Heart Failure Management

Introduction to SGLT2 Inhibitors

• The American Heart Association/American College of Cardiology and the European Society of Cardiology recommend SGLT2 inhibitors for patients with heart failure, particularly those with heart failure with reduced ejection fraction (HFrEF), with benefits seen regardless of diabetes status 1, 2, 3
• SGLT2 inhibitors significantly reduce cardiovascular mortality and heart failure hospitalizations in patients with heart failure, regardless of ejection fraction or diabetes status, with a 21% reduction in the primary composite outcome of cardiovascular death or hospitalization for heart failure (HR 0.79 [95% CI 0.69-0.90]; P<0.001) 3, 4, 5

Benefits and Efficacy of SGLT2 Inhibitors

• SGLT2 inhibitors demonstrate modest reductions in blood sugar levels (approximately 0.5-0.7% reduction compared to placebo) and provide renal protection with slower decline in kidney function 2, 6
• The benefits of SGLT2 inhibitors are consistent across patients with or without diabetes and should not be withheld based on diabetes status, as their benefits are independent of glycemic effects 4, 5
• The following table summarizes the reduction in composite risk for SGLT2 inhibitors:

• Benefits of SGLT2 inhibitors occur early (within weeks) after initiation and are maintained in vulnerable populations, including the elderly and those with recent heart failure hospitalization 1

Patient Selection and Dosing

• SGLT2 inhibitors are recommended for patients with Stage C heart failure with LVEF ≤40% (HFrEF) and for patients with HFpEF (LVEF >40%), excluding those with NYHA class I symptoms 3
• Patients with heart failure with preserved ejection fraction (HFpEF) and left ventricular ejection fraction (LVEF) >40% may benefit from SGLT2 inhibitors, with the greatest benefit observed in NYHA class II-III patients with frequent symptoms or hospitalizations for heart failure 7
• The recommended dosing for empagliflozin and dapagliflozin is 10 mg once daily, with standard dosing applying to patients with eGFR ≥25 mL/min/1.73 m² 7, 8
• SGLT2 inhibitors should not be initiated if eGFR <25 mL/min/1.73 m² and should be withheld for at least 3 days before major surgery or procedures requiring prolonged fasting, and resumed when the patient is clinically stable and has resumed oral intake 7, 8, 9, 10

Safety and Monitoring

• Common adverse effects to monitor include genital mycotic infections, urinary tract infections, volume depletion/hypotension, and euglycemic diabetic ketoacidosis (rare but serious) 7, 9, 11, 12, 4, 5
• It is essential to monitor for genital tract infections and to assess renal function and volume status before initiation of SGLT2 inhibitors 7, 8

Combination Therapy and Long-Term Management

• Additional therapies based on comorbidities may include diuretics, blood pressure control with RAAS antagonists, mineralocorticoid receptor antagonists (MRAs), and evidence-based beta blockers 2, 13
• SGLT2 inhibitors should be continued indefinitely as part of heart failure management, with benefits appearing greatest in patients with LVEF between 41% and 65% 7, 11, 12, 4