Eligibility and prescribing rates of SGLT2 inhibitors for ambulatory patients with heart failure and reduced ejection fraction in a multidisciplinary heart failure management programme
Authors: Nadarajah R , Younis A , Aktaa S , Gale C P 
Published: November 2023

Abstract

Introduction
Sodium-glucose cotransporter 2 (SGLT2) inhibitors dapagliflozin or empagliflozin are recommended, in addition to optimal medical therapy (OMT), for patients with heart failure with reduced ejection fraction (HFrEF) regardless of diabetes status.(1) Both have been licensed for use in the UK NHS by NICE,(2,3) but the proportion of 'real world' heart failure (HF) patients for whom these guidelines are applicable is unknown. For those eligible, multidisciplinary HF management programmes (HF-MPs), may enable more rapid translation of guidelines into practice.(1)

Purpose
We aimed to identify the patients eligible to start, and those prescribed, SGLT2 inhibitors amongst patients attending a HF-MP at a tertiary centre in the UK. We also assessed for variation by age and sex.

Methods
In this single-centre retrospective study we selected consecutive patients who attended a heart failure clinic appointment between 01 November 2020 - 01 March 2021. We extracted information pertaining to baseline demographics, investigations, and therapies relevant to eligibility for SGLT2 inhibitors, and prescription of SGLT2 inhibitors at baseline and 2-year follow-up. Differences in SGLT2 inhibitor prescription by age and sex were analysed using the χ2 test. All tests were two-sided, and statistical significance was considered as p value &lt;0.05.

Results
Over this period, 296 stable chronic HF patients attended the centre. The majority of patients had HFrEF (53%),4 and there was a broad age distribution including the very elderly (28% &gt; 80 years) (Table 1). Patients with HFrEF were well optimised [beta blocker (86%), angiotensin-converting enzyme/ angiotensin receptor blocker (61%), sacubitril- valsartan (23%), mineralocorticoid receptor antagonist (50%)] (Table 1).
Of the whole cohort, 107 (36%) patients met eligibility for SGLT2 inhibitor prescription, with 24 (8%) already receiving a SGLT2 inhibitor at the point of guideline implementation, of whom 15 (5%) had diabetes mellitus (Figure 1). At 2-year follow-up 64 eligible individuals (22%) were prescribed a SGLT2 inhibitor, meaning that prescription amongst eligible individuals had increased from 22% to 60%, with greater improvement in younger individuals (Figure 1).
Age-stratified analysis revealed that at least 30% of clinic attendees in each decile were eligible for SGLT2 inhibitors, and almost half of sexagenarian attendees (47%). Though there was not a disparity in prescription of SGLT2 inhibitors for women compared to men (51% vs 64% p=0.22), those aged ≥80 years less frequently received SGLT2 inhibitors compared with younger individuals (33% vs 69%, p&lt;0.001).

Conclusions
Among stable HF patients in a ‘real world’ setting, a significant proportion are eligible for SGLT2 inhibitors. Patients attending a HF-MP have benefitted from early implementation of novel guidelines, though there are age-determined gaps in SGLT2 inhibitor prescription that represent an actionable target.Table 1Figure 1