ESC 2022: SGLT2 Inhibitors as Hope for HFpEF: How to Implement Them in Practice?
Patients with heart failure (HF) can significantly benefit from the inclusion of sodium-glucose co-transporter 2 inhibitors (SGLT2i, i.e., gliflozins) in their treatment strategy according to current findings. This also applies to patients with preserved left ventricular ejection fraction (HFpEF). At the ESC 2022 congress, useful information for practical applications was presented in addition to study data. For illustration, we bring a case study from a German practice.
The Number of Patients with HFpEF is Increasing Long-term
The rate of hospitalizations and mortality due to heart failure remains unacceptably high despite established treatment strategies, noted Professor Stefan Anker of Charité University Hospital in Berlin. The proportion of patients with HF and preserved left ventricular ejection fraction has significantly increased over time. These patients also benefit from treatment with gliflozins, as noted in the article “ESC 2022: How to Use Gliflozins for Heart Failure? American Guidelines Already Consider the EMPEROR-Preserved Study,” where we also summarize the most critical findings from the mentioned study. These were covered during this symposium by Professor Giuseppe M. C. Rosano from St. George's Hospital Medical School in London.
Implementing Empagliflozin for HFpEF in Practice – Experiences from Germany
Dr. Michael Böhm from Saarland University Hospital in Hamburg shared his experiences with the administration of empagliflozin, illustrated by the case of a 78-year-old woman diagnosed with heart failure 2 years ago. She is being treated for dyslipidemia and hypertension, has impaired kidney function (estimated glomerular filtration rate [eGFR] 38 ml/min/1.73 m2, potassium concentration 4.5 mmol/l), and a BMI of 28 kg/m2. She struggles with fatigue, dizziness, frequent joint swelling, and shortness of breath. Examination showed blood pressure of 95/60 mmHg, heart rate of 58/min, sinus rhythm, ejection fraction of 48% (i.e., HFpEF), and NYHA class III. Her cardiovascular medication included daily doses of enalapril 20 mg, metoprolol XL 100 mg, acetylsalicylic acid (ASA) 81 mg, simvastatin 40 mg, spironolactone 25 mg, and furosemide 80 mg twice daily.
Factors Influencing Treatment Decisions
A crucial part of deciding to initiate SGLT2i therapy involves discussing it with patients and setting their expectations. Patients with more severe disease symptoms are more likely to prioritize quality of life over longevity. It is also important to consider whether early treatment initiation is necessary or if the clinician can afford to wait. Additionally, the suitability of therapy for a specific patient must be assessed, especially if they are elderly, hypotensive, have renal impairment, or diabetes. According to subgroup analyses from the EMPEROR-Preserved study, empagliflozin improves clinical outcomes in HFpEF patients regardless of age, blood pressure values, or the presence of diabetes [1, 2].
The lecturer also emphasized the need to reassess other cardiovascular medications for such a patient, keeping in mind the different pharmacokinetics of various diuretics, and preferring effective substances with a longer half-life. Similarly, in the case of the demonstrated patient with HFpEF, it was advisable to reassess the adequacy of using the current beta-blocker – a recent Spanish study indicates that beta-blocker withdrawal in HFpEF patients increased functional lung capacity [3].
Conclusion
Dr. Böhm concluded by stating that SGLT2i treatment for HFpEF patients should be started early, its effects are sustained even in older age, low blood pressure is not an obstacle, treatment can be initiated, and renoprotective effects can be expected at an eGFR value of > 20 ml/min/1.73 m2.
Eva Srbová
editorial team, proLékaře.cz
Sources:
1. Böhm M., Butler J., Filippatos G. et al. Empagliflozin improves outcomes in patients with heart failure and preserved ejection fraction irrespective of age. J Am Coll Cardiol 2022; 80 (1): 1–18, doi: 10.1016/j.jacc.2022.04.040.
2. Böhm M. Implementing empagliflozin for HFpEF treatment in my practice. SGLT2 inhibitors in practice (part 2): how do we implement new treatments in HFpEF? ESC Congress, Barcelona, 2022 Aug 27.
3. Palau P., Seller J., Domínguez E. et al. Effect of β-blocker withdrawal on functional capacity in heart failure and preserved ejection fraction. J Am Coll Cardiol 2021; 78 (21): 2042–2056, doi: 10.1016/j.jacc.2021.08.073.
4. Anker S. Introduction and recap. SGLT2 inhibitors in practice (part 2): how do we implement new treatments in HFpEF? ESC Congress, Barcelona, 2022 Aug 27.
5. Rosano G. M. C. What is the evidence for empagliflozin in HFpEF? SGLT2 inhibitors in practice (part 2): how do we implement new treatments in HFpEF? ESC Congress, Barcelona, 2022 Aug 27.
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