterload
- Improves cardiac metabolism
- Reduces myocardial fibrosis
- Decreases inflammation
Clinical Application
Patient Selection
Dapagliflozin 10mg daily is appropriate for patients with:
- Symptomatic heart failure with preserved ejection fraction (HFpEF/diastolic heart failure)
- NYHA class II-IV symptoms
- eGFR ≥25 mL/min/1.73m² (dose adjustment not required until eGFR falls below 25) 4
Expected Benefits
- Reduced risk of heart failure hospitalization
- Decreased cardiovascular mortality
- Improved quality of life
- Renal protection (slows eGFR decline) 4
- Weight loss and blood pressure reduction as additional benefits 5
Monitoring
- Assess volume status and renal function within first several weeks of therapy
- Monitor for genital mycotic infections
- No need for routine glucose monitoring in non-diabetic patients
- Consider temporary discontinuation during acute illness or procedures with restricted oral intake
Special Considerations
Patients with Advanced Kidney Disease
- Dapagliflozin has proven benefits in patients with CKD (eGFR as low as 25 mL/min/1.73m²) 4
- The DAPA-CKD trial showed 39% reduction in the primary composite endpoint of ≥50% sustained decline in eGFR, progression to end-stage kidney disease, CV or renal death 4
Patients with Decompensated Heart Failure
- Evidence suggests dapagliflozin can be safely added to furosemide in patients with decompensated heart failure 6
- Provides additional diuresis and weight loss without significant electrolyte disturbances 6
Severe Heart Failure
- Patients with severe heart failure (NYHA III/IV with recent hospitalization) derive particular benefit from dapagliflozin 1
- Treatment effect is consistent regardless of heart failure severity across the ejection fraction spectrum 1
Safety Profile and Precautions
Common Side Effects
- Genital mycotic infections (most common adverse effect)
- Volume depletion (monitor in elderly or those on diuretics)
- Rare risk of diabetic ketoacidosis (primarily in diabetic patients)
Precautions
- Temporarily discontinue before major surgical procedures
- Use caution when combining with loop diuretics in volume-depleted patients
- Monitor for urinary tract infections and genital mycotic infections
Conclusion
Dapagliflozin represents a significant advancement in the treatment of diastolic heart failure, with proven benefits in reducing hospitalizations and improving outcomes across the heart failure spectrum, regardless of diabetes status. The 2022 AHA/ACC/HFSA guidelines strongly support the use of SGLT2 inhibitors like dapagliflozin in heart failure patients 3.