From the Guidelines
SGLT2 inhibitors are strongly recommended for patients with heart failure, particularly those with reduced ejection fraction (HFrEF), regardless of diabetes status. Medications like empagliflozin (10mg daily), dapagliflozin (10mg daily), and canagliflozin (100-300mg daily) have demonstrated significant benefits in reducing heart failure hospitalizations and cardiovascular death, as shown in the DAPA-HF and EMPEROR-Reduced trials 1.
Key Benefits of SGLT2 Inhibitors
- Reduced risk of heart failure hospitalizations and cardiovascular death
- Improved cardiac energetics, reduced cardiac fibrosis, decreased preload and afterload, and beneficial effects on sodium handling
- Benefits consistent across age, sex, and in patients with or without diabetes
Monitoring and Side Effects
When starting an SGLT2 inhibitor, patients should be monitored for potential side effects including:
- Genital mycotic infections
- Urinary tract infections
- Volume depletion Temporary discontinuation may be necessary during acute illness or before surgical procedures to prevent euglycemic diabetic ketoacidosis, as noted in the 2025 standards of care in diabetes 1.
Standard Therapy
SGLT2 inhibitors should be considered as part of standard therapy alongside:
- ACE inhibitors/ARBs
- Beta-blockers
- Mineralocorticoid receptor antagonists for optimal heart failure management, as recommended in the 2024 update to the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1.
Recent Guidelines
Recent guidelines, including the 2025 standards of care in diabetes, emphasize the importance of SGLT2 inhibitors in reducing cardiovascular disease and heart failure outcomes in people with diabetes 1, and the 2024 standards of care in diabetes also support the use of SGLT2 inhibitors to prevent incident heart failure and hospitalization from heart failure 1.
Conclusion Not Needed
The use of SGLT2 inhibitors in patients with heart failure is supported by strong evidence, and their benefits in reducing morbidity, mortality, and improving quality of life make them a crucial part of heart failure management.
From the Research
SGLT2 Inhibitors for Heart Failure
- SGLT2 inhibitors, such as empagliflozin, have been shown to reduce cardiovascular risk in patients with type 2 diabetes mellitus (T2DM) and heart failure with reduced ejection fraction (HFrEF) 2, 3, 4, 5.
- A study published in 2022 found that empagliflozin did not significantly reduce hospital admissions or cardiovascular deaths in patients with T2DM and HFrEF, but further research is needed to confirm these findings 2.
- Another study published in 2023 reviewed the clinical evidence of empagliflozin for patients with heart failure and T2DM, and found that it brings clinical benefit to these patients, although the potential mechanism is not fully understood 3.
- The EMPEROR-Reduced trial, published in 2021, found that empagliflozin reduced the composite risk of cardiovascular death or hospitalization for heart failure, and improved health status and functional class in patients with heart failure and reduced ejection fraction 4.
Benefits and Mechanisms of SGLT2 Inhibitors
- SGLT2 inhibitors have been found to have a diuretic effect, which may contribute to their ability to reduce serious heart failure events 4.
- However, the EMPEROR-Reduced trial found that the benefits of empagliflozin were not more marked in patients with recent volume overload, suggesting that diuresis may not be the primary mechanism of action 4.
- SGLT2 inhibitors may target different pathophysiological pathways in heart failure, making them a potential treatment option for patients without diabetes 5.
Comparison with Other Treatments
- β-blockers are a mainstay of treatment for heart failure with reduced ejection fraction, but may be underused due to misconceptions about their safety and efficacy 6.
- SGLT2 inhibitors may be considered as a first-line treatment for diabetic patients at high risk for cardiovascular diseases and heart failure, although further research is needed to confirm their benefits in non-diabetic patients 5.