Is Jardiance (empagliflozin) effective for treating diastolic heart failure, particularly in patients with type 2 diabetes?

Empagliflozin (Jardiance) for Diastolic Heart Failure

Empagliflozin is highly effective for treating diastolic heart failure (heart failure with preserved ejection fraction or HFpEF) and is recommended for patients regardless of their diabetes status. 1, 2

Efficacy in Diastolic Heart Failure

• The EMPEROR-Preserved trial demonstrated that empagliflozin 10mg daily reduced the composite outcome of cardiovascular death or hospitalization for heart failure by 21% (HR 0.79 [95% CI 0.69-0.90]; P < 0.001) in patients with heart failure and ejection fraction >40% 1
• This benefit was consistent in patients with and without type 2 diabetes, making empagliflozin an effective treatment option regardless of diabetes status 1
• A large meta-analysis of data from multiple trials (including EMPEROR-Preserved, EMPEROR-Reduced, DAPA-HF, DELIVER, and SOLOIST-WHF) confirmed reduced risk for cardiovascular death, hospitalization for heart failure, and all-cause mortality across the spectrum of heart failure patients 1

Clinical Application for Diastolic Heart Failure

• Empagliflozin 10mg once daily is the recommended dose for patients with diastolic heart failure 1, 3
• Benefits appear early after initiation (within weeks) and are sustained during long-term therapy 4
• Treatment improves symptoms, physical limitations, and quality of life in patients with heart failure 1
• The benefits of empagliflozin in heart failure appear independent of its glucose-lowering effects, representing a direct cardiovascular benefit 2

Mechanism of Action in Heart Failure

• While initially developed for type 2 diabetes, empagliflozin's cardiovascular benefits likely stem from multiple mechanisms beyond glycemic control 5
• The diuretic effect of empagliflozin may contribute to its efficacy in preventing heart failure exacerbations 6
• Empagliflozin reduces the risk of worsening heart failure events, with benefits seen early after treatment initiation 4

Safety Considerations

• Empagliflozin is generally well-tolerated in heart failure patients 3
• Common adverse effects include genital infections, volume depletion, and potential hypotension, especially when combined with other diuretics 6
• Caution is needed in patients with severe renal impairment (eGFR <30 mL/min/1.73 m²) as efficacy is reduced 7
• Monitor for euglycemic ketoacidosis, especially in patients with diabetes 2

Guidelines and Recommendations

• Current diabetes care standards recommend SGLT2 inhibitors, including empagliflozin, for patients with established HFpEF or HFrEF to reduce the risk of worsening heart failure and cardiovascular death 1
• The American College of Cardiology strongly recommends SGLT2 inhibitors for all patients with symptomatic heart failure regardless of ejection fraction or diabetes status 2
• European Society of Cardiology guidelines recommend empagliflozin in patients with type 2 diabetes and cardiovascular disease to reduce cardiovascular events and risk of death 1

Practical Implementation

• Start empagliflozin 10mg once daily in patients with diastolic heart failure 1, 3
• No dose adjustment is needed based on diabetes status 1
• Monitor for volume depletion, especially when initiating therapy or in patients on concomitant diuretics 6
• Consider temporary discontinuation during acute illness or procedures that may increase risk of volume depletion 7

Empagliflozin represents a significant advancement in the management of diastolic heart failure, offering mortality and morbidity benefits as well as improved quality of life for patients with this challenging condition.