Yes, Add an SGLT2 Inhibitor Immediately
You should absolutely add an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) to this patient's current regimen of torsemide, carvedilol, and lisinopril. This is a Class I, Level A recommendation for all patients with heart failure with reduced ejection fraction, regardless of blood pressure concerns 1, 2.
Why SGLT2 Inhibitors Are Essential in HFrEF
SGLT2 inhibitors reduce cardiovascular death by 18% and heart failure hospitalizations by 30% in HFrEF patients, with benefits appearing within weeks of initiation 2, 3. The evidence is unequivocal:
- Dapagliflozin reduced the composite outcome of worsening heart failure or cardiovascular death by 26% (HR 0.74,95% CI 0.65-0.85) in the DAPA-HF trial with 4,744 patients 2
- Empagliflozin reduced cardiovascular death or heart failure hospitalization by 25% (HR 0.75,95% CI 0.65-0.86) in EMPEROR-Reduced with 3,730 patients 2
- A 2026 Danish nationwide cohort study of 6,750 HFrEF patients showed that initiating SGLT2 inhibitors as third-line therapy (after RASI and beta-blockers, exactly like your patient) resulted in 30% lower all-cause mortality compared to adding an MRA (wHR 0.70,95% CI 0.57-0.86) 3
SGLT2 Inhibitors Have Minimal Blood Pressure Impact
The most critical advantage for your patient: SGLT2 inhibitors have the least impact on blood pressure among all guideline-directed medical therapies 1. The 2025 European Heart Failure Association consensus specifically states that when managing HFrEF patients with low blood pressure concerns, SGLT2 inhibitors should be prioritized and continued because they minimally affect BP 1.
- In the EMPULSE trial, hypotension occurred in only 5.7% of patients on SGLT2 inhibitors, with serious adverse events actually lower than placebo (32.3% vs 43.6%) 2
- The 2025 HFA algorithm explicitly recommends initiating SGLT2 inhibitors in all HFrEF patients with eGFR >20 mL/min/1.73 m², even those with systolic BP as low as 90 mmHg 1
Practical Implementation Strategy
Start dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily immediately—no titration required 1, 2. Unlike ACE inhibitors or beta-blockers, SGLT2 inhibitors are initiated at target dose:
- Dapagliflozin: Can be used with eGFR as low as 25 mL/min/1.73 m² 2
- Empagliflozin: Can be used with eGFR ≥30 mL/min/1.73 m² 2
- No dose adjustment needed for blood pressure 1
- Benefits independent of diabetes status 1, 2, 4
Addressing Common Concerns
Renal function considerations: A transient eGFR decline of 5-10% after initiation is expected and provides long-term kidney protection—this should not prompt discontinuation 2. The National Kidney Foundation explicitly recommends not withholding SGLT2 inhibitors for mild-to-moderate renal impairment 2.
Medication spacing: If concerned about cumulative hypotensive effects, space the SGLT2 inhibitor administration time from your other medications (e.g., give torsemide in morning, SGLT2 inhibitor at lunch, carvedilol/lisinopril in evening) 1.
Monitoring requirements: Watch for genital mycotic infections (1.5-1.7%), urinary tract infections (2.3-2.7%), and volume depletion, but these are generally mild 2. If the patient has diabetes, monitor for euglycemic ketoacidosis 2.
Critical Pitfall to Avoid
Do not discontinue or reduce the patient's existing ACE inhibitor, beta-blocker, or diuretic to "make room" for the SGLT2 inhibitor 2. SGLT2 inhibitors provide additive mortality benefit on top of optimal background therapy—they are not a replacement 1, 2. The 2022 AHA/ACC/HFSA guidelines emphasize that SGLT2 inhibitors should be added irrespective of other medications 1.
The Bottom Line
All patients with HFrEF should receive all four foundational therapies: ACE inhibitor/ARB/ARNI, beta-blocker, MRA, and SGLT2 inhibitor 1, 5. Your patient currently has only two of these four pillars. The 2025 HFA consensus and 2022 AHA/ACC guidelines both state that SGLT2 inhibitors are now a cornerstone of HFrEF treatment across all blood pressure ranges 1. Persistence of treatment is crucial, as benefits decline rapidly after discontinuation 6.