Cardiology Pharmaceuticals

SGLT2i: A Universal Heart Failure Solution?

In the recent JACC issue, researchers provided further evidence supporting the use of SGLT2 inhibitors for nearly all heart failure (HF) cases. They also dig into a fundamental question: when should these medications be initiated?

The authors performed a secondary analysis of the DELIVER trial (published August 2022) to investigate whether the SGLT2 inhibitor dapagliflozin reduced the risk of worsening HF or CV death, even for patients who were hospitalized for HF within the previous 30 days.  About 10% of the DELIVER patients (n = 654) met this criterion. Not too surprisingly, these patients were sicker at baseline and had higher event rates than those who were recently hospitalized: 

  • Patients with recent HF hospitalization were almost twice as likely to experience cardiovascular death or worsening HF after multivariable adjustment (HR: 1.88).

This cohort may have been more vulnerable, but they still reaped the benefits of dapagliflozin: 

  • Dapagliflozin reduced the primary outcome (worsening HF events or CV death) by 22% in recently hospitalized patients, compared to 18% in patients who were not recently hospitalized.
  • The recent hospitalization group also showed consistent quality of life improvement.
  • Dapagliflozin did not increase adverse event rates in either group.

Despite the risk reductions demonstrated in multiple RCTs (see EMPULSE and SOLOIST), financial barriers still thwart patient adoption. The current list price for dapagliflozin (Forxiga) is $548. Empagliflozin, another common SGLT2i, is $570. For patients with Medicare Part D coverage, 40% of patients pay about $163 each month out-of-pocket. 

The Takeaway

A vast body of evidence supports prescribing SGLT2 inhibitors for HF. Insights from the present study provide practical evidence to substantiate the initiation of SGLT2 inhibitors during or right after a hospitalization for heart failure. But more work lies ahead to make this heart failure solution financially accessible to patients. 

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-- The Cardiac Wire Team