The 2022 AHA/ACC/HFSA guidelines for heart failure with preserved ejection fraction (HFpEF)

DAPA-HF trials showed a 13% reduction in all-cause death, 14% reduction in death due to cardiovascular events, 31% reduction in first hospitalization for HF, and 38% reduction in adverse renal outcomes in patients on SGLT2 inhibitor management.14 The EMPEROR-Preserved trial demonstrated that among patients with symptomatic stable HFpEF (EF >40%), empagliflozin was superior to placebo in improving outcomes regardless of diabetes status or sex.15 A recent meta-analysis has further suggested that the use of SGLT2 inhibitors in patients with HFpEF may reduce the risk for hospitalization for heart failure and improve the severity of heart failure and quality of life.16

Role of SGLT2 Inhibitors in Acute Heart Failure

In cases of new-onset ADHF or cases of acute or chronic heart failure with variable outpatient management or compliance, patients may not be on an SGLT2 inhibitor prior to hospitalization. Relative uncertainty regarding safety, tolerability, and efficacy of inpatient initiation of SGLT2 inhibitors for patients with acute heart failure may lead hospital clinicians to defer this decision-making until outpatient follow-up.17

Findings from a recent systematic review and meta-analysis support the initiation of SGLT2 inhibitors for inpatients hospitalized with acute heart failure.18 Included in the metaanalysis were the EMPA-RESPONSE-AHF and EMPULSE trials, which found that empagliflozin was superior to placebo regardless of ejection fracture or diabetes status in patients with ADHF.19,20 Also included was the SOLOIST-WHF trial, which demonstrated that sotagliflozin was superior to placebo in patients with type 2 diabetes and worsening heart failure.21 The systematic review showed an overall 48% reduction in the odds of rehospitalization because of heart failure among those initiated on an SGLT2 inhibitor during an acute heart failure hospitalization or early postdischarge (within 3 days).14 Additional findings were improved patient-reported outcomes and no excess risk for acute kidney injury, hypotension, or hypoglycemia.18

Contraindications

Notable contraindications to the use of SGLT2 inhibitors include the following: type 1 diabetes, type 2 diabetes with prior or predisposition to diabetic ketoacidosis, volume depletion or symptomatic hypotension, estimated glomerular filtration rate less than 30 mL, frequent urinary tract infections or yeast infections, and risk factors for foot amputation.9,10

Case Application

This case features a 56-year-old man admitted to the hospital for typical atrial flutter with rapid ventricular response and a new diagnosis of ADHF (HFpEF). His typical atrial flutter was surgically resolved with a successful cavotricuspid isthmus ablation, and he was medically managed with aggressive diuresis, resulting in a greater than 90-lb reduction in his weight during the course of the admission. Given that this patient’s ejection fraction was preserved, his discharge medications were focused on blood pressure management, rate and rhythm control, and management of comorbidities, rather than complete GDMT. He was discharged on an oral anticoagulant, β-blocker, diuretic to take as needed, dipeptidyl peptidase-4 inhibitor for diabetes, and SGLT2 inhibitor.

This patient was an appropriate candidate for initiation of an SGLT2 inhibitor because of his history of type 2 diabetes as well as acute hospitalization for heart failure. The patient should continue taking the SGLT2 inhibitor as part of his outpatient medication regimen not only for management of his diabetes but also for reduced risk for rehospitalization for heart failure and improved quality of life. ■

Ana-Maria Drobeniuc, MPA, PA-C, MPH, is a graduate of the Physician Assistant Program at Augusta University in Augusta, GA, and has accepted a position as a physician assistant at Piedmont Heart Institute in Atlanta, GA; E. Rachel Fink, MPA, PA-C, is a physician assistant at Augusta Urology Associates and an assistant professor in the Physician Assistant Program at Augusta University.

LESSONS LEARNED:

Application of Findings for Emergency and Primary Care Clinicians

Lesson 1: SGLT2 inhibitors are a safe and effective secondary therapy for the treatment of acute heart failure in patients with and without type 2 diabetes and are guidelinerecommended agents.

Lesson 2: Failure to initiate SGLT2 inhibitors in patients with acute heart failure during or shortly following hospitalization or failure to continue an SGLT2 inhibitor initiated during an acute heart failure hospitalization may be a significant missed opportunity to prevent rehospitalization and improve patient quality of life.