ESC 2022: Initiating Gliflozin in HFpEF During Hospitalization Can Benefit the Patient. This is Also Evidenced by Experience from the USA
Based on evidence from clinical studies, gliflozins are currently being introduced into practice for heart failure with preserved ejection fraction (HFpEF) as early as hospitalization. Sharing experiences is therefore very valuable. Several symposia at the ESC 2022 congress focused on the issue of introducing these drugs into HF treatment, some of which also included illustrative case studies. For example, the case of a patient with HFpEF from the USA demonstrated the early initiation of empagliflozin during hospitalization.
Early Inclusion of SGLT2i in HF is Beneficial
Early initiation of heart failure treatment in the hospital is associated with improved adherence, as noted by Dr. Javed Butler from the University of Mississippi in Jackson during the symposium’s opening remarks. He reminded that the European, Canadian, and American guidelines emphasize the importance of adopting all four primary pillars of treatment for HF with reduced EF (HFrEF), including sodium-glucose cotransporter 2 inhibitors (SGLT2i, i.e., gliflozins), as early as possible. The updated American guidelines from this year (AHA/ACC/HFSA 2022) recommend gliflozins even for patients with preserved EF. This point is highlighted in the article, ESC 2022: How to Use Gliflozins in Heart Failure? The American Guidelines Already Consider the EMPEROR-Preserved Study.
Initiating Gliflozin During Hospitalization – A Case Study from the USA
Dr. Maria Rosa Costanzo from the Advocate Heart Institute in Naperville shared the story of her patient.
Medical History and Initial Diagnosis
An 85-year-old man was first referred to her facility in 2015. He exhibited persistent signs and symptoms of heart failure and hypervolemia. His medical history included long-standing moderate chronic obstructive pulmonary disease (COPD), atrial fibrillation (AF) diagnosed in 2010, non-obstructive coronary artery disease (CAD), a left ventricular ejection fraction (LVEF) of 62%, normal glucose tolerance, and no type 2 diabetes. His medication regimen included 2.5 mg warfarin once daily, 0.5 mg dutasteride, 40 mg furosemide, 240 mg extended-release diltiazem, and 4 times daily inhaler (albuterol), along with multivitamins. Lab results showed an estimated glomerular filtration rate (eGFR) of 43 ml/min/1.73 m2, blood urea nitrogen (BUN) level of 21 mg/dl, and serum creatinine of 1.48 mg/dl. ECG conclusions were: AF with slow ventricular response, anteroseptal infarction, abnormal ECG.
Initial Treatment
Diltiazem was discontinued, metoprolol succinate was initiated, furosemide was switched to torsemide, and the patient was referred for polysomnography. This approach led to an improvement in NYHA classification from IIb to II and resolution of lower extremity (LE) edema. Continuous positive airway pressure (CPAP) was also initiated due to documented obstructive sleep apnea (OSA). In 2018, oral spironolactone 25 mg once daily was added. By January 2021, the patient was stably in NYHA class II, with no recurrence of LE edema and excellent adherence to CPAP.
Condition Deterioration and Subsequent Therapy
Subsequently, an unscheduled visit was made for worsening dyspnea, leading to extensive evaluation: Coronary calcium (Agatston) score was 795 – coronary arteries could not be visualized, but a coronary angiogram later showed minimal non-obstructive CAD. Right heart catheterization was performed, and it was decided to initiate sacubitril/valsartan with gradual uptitration to the maximum dose.
In November 2021, due to gout recurrence, the torsemide dose was progressively reduced from 20 mg twice daily to 5 mg once daily, without worsening symptoms. Echocardiogram showed preserved LV systolic function, biatrial enlargement, and pulmonary hypertension.
In March 2022, during a routine check-up, worsening LE edema was noted. A detailed interview revealed worsening exertional dyspnea, which the patient dealt with by progressively reducing physical activity. He was hospitalized due to the need for intravenous diuresis, which continued for 48 hours. Interventions before discharge (72 hours) included repeated counseling on sodium restriction, and the previous dose of torsemide was restored, with 10 mg empagliflozin added.
Further Monitoring
In July 2022, close clinical monitoring showed an improvement leading to the resolution of LE edema and subjective improvement in exertional dyspnea. By June, during a follow-up check, there was only mild exertional dyspnea, improved renal functions, and no presence of LE edema.
Conclusion
In this patient with HFpEF and no diabetes, the inclusion of empagliflozin was associated with an improvement in symptoms, signs of hypervolemia, and renal function after a transient worsening, without incidents of hypotension or the need for higher doses of diuretics or hospitalization for heart failure.
Eva Srbová
Editorial team proLékaře.cz
Sources:
1. Butler J. Introduction and recap. SGLT2 inhibitors in practice (part 4): Initiating heart failure treatment in hospital. ESC Congress, Barcelona, 2022 Aug 28.
2. Costanzo M. R. Implementing in-hospital initiation of an SGLT2 inhibitor in my practice. SGLT2 inhibitors in practice (part 4): Initiating heart failure treatment in hospital. ESC Congress, Barcelona, 2022 Aug 28.
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