SGLT2 Inhibitors in Heart Failure with Mildly Reduced Ejection Fraction

Guideline-Directed Recommendations for HFmrEF

• The American College of Cardiology recommends SGLT2 inhibitors for patients with HFmrEF (LVEF 41-49%), as they decrease heart failure hospitalizations and cardiovascular mortality, with a Class 2a recommendation (moderate strength) 1
• The European Society of Cardiology guidelines recommend SGLT2 inhibitors (dapagliflozin or empagliflozin) in patients with HFmrEF to reduce the risk of HF hospitalization or cardiovascular death 3

Specific Considerations in Cirrhosis

• Diuretics are recommended in patients with HFmrEF who have signs or symptoms of fluid congestion to improve symptoms, according to the European Heart Journal 4, 1
• The American College of Cardiology suggests that SGLT2 inhibitors can be initiated in patients with cirrhosis and HFmrEF who are on diuretics, as they reduce heart failure hospitalizations and cardiovascular mortality while potentially offering liver-protective benefits 1

Safety Profile in This Population

• Regular monitoring of renal function is recommended when initiating SGLT2 inhibitors, as stated by Praxis Medical Insights 2
• Volume status should be assessed regularly in patients with HFmrEF taking SGLT2 inhibitors due to their diuretic effects, according to Praxis Medical Insights 2

Practical Implementation Algorithm

• The European Heart Journal recommends starting dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily for HFmrEF 4, 3
• The American College of Cardiology suggests continuing furosemide and spironolactone for volume management in cirrhosis, and considering adding or optimizing ACE inhibitors/ARBs, beta-blockers, or MRAs for HFmrEF 1, 4