Should Empagliflozin (Empagliflozin) be held in a patient with heart block?

From the Guidelines

Empagliflozin should generally not be held specifically for heart block unless the patient is hemodynamically unstable or severely symptomatic. For patients with stable heart block who are euvolemic and have adequate blood pressure, empagliflozin can typically be continued, especially if prescribed for heart failure, type 2 diabetes, or chronic kidney disease. However, caution is warranted in patients with advanced heart block (second-degree type II or third-degree) who are symptomatic, as the medication's diuretic effect could potentially exacerbate hypotension. If a patient with heart block is experiencing dizziness, syncope, or hypotension, temporarily holding empagliflozin may be reasonable until the patient is stabilized. The concern with empagliflozin in heart block is not direct worsening of conduction abnormalities, but rather its volume-reducing effects that could compound hemodynamic compromise in patients with significant bradycardia. Regular monitoring of blood pressure, heart rate, and symptoms is important when continuing empagliflozin in patients with heart block, as supported by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Key considerations include the patient's overall clinical status, the presence of heart failure, and the potential benefits of empagliflozin in reducing the risk of HF hospitalization and cardiovascular death, as demonstrated in the EMPEROR-Preserved trial 1. Ultimately, the decision to continue or hold empagliflozin in a patient with heart block should be individualized based on the patient's specific circumstances and clinical priorities. Some key points to consider when making this decision include:

• The patient's hemodynamic stability and symptoms
• The presence and severity of heart failure
• The potential benefits and risks of empagliflozin in the patient's specific clinical context
• The need for regular monitoring of blood pressure, heart rate, and symptoms when continuing empagliflozin in patients with heart block.

From the Research

Heart Block and Empagliflozin

• There is no direct evidence in the provided studies that specifically addresses the management of empagliflozin in patients with heart block.
• However, the studies suggest that empagliflozin has cardiovascular benefits, including reducing the risk of heart failure hospitalizations and cardiovascular death in patients with type 2 diabetes mellitus 2, 3, 4, 5, 6.
• The mechanism of empagliflozin's benefits in heart failure is not fully understood, but it is thought to involve multiple metabolic and hemodynamic mechanisms, including decreasing proximal tubular sodium and chloride reabsorption, inducing plasma volume contraction, and improving diuretic and natriuretic responses 6.
• Empagliflozin has been shown to be beneficial in patients with heart failure and type 2 diabetes mellitus, and it is now included as a pillar of therapy in both American and European guidelines for the management of heart failure 4.
• There is no evidence to suggest that empagliflozin should be held in patients with heart block, but the decision to continue or discontinue empagliflozin in these patients should be made on a case-by-case basis, taking into account the individual patient's clinical status and medical history.

Empagliflozin's Cardiovascular Benefits

• Empagliflozin has been shown to reduce the risk of cardiovascular death, heart failure hospitalizations, and end-stage kidney disease in patients with type 2 diabetes mellitus 2, 3, 6.
• The cardiovascular benefits of empagliflozin are thought to be due to its effects on multiple pathways, including hemodynamic, neurohumoral, metabolic, and vascular endothelial pathways 6.
• Empagliflozin has been shown to decrease vascular stiffness and improve endothelial function in patients with diabetes, which may contribute to its cardiovascular benefits 6.

Clinical Evidence and Mechanism

• The clinical evidence for empagliflozin's benefits in patients with heart failure and type 2 diabetes mellitus is based on several landmark clinical trials, including the EMPA-REG OUTCOME trial 2, 3, 5.
• The mechanism of empagliflozin's benefits in heart failure is not fully understood, but it is thought to involve multiple metabolic and hemodynamic mechanisms, including decreasing proximal tubular sodium and chloride reabsorption, inducing plasma volume contraction, and improving diuretic and natriuretic responses 6.