SGLT2 inhibitors used less frequently in HFrEF patients despite potential CV benefits: JAMA

A cohort study of 49 399 patients hospitalized for HFrEF revealed that one in five patients was discharged with prescriptions for SGLT2i therapy; rates were also low for patients with comorbid type 2 diabetes (T2D) and chronic kidney disease (CKD). There was a wide variation in the hospital-level discharge prescriptions of SGLT2 inhibitors, independent of hospital and patient characteristics.

Clinical guidelines for HFrEF patients strongly recommend treatment with a sodium-glucose cotransporter-2 inhibitor (SGLT2i) to decrease heart failure hospitalization or cardiovascular mortality. There is no clarity on the nationwide adoption of SGLT2 inhibitors for heart failure with reduced ejection fraction in the US.

Against the above background, Jacob B. Pierce, Duke University School of Medicine, Durham, North Carolina, and colleagues aimed to determine the prevalence and variability of sodium-glucose cotransporter-2 inhibitor use among patients hospitalized for HFrEF in the US in a retrospective cohort study.

The study included data from 49 399 patients hospitalized for HFrEF in the Get With The Guidelines–Heart Failure (GWTG-HF) registry between 2021 and 2022. Of 49 399 included patients, 33.5% were female, and the median age was 67 years. Patients with an eGFR (estimated glomerular filtration rate) of less than 20 mL/min/1.73 m2, previous intolerance to SGLT2i, and type 1 diabetes.

Patient-level and hospital-level prescriptions of SGLT2i at hospital discharge were determined.

The study led to the following findings:

• 20.2% of patients were prescribed an SGLT2i.
• SGLT2i prescription was less likely among patients with chronic kidney disease (CKD; 18.6% versus 21.8%) but more likely among patients with type 2 diabetes (T2D; 26.2% versus 15.5%) and those with both T2D and CKD (23.7% versus 19.1%).
• Patients prescribed SGLT2i therapy were more likely to be prescribed triple background therapy with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor, β-blocker, and mineralocorticoid receptor antagonist (46.3% versus 27.6%), and 4624 of 49 399 total study patients (9.4%) were discharged with prescriptions for quadruple medical therapy including SGLT2i.
• Among 461 hospitals with ten or more eligible discharges, 4.1% discharged 50% or more of patients with prescriptions for SGLT2i, whereas 74.6% discharged less than 25% of patients with prescriptions for SGLT2i (including 6.3% that discharged zero patients with SGLT2i prescriptions).
• There was high between-hospital variance in the rate of SGLT2i prescription in unadjusted models (median odds ratio, 2.53) and after adjustment for patient and hospital characteristics (median odds ratio, 2.51).

"In this study, there was a low SGLT2i prescription at hospital discharge among eligible patients with HFrEF, including patients with comorbid CKD and T2D who have multiple indications for therapy, with substantial variation among US hospitals," the researchers wrote. "Further efforts are required to overcome implementation barriers and improve SGLT2i use among HFrEF patients."

Reference:

Pierce JB, Vaduganathan M, Fonarow GC, et al. Contemporary Use of Sodium-Glucose Cotransporter-2 Inhibitor Therapy Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in the US: The Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. Published online May 22, 2023. doi:10.1001/jamacardio.2023.1266