Is Jardiance (empagliflozin) beneficial for patients with Hypertrophic Cardiomyopathy (HCM) and normal ejection fraction (EF) who have atrial flutter and are on Eliquis (apixaban)?

Empagliflozin (Jardiance) for Hypertrophic Cardiomyopathy with Preserved EF and Atrial Flutter

Empagliflozin is beneficial for patients with hypertrophic cardiomyopathy (HCM) who have preserved ejection fraction (EF >50%) and atrial flutter on Eliquis, as it reduces the risk of heart failure hospitalizations and cardiovascular mortality regardless of atrial fibrillation/flutter status.

Benefits of Empagliflozin in HCM with Preserved EF

• SGLT2 inhibitors like empagliflozin are recommended for patients with heart failure with preserved ejection fraction (HFpEF) to reduce the risk of heart failure hospitalization and cardiovascular death (Class I, Level A recommendation) 1
• The benefits of empagliflozin are consistent across the spectrum of ejection fractions from <25% to <65%, with only slightly attenuated effects in patients with very high EF (≥65%) 2
• Empagliflozin reduces the risk of heart failure hospitalizations by approximately 30% in patients with preserved EF, which would benefit patients with HCM who have EF >50% 2

Empagliflozin in Patients with Atrial Fibrillation/Flutter

• Empagliflozin reduces cardiovascular death or heart failure hospitalization to a similar extent in patients with and without atrial fibrillation/flutter (hazard ratio 0.78) 3
• Patients with HCM and atrial flutter are at high risk of stroke, requiring anticoagulation with Eliquis (apixaban) or other anticoagulants regardless of CHA₂DS₂-VASc score 1
• Recent evidence shows empagliflozin inhibits increased sodium influx in atrial cardiomyocytes of patients with HFpEF, which may provide additional anti-arrhythmic benefits for patients with atrial flutter 4

Management Algorithm for HCM with Preserved EF and Atrial Flutter

1. Continue anticoagulation with Eliquis (apixaban)

   • All patients with HCM and atrial fibrillation/flutter should receive lifelong oral anticoagulation due to high stroke risk 1

2. Add empagliflozin to the treatment regimen

   • Start with standard dosing of 10 mg once daily 3, 5
   • Benefits are seen early (within 12-28 days) and maintained during long-term therapy 6
   • Benefits occur regardless of diabetes status 5

3. Monitor for improvement in heart failure symptoms

   • Empagliflozin improves New York Heart Association (NYHA) functional class with effects apparent within 28 days of treatment initiation 6

4. Continue other appropriate medications for HCM

   • Rate control medications (beta-blockers or non-dihydropyridine calcium channel antagonists) should be continued for atrial flutter 1
   • Consider rhythm control strategies if rate control is inadequate 1

Special Considerations

• In patients with HCM who develop systolic dysfunction (EF <50%), it is reasonable to discontinue negative inotropic agents (verapamil, diltiazem, disopyramide) 1
• Empagliflozin slows the decline in estimated glomerular filtration rate over time in patients with and without atrial fibrillation/flutter, providing additional cardiorenal protection 3
• The benefits of empagliflozin in heart failure are independent of its glucose-lowering effects, making it appropriate for patients with or without diabetes 7, 5

Potential Pitfalls and Caveats

• Monitor for volume depletion, especially during initiation, as patients with HCM may be sensitive to changes in preload 1
• Be vigilant for urinary tract infections and genital mycotic infections, which are known side effects of SGLT2 inhibitors 1
• Empagliflozin should not replace other essential therapies for HCM and atrial flutter but should be added to optimize management 1
• Patients with HCM and atrial flutter should be enrolled in a multidisciplinary HF management program to improve outcomes 1