Can empagliflozin be prescribed to a 71‑year‑old patient with coronary artery disease who underwent percutaneous coronary intervention, has a normal left ventricular ejection fraction, and an NT‑proBNP of 9000 pg/mL?

Can Empagliflozin Be Given to This Patient?

Yes, empagliflozin should be initiated at 10 mg once daily in this 71-year-old patient with coronary artery disease, normal ejection fraction, and NT-proBNP of 9000 pg/mL, as the markedly elevated natriuretic peptide indicates significant cardiac stress and high risk for heart failure progression, making SGLT2 inhibitor therapy both appropriate and beneficial for cardiovascular protection.

Clinical Context and Risk Assessment

The NT-proBNP level of 9000 pg/mL is profoundly elevated and indicates substantial myocardial stress, even in the presence of normal left ventricular ejection fraction 1. This elevation places the patient at very high risk for adverse cardiovascular outcomes including heart failure hospitalization and cardiovascular death 2. Patients with NT-proBNP levels in this range demonstrate 2- to 5-fold higher incidence rates for cardiac events compared to those with lower levels 2.

The combination of established coronary artery disease with recent percutaneous coronary intervention and markedly elevated NT-proBNP suggests either:

• Heart failure with preserved ejection fraction (HFpEF) that may not yet be clinically apparent
• Stage B heart failure (pre-HF with structural heart disease and elevated biomarkers) 1
• High risk for incident heart failure requiring preventive therapy 3

Evidence Supporting Empagliflozin Initiation

Cardiovascular Protection in Preserved Ejection Fraction

Empagliflozin reduces the risk of cardiovascular death or heart failure hospitalization by 21-26% in patients with heart failure and preserved ejection fraction, with benefits consistent regardless of diabetes status 4. In the EMPEROR-Preserved trial, empagliflozin reduced first heart failure hospitalizations (HR 0.79,95% CI 0.67-0.94) and total heart failure hospitalizations, with effects preserved across the entire range of baseline NT-proBNP levels 4, 2.

Post-Myocardial Infarction and Coronary Disease Benefits

In patients with recent acute coronary events, empagliflozin reduces first heart failure hospitalization by 23% (HR 0.77,95% CI 0.60-0.98) and total heart failure hospitalizations by 33% (RR 0.67,95% CI 0.51-0.89) 5. These benefits are consistent across the spectrum of left ventricular function and regardless of congestion status 6.

For patients with established atherosclerotic cardiovascular disease (which includes coronary artery disease requiring angioplasty), empagliflozin provides significant cardiovascular protection with a 14% reduction in the composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (HR 0.86,95% CI 0.74,0.99), driven primarily by a 38% reduction in cardiovascular death (HR 0.62,95% CI 0.49,0.77) 7.

Efficacy Across Age Groups

At 71 years of age, this patient falls into the 65-74 year age group where empagliflozin demonstrates consistent benefit. The reduction in cardiovascular death or heart failure hospitalization is 28% in patients aged 65-74 years (HR 0.72,95% CI 0.57-0.93), with no increased adverse events compared to placebo 8. Even in patients ≥75 years, empagliflozin maintains efficacy (HR 0.86,95% CI 0.67-1.10) with a consistent safety profile 8.

Biomarker-Guided Therapy

The markedly elevated NT-proBNP of 9000 pg/mL strongly supports empagliflozin initiation. Empagliflozin modestly reduces NT-proBNP levels over time, with an adjusted mean difference of 7% from placebo by 100 weeks 2. More importantly, the cardiovascular benefits of empagliflozin are preserved across the entire range of baseline NT-proBNP concentrations, including very high levels 2.

Practical Implementation Algorithm

Step 1: Verify Eligibility Criteria

• Check current eGFR: Empagliflozin can be initiated if eGFR ≥20 mL/min/1.73 m² for cardiovascular protection 3, 9
• Exclude absolute contraindications: Pregnancy, breastfeeding, or dialysis dependence 3
• Assess volume status: Correct any volume depletion before initiation and consider reducing concurrent diuretic doses 3, 9

Step 2: Initiate Therapy

• Start empagliflozin 10 mg once daily – this is the fixed dose for cardiovascular protection with no titration required 3, 7
• Continue all existing cardiovascular medications including ACE inhibitors/ARBs, beta-blockers, and antiplatelet agents without adjustment 3, 9
• If the patient is on insulin or sulfonylureas, consider modest dose reductions to mitigate hypoglycemia risk, though this is less relevant in a patient with normal EF and likely no diabetes 3

Step 3: Monitor After Initiation

• Recheck eGFR within 1-2 weeks: An acute, reversible decline of 2-5 mL/min/1.73 m² is expected and represents hemodynamic adaptation, not kidney injury – do not discontinue therapy for this expected change 3, 9
• Reassess volume status at follow-up, particularly if the patient is on diuretics 9
• Continue long-term monitoring: eGFR every 3-6 months if eGFR 25-59 mL/min/1.73 m², or annually if ≥60 mL/min/1.73 m² 3

Safety Precautions and Patient Education

Sick-Day Management

Instruct the patient to temporarily withhold empagliflozin during acute illness with reduced oral intake, fever, vomiting, or diarrhea to prevent volume depletion and euglycemic diabetic ketoacidosis 3, 9. The medication should be stopped at least 3 days before major surgery or procedures requiring prolonged fasting 3, 9.

Monitoring for Adverse Effects

• Genital mycotic infections occur in approximately 6% of patients versus 1% with placebo; counsel on daily hygiene measures 3
• Euglycemic diabetic ketoacidosis can occur even with normal blood glucose; advise immediate medical evaluation for unexplained malaise, nausea, vomiting, or abdominal pain 3, 9
• Volume depletion risk is higher in elderly patients and those on concurrent diuretics; assess for orthostatic hypotension, dizziness, or clinical dehydration 9

Common Pitfalls to Avoid

Do not withhold empagliflozin because the patient has "normal" ejection fraction – the markedly elevated NT-proBNP indicates significant cardiac pathology requiring treatment 1, 2.

Do not discontinue empagliflozin if eGFR falls below 45 mL/min/1.73 m² during follow-up, as cardiovascular and renal protective benefits persist even when glycemic efficacy is lost 3, 9.

Do not stop empagliflozin in response to the expected initial eGFR dip of 2-5 mL/min/1.73 m² within the first 2-4 weeks – this hemodynamic change is transient, reversible, and associated with long-term renal protection 3, 9.

Do not reduce the dose below 10 mg for cardiovascular indications; all outcome trials demonstrating benefit used the fixed 10 mg daily dose 3, 7.

Integration with Post-PCI Management

Empagliflozin complements standard post-angioplasty care and should be added to the patient's existing regimen of antiplatelet therapy, statins, ACE inhibitors/ARBs, and beta-blockers 7. The drug provides additive cardiovascular protection beyond these established therapies, with particular benefit in reducing heart failure risk – a critical consideration given the patient's markedly elevated NT-proBNP 5, 6.