SGLT2 Inhibitors in Heart Failure and CKD

Primary Recommendation

The American College of Cardiology recommends continuing SGLT2 inhibitors in all patients with heart failure and CKD who have eGFR ≥20 mL/min/1.73 m², as they reduce mortality, heart failure hospitalizations, and CKD progression 1, 2, 3
For heart failure with reduced ejection fraction (LVEF ≤40%), SGLT2 inhibitors are a Class 1 recommendation to reduce cardiovascular death and heart failure hospitalization, according to the American College of Cardiology 4
For heart failure with preserved ejection fraction (LVEF >40%), SGLT2 inhibitors provide a Class 2a benefit for decreasing heart failure hospitalizations, as recommended by the American College of Cardiology 4

The EMPEROR-Reduced and EMPEROR-Preserved trials demonstrated efficacy of SGLT2 inhibitors at eGFR levels as low as 20 mL/min/1.73 m² in patients with heart failure, with a reduction in cardiovascular mortality and heart failure hospitalizations 1, 5
In very high-risk CKD patients with heart failure, SGLT2 inhibitors decrease all-cause mortality by 48 fewer deaths per 1000 patients, and cardiovascular mortality by 10 fewer deaths per 1000 patients, as reported by the BMJ 3

SGLT2 inhibitors reduce kidney failure by 58 fewer events per 1000 patients in very high-risk CKD, according to the BMJ and Annals of Internal Medicine 3, 8
These agents slow CKD progression independent of glycemic control through reduction in intraglomerular pressure, as demonstrated in studies published in Diabetes Care and Annals of Internal Medicine 7, 8

Once initiated, continue SGLT2 inhibitors even if eGFR falls below 20 mL/min/1.73 m², unless kidney replacement therapy is initiated, as recommended by Kidney International 2
For patients with type 2 diabetes and CKD, use SGLT2 inhibitors down to eGFR >20 mL/min/1.73 m², according to Diabetes Care and Kidney International 1, 2, 5

Patients with eGFR 20-45 mL/min/1.73 m² AND heart failure receive a strong recommendation for SGLT2 inhibitors, with high certainty of survival benefit and reduced kidney failure, as reported by the BMJ 3