SGLT2 Inhibitors in Heart Failure with Reduced Ejection Fraction

Recommendations for HFrEF Patients

The European Society of Cardiology recommends SGLT2 inhibitors (dapagliflozin and empagliflozin) as foundational therapy for patients with HFrEF to reduce the risk of heart failure hospitalization and death 1, 2, 3
The American College of Cardiology recommends using SGLT2 inhibitors alongside other guideline-directed medical therapy, including ACE inhibitors, mineralocorticoid receptor antagonists (MRAs), and beta-blockers, for patients with HFrEF 1, 4
Clinical trials have demonstrated a 21-35% reduction in hospitalization for heart failure with SGLT2 inhibitors, regardless of the presence or absence of diabetes, in patients with HFrEF 5, 2

The European Association for the Study of Diabetes does not recommend SGLT2 inhibitors for patients with Type 1 Diabetes Mellitus due to increased risk of diabetic ketoacidosis 6
The American Diabetes Association recommends against using SGLT2 inhibitors in T1DM patients, even those with heart failure, due to the risk of diabetic ketoacidosis 7, 6

For T1DM patients with HFrEF, the American Heart Association recommends prioritizing standard heart failure therapies, including ACE inhibitors or ARBs, beta-blockers, mineralocorticoid receptor antagonists, and diuretics as needed for congestion 7, 2, 8
The European Society of Cardiology suggests considering sacubitril/valsartan as a replacement for ACE inhibitors or ARBs in appropriate T1DM patients with HFrEF 1, 7

The American College of Cardiology recommends regular monitoring of renal function when initiating SGLT2 inhibitors in patients with HFrEF 5
The European Society of Cardiology advises educating patients about the symptoms of diabetic ketoacidosis, especially those with diabetes, when using SGLT2 inhibitors 6
The American Heart Association recommends assessing volume status regularly in patients with HFrEF taking SGLT2 inhibitors due to their diuretic effects 2
The benefits of SGLT2 inhibitors extend to patients with mildly reduced ejection fraction (HFmrEF, LVEF 41-49%), with a 21% reduction in the composite endpoint of cardiovascular death or heart failure hospitalization in the EMPEROR-Preserved trial 2, 8, 9