The clinical benefits  of sodium-glucose contransporter-2 inhibitors (SGLT2i) for patients with heart failure with reduced ejection fraction (HFrEF) provide compelling evidence that the therapy should be adopted for routine in-hospital initiation, a clinical review study recommends.

Stephen J. Greene, MD, a Duke advanced heart failure specialist and senior author of the November 2021 review in the Journal of the American College of Cardiology, describes hospitalization of patients with HFrEF as “seminal moments” in the disease trajectory that represent opportunities for high-impact therapy.

“The clinical benefits from the use of SGLT2 inhibitors appear very early after initiation, within days to few weeks,” Greene says. “Delaying the initiation of therapy exposes eligible patients to excess clinical risk. Patients hospitalized for HFrEF are at exceptionally high risk, and they need all the risk reduction we can provide.”

Routine delays among eligible patients will lead to harm as a result of of deaths and hospitalizations that can be prevented by initiating early, appropriate SGLT2 inhibitor therapy, Greene says.

“Unfortunately, one in four patients hospitalized for HFrEF are back in the hospital or deceased within 30 days of discharge,” Greene says. “To have an eligible patient in front of you and routinely defer initiation of a therapy proven to rapidly reduce risk of death and hospitalization is highly problematic.”

Data associated with guideline-directed medical therapies for HFrEF have repeatedly shown that delaying the therapy before discharge substantially increases the risk that eligible patients will never receive the therapy at all, even they are followed for several months, Greene says.

Some physicians remain hesitant to begin a new therapy for patients during a hospitalization due to concern that such patients may be tenuous or have side effects, Greene says. “But we want to emphasize that this therapy’s safety profile is exceptionally strong, with minimal to no effect on blood pressure. It also is very easy to use for clinicians and patients – one pill, once per day, no dose titration.”

Hospitalizations for patients with HFrEF should be viewed as opportunities to initiate guideline-directed therapy that helps patients enjoy better short-, intermediate, and longer-term health, Greene notes.

Key points of the review

• Approximately one-quarter of patients hospitalized for worsening HFrEF die or are readmitted within 30 days following discharge.
• Benefits of SGLT2i medication on the risks for death and hospitalization in patients with HFrEF accrue within days to weeks after initiation.
• Safety and tolerability make SGLT2i therapy appropriate for in-hospital initiation among patients with HFrEF.

“The SGLT2 inhibitors are mortality-reducing, disease-modifying drugs for these patients,” Greene says. “We want clinicians to understand the value and strong rationale for initiating these drugs while these patients are in the hospital undergoing treatment for HF.”

Greene was one of several Duke Heart physicians and researchers who contributed to the review article. Other authors associated with Duke Health, the Duke Clinical Research Institute, or the Duke University School of Medicine include Vishal N. Rao, MD, MPH; Evan Murray, BS; Mona Fiuzat, PharmD; Jennifer B. Green, MD; Neha J. Pagidipati, MD, MPH; and Robert J. Mentz, MD.