From the Guidelines
SGLT2 inhibitors (SGLT2i) should be started in the "wet" phase of acute heart failure if no other contraindications exist, as they have been shown to improve outcomes in heart failure patients across the range of left ventricular ejection fraction (LVEF) 1. The European Society of Cardiology quality indicators update for the care and outcomes of adults with heart failure recommends SGLT2 inhibitors as a main quality indicator for patients with heart failure, independent of LVEF, in the absence of contraindications 1. Recent studies have demonstrated the benefits of in-hospital initiation of SGLT2i therapy for patients hospitalized for heart failure, including reduced risk of early post-discharge clinical worsening and death 1. Key points to consider when initiating SGLT2i in the "wet" phase of acute heart failure include:
- Monitoring for potential adverse effects such as excessive diuresis, electrolyte abnormalities, or acute kidney injury
- Adjusting diuretic therapy as needed to minimize the risk of these adverse effects
- Ensuring the patient's renal function is adequate to tolerate SGLT2i therapy, with an estimated glomerular filtration rate (eGFR) of at least 30 ml/min/1.73m2
- Starting with a standard dose of SGLT2i, such as empagliflozin 10 mg daily or dapagliflozin 10 mg daily, and adjusting as needed based on patient response and tolerability. Overall, the benefits of SGLT2i therapy in heart failure patients, including reduced hospitalizations and mortality, support the initiation of these medications in the "wet" phase of acute heart failure, even in the absence of other contraindications 1.
From the Research
SGLT2 Inhibitors in Acute Heart Failure
- The use of SGLT2 inhibitors in the "wet" phase of acute heart failure has been investigated in several studies 2, 3, 4.
- These studies suggest that SGLT2 inhibitors may have a role in the inpatient management of acute heart failure, provided there is close monitoring for fluctuations in hemodynamic, fluid, and electrolyte status 2.
- The initiation of SGLT2 inhibitors at the time of acute heart failure may promote optimized guideline-directed medical therapy, continued medication adherence, and reduced risk of cardiovascular outcomes 2.
Benefits of SGLT2 Inhibitors
- SGLT2 inhibitors have been shown to reduce the risk of cardiovascular hospitalization and kidney injury in patients with heart failure 5.
- A meta-analysis of randomized controlled trials found that SGLT2 inhibitors reduced the risk of heart failure events and readmissions by 62% and 24%, respectively 3.
- The EMPULSE trial found that empagliflozin improved clinical outcomes in patients hospitalized for acute heart failure, regardless of left ventricular ejection fraction 4.
Safety and Tolerability
- SGLT2 inhibitors have been found to be well tolerated in patients with acute heart failure, with a similar incidence of hypotension, hypokalemia, and acute renal failure compared to placebo 2, 4.
- Serious adverse events were reported in 32.3% and 43.6% of empagliflozin- and placebo-treated patients, respectively, in the EMPULSE trial 4.
Clinical Considerations
- The exact mechanisms for how SGLT2 inhibitors are beneficial in heart failure are unknown, but current hypotheses include multiple metabolic and hemodynamic mechanisms 6.
- Nurses should be aware of the potential benefits and risks of SGLT2 inhibitors in patients with heart failure and monitor patients closely for adverse effects 6.