Written by Megan Hilbert
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are known to have cardioprotective effects and are now recommended for all heart failure patients no matter their baseline ejection fraction (EF) or starting medication regimens.
Why does this matter?
Clinical practice guidelines previously supported use of SGLT-2 inhibitors in reduced EF patients (class I evidence) but provided weaker support for use in preserved EF patients (class II evidence). This demonstrates a strengthening of evidentiary support to expand SGLT-2 use across the spectrum of baseline EF.
SGLT-2 Inhibitors – not just for diabetes
This meta-analysis included studies done on heart failure patients with both reduced (DAPA-HE and EMPEROR-Reduced) and preserved (DELIVER and EMPEROR-Preserved) EF. The primary endpoint measured was time to occurrence of first hospitalization for heart failure or cardiovascular death (as measured from time of randomization). Quality of life was also assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ) (with higher scores corresponding to better health status).
There was not significant heterogeneity demonstrated between the trials, so the composite data will be reviewed here.
SGLT-2 inhibitors, when compared to placebo, demonstrated a reduction in cardiovascular death or hospitalization for heart failure within a 23 month follow up period (HR 0.77 [95% CI 0.72-0.82), with a NNT of 25. This corresponds to a 28% relative reduction in risk for hospitalization. Death from any cause was also reduced (HR 0.92 [0.86-0.99], NNT 92). Finally, patients were 10-20% more likely to report improvements in health status. This effect was present, but attenuated in patients with NYHA functional class of III or higher.
This provides an opportunity for us as ED physicians – the next time you have a heart failure patient make sure to do a thorough medication review. If you don’t see an SGLT-2 inhibitor on the list, encourage the patient to reach out to their cardiologist to discuss starting one.
Editor’s note: We will see SGLT-2 inhibitors increasingly used. Know the benefits and risks, such as euglycemic DKA. ~Clay Smith
SGLT-2 inhibitors in patients with heart failure: a comprehensive meta-analysis of five randomised controlled trials. Lancet. 2022 Sep 3;400(10354):757-767. doi: 10.1016/S0140-6736(22)01429-5. Epub 2022 Aug 27.