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Expert Guidance in Heart Failure and SGLT2 Inhibitors
Expert Guidance in Heart Failure: Closing the Gap in SLGT2 Inhibitor Evidence vs Use

Released: April 24, 2025

Expiration: April 23, 2026

Javed Butler
Javed Butler, MD, MPH, MBA
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Key Takeaways
  • SLGT2 inhibitors provide benefit in reducing cardiovascular-related death and hospitalizations across the heart failure spectrum, regardless of ejection fraction.
  • Issues with SGLT2 inhibitor therapy uptake for heart failure management persist because of execution, not healthcare professionals’ lack of knowledge.
  • GLP-1 receptor agonists can help patients with HFpEF, especially those with comorbid obesity and type 2 diabetes, but they should not be used as a dedicated heart failure treatment.      

At a recent symposium for the “Do It Better: Raising the Bar in Heart Failure Care With Practical Strategies for Treatment With SGLT2 Inhibitors” program, I had the pleasure of joining my colleague Ty Gluckman, MD, MHA, in a discussion that centered on 1 of the most pressing cardiology issues today—translating the wealth of evidence supporting guideline-directed medical therapy (GDMT) for heart failure (HF) into routine and practical care delivery. The evidence base for sodium-glucose cotransporter 2 (SGLT2) inhibitors has grown substantially in recent years, demonstrating consistent benefits across the spectrum of HF, regardless of ejection fraction. These agents also reduce the risk of cardiovascular-related death and HF-related hospitalization in patients who have HF with reduced ejection fraction (HFrEF) or HF with preserved ejection fraction (HFpEF). Further, they carry additional benefits for patients with chronic kidney disease and type 2 diabetes (T2D). 

Integrating Evidence Into Practice
Despite these outcomes, the implementation of SGLT2 inhibitors remains suboptimal. During the symposium, I emphasized that the challenge persists because of execution rather than healthcare professionals’ (HCP) lack of knowledge. But there is no single intervention that will close this gap. Implementation science tells us that multifactorial strategies work best, such as integration of best practices in electronic health records (EHRs), clinical decision support tools, EHR nudges that require acknowledgment or action, care coordination by clinical pharmacists or advanced practice providers, and provider–patient education. One approach that is particularly effective in my practice is empowering patients early by discussing the therapies they may receive and encouraging them to advocate for those treatments.

Dr Gluckman contributed valuable insights throughout his portion of the presentation, in particular, the topic of therapeutic inertia and missed opportunities to optimize care. He highlighted the importance of avoiding unnecessary delays or interruptions in therapy, especially with agents like SGLT2 inhibitors, because they offer cardiovascular and renal protection. What should HCPs do when patients prescribed an SGLT2 inhibitor experience a decline in estimated glomerular filtration rate (eGFR)? This is an important and nuanced clinical scenario that, based on evidence from large-scale trials (ie, DAPA-HF, EMPEROR-Reduced), suggests SGLT2 inhibitors can be initiated in patients with an eGFR as low as 20 mL/min/1.73m². A modest decline in eGFR is expected shortly after initiation due to hemodynamic changes at the glomerular level, but this typically stabilizes and does not represent intrinsic kidney injury. Continuation of therapy is appropriate even if patients’ eGFR falls below 20 after initiation, as current guidelines support this approach. Therapy discontinuation with SGLT2 inhibitors is not required unless patients progress to dialysis for end-stage kidney disease, in which case continuation becomes a matter of clinical judgment. Of note, ongoing clinical trials are evaluating SGLT2 inhibitors in patients receiving dialysis, and I expect more definitive data upon their completion.

The final concern regarding SGLT2 inhibitors centers on their diuretic effect. These agents promote mild diuresis through osmotic diuresis from glucosuria and natriuresis via inhibition of sodium uptake in the proximal tubule. The degree of diuresis is more pronounced in patients with poorly controlled hyperglycemia, and this effect attenuates over time as homeostatic adaptations occur. Of importance, there is no established equivalence between SGLT2 inhibitors and loop diuretics like furosemide, so I advise against using SGLT2 inhibitor dosing to guide loop diuretic titration. Rather, loop diuretics should continue to be adjusted in patients based on congestion status, renal function, and clinical response.

Do GLP-1 Receptor Agonists Have a Role?
There are currently no large, randomized trials that support the use of GLP-1 receptor agonists in patients with HFrEF, with early and small studies signaling concern for this population. In contrast, studies of patients with HFpEF (ie, SELECT, STEP-HFpEF) have shown improvements in patient-reported outcomes, including quality of life and functional capacity, after treatment with semaglutide. However, these trials were not powered for major cardiovascular outcomes. Therefore, in HFpEF and particularly for patients with obesity or T2D, GLP-1 receptor agonists may be used for their FDA-approved indications but should not be considered an HF-specific therapy until additional data are available. I caution against extrapolating the benefits seen beyond the current evidence.

Future Directions in Heart Failure
At the conclusion of the symposium, Dr Gluckman and I observed that the opportunity to improve outcomes in HF is significant; it just depends on HCPs translating the evidence into action. The clinical benefits of SGLT2 inhibitors are well established, but the key to achieving their benefits lies in system-based implementation. This means aligning institutional processes with transitions of care optimization, education at every level, and multidisciplinary collaboration. HF management does not occur in a vacuum; it requires coordination across the care continuum from hospital to home and from cardiology to primary care.

Your Thoughts
The level of engagement and the quality of questions we received during the symposium were encouraging and reflected a collective determination to raise the standard of care in HF. With continued focus on education, implementation, and collaboration, HCPs can ensure that every eligible patient receives the therapies that offer them the best chance at a longer and healthier life. How often do you face barriers to SGLT2 inhibitor implementation in managing patients with HF? You can get involved in the conversation by answering the poll question and posting a comment below.

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How often do you face barriers to SGLT2 inhibitor implementation in managing patients with HF?

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