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SGLT2 Inhibitors in Heart Failure
Addressing Gaps in SGLT2 Inhibitor Use in Heart Failure Management

Released: February 12, 2025

Expiration: February 11, 2026

Ty J. Gluckman
Ty J. Gluckman, MD, MHA
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Key Takeaways
  • The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure underscores SGLT2 inhibitors as cornerstone therapy for both HFrEF and HFpEF, supported by evidence from DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved, and DELIVER, all showing significant reductions in HF-related hospitalizations and cardiovascular mortality.
  • The SOLOIST-WHF trial highlighted the efficacy of sotagliflozin in reducing HF-related events across the LVEF spectrum in patients with type 2 diabetes.
  • SGLT2 inhibitors also provide substantial renal protection, as demonstrated in the DAPA-CKD and EMPA-KIDNEY trials, which showed slowed CKD progression and improved cardiovascular outcomes, complementing findings from the CREDENCE trial.

Introduction
Heart failure (HF) continues to be one of the leading causes of morbidity and mortality worldwide, placing a substantial burden on patients, caregivers, and healthcare systems. Despite significant progress in guideline-directed medical therapy (GDMT), gaps in the timely adoption and integration of newer therapies remain pervasive, hindering their potential to improve patient outcomes. Among the most transformative advances in HF management has been the introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors, which have demonstrated significant cardiovascular and renal benefits across the spectrum of conditions associated with reduced left ventricular ejection fraction (LVEF). This commentary examines critical gaps in HF management, highlights the benefits of SGLT2 inhibitors, and proposes actionable strategies that healthcare professionals (HCPs) can use to address barriers to their optimal use, incorporating insights from recent guideline updates and real-world practices.

Gaps in HF Management
Inconsistencies in GDMT application stem from several challenges, including delayed diagnosis, therapeutic inertia, misconceptions about novel therapies, and fragmented care pathways. Diagnosing HF early in the disease course remains difficult, particularly for patients with HF with preserved ejection fraction (HFpEF), often resulting in missed opportunities to initiate effective therapies like SGLT2 inhibitors. In addition, therapeutic inertia—defined as reluctance to escalate or a delay in escalating treatment—frequently prevents timely initiation of life-saving therapies. The 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) Guideline for the Management of Heart Failure reaffirms the importance of GDMT, emphasizing the role of SGLT2 inhibitors as a cornerstone therapy for HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), and HFpEF. However, real-world data from the CHAMP-HF registry and similar studies underscore widespread underuse, with many patients not receiving optimal doses of GDMT.

Benefits of SGLT2 Inhibitors
The clinical evidence supporting the use of SGLT2 inhibitors in HF management is robust and well documented. Initially developed to manage hyperglycemia in patients with type 2 diabetes, these agents have demonstrated profound cardiovascular and renal benefits in patients with HF, regardless of diabetes status. The DAPA-HF trial and EMPEROR-Reduced trial established that dapagliflozin and empagliflozin, respectively, significantly reduced HF-related hospitalizations and cardiovascular mortality in patients with HFrEF. More recently, the EMPEROR-Preserved trial and DELIVER trial extended these benefits to patients with HFpEF and HFmrEF, respectively, populations with fewer effective treatment options. These findings are reinforced by the mechanisms of action of SGLT2 inhibitors, which include osmotic diuresis, natriuresis, myocardial energy modulation, anti-inflammatory effects, and renal protection. In addition, the SOLOIST-WHF trial demonstrated the benefits of sotagliflozin in reducing HF-related events across the spectrum of conditions associated with LVEF, highlighting the potential of these therapies in a broad range of patients with HF.

In addition, the STRONG-HF trial demonstrated that rapid up-titration of GDMT after hospital admission for HF was associated with reduced symptoms, improved quality of life, and a lower risk of all-cause death or HF readmission at 180 days. Although SGLT2 inhibitors were not included in the protocol design or intervention group, the findings underscore the benefits of timely and comprehensive implementation of GDMT in HF management.

Barriers to SGLT2 Inhibitor Use
Although the clinical benefits of SGLT2 inhibitors are well documented, barriers to their widespread use persist. Misconceptions about adverse effects, including concerns about genitourinary infections and euglycemic diabetic ketoacidosis, may deter HCPs from prescribing these agents. However, pooled analyses from major trials indicate that such events are rare, and the benefits of SGLT2 inhibitors far outweigh their risks in most populations. Patient education and reassurance from HCPs about the favorable safety profile of these therapies are critical for improving their adoption.

Structural barriers also play a significant role in limiting the timely initiation of SGLT2 inhibitors. High out-of-pocket costs, inadequate insurance coverage for newer therapies, and limited access to specialists disproportionately affect underserved populations. These barriers can be addressed through systemic changes, such as expanding coverage for essential medications; increasing the availability of patient assistance programs; and fostering collaborations among cardiologists, primary care HCPs, endocrinologists, and nephrologists. Initiatives like the Optimize Heart Failure Care program have demonstrated success in improving GDMT adherence rates through quality improvement frameworks that focus on education, care coordination, and performance tracking.

To further enhance the implementation of GDMT, clinical decision support tools integrated into electronic health records can be helpful. These tools can provide timely reminders and facilitate evidence-based prescribing, ensuring that eligible patients receive guideline-recommended therapies without delay. Patient-centric approaches, such as shared decision-making and transparent discussions about benefits, adverse effects, and quality-of-life improvements, are equally important in fostering adherence. In addition, community-based interventions, including HF-focused education programs and telemedicine services, can help bridge the gap between guideline recommendations and real-world practices.

Benefits of SGLT2 Inhibitors Beyond HF
The renal benefits of SGLT2 inhibitors also warrant discussion because HF and chronic kidney disease often coexist, creating a vicious cycle of worsening disease. Trials such as CREDENCE, DAPA-CKD, and EMPA-KIDNEY have demonstrated that SGLT2 inhibitors mitigate hyperfiltration, reduce albuminuria, and preserve renal function, significantly slowing chronic kidney disease progression while improving cardiovascular outcomes. These dual benefits further underscore the importance of early and sustained use of these agents in eligible patients.

By addressing gaps in diagnosis, overcoming therapeutic inertia, and mitigating structural barriers, the timely initiation and integration of SGLT2 inhibitors can transform HF management. The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure provides a clear framework for optimizing GDMT, but successful implementation requires a concerted effort from HCPs, healthcare systems, and policymakers. As the evidence base continues to grow, HCPs must remain proactive in applying these therapies to their fullest potential, ensuring that all eligible patients benefit from the advances in HF treatment. By closing these gaps, we can improve not only survival but also the quality of life for patients with HF.

Your Thoughts
What other gaps, if any, have you found regarding the management of HF in your practice? Join the discussion by posting a comment below.

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How often are you initiating the use of SGLT2 inhibitors in your patients with HF? 

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