A 57-year-old woman with known ischemic cardiomyopathy, heart failure with reduced ejection fraction (HFrEF), and left ventricular ejection fraction (LVEF) 25% is seen in the heart failure (HF) clinic. She has no acute concerns.
Her blood pressure is 110/60 mm Hg, heart rate is 72 bpm, oxygen saturation is 97% on room air, and jugular venous pressure is 8 cm H2O. There is a regular rate and rhythm. There is no edema. Laboratory studies performed in the clinic show potassium level 3.7 mmol/L, serum creatinine level 0.9 mg/dL with estimated glomerular filtration rate 75 mL/min/1.73m2, and N-terminal pro–B-type natriuretic peptide (NT-proBNP) level 601 pg/mL. She is currently on sacubitril/valsartan 49/51 mg BID, carvedilol 25 mg BID, spironolactone 25 mg daily, and furosemide 20 mg daily.
She feels well overall and is hesitant to start new medications.
The correct answer is: Fiction
The best next step is to consider initiating a sodium-glucose cotransporter-2 (SGLT2) inhibitor. SGLT2 inhibitors are strongly recommended in guidelines to treat patients with HFrEF.1 There are currently sufficient randomized controlled trial data to support the initiation of SGLT2 inhibitors for the reductions in both surrogate and clinical endpoints across the spectrum of HF ranging from acute to chronic, regardless of LVEF, with and without type 2 diabetes mellitus, and chronic kidney disease.2 In addition, although this patient appears to be symptomatically stable, higher baseline NT-proBNP levels have been associated with a more severe clinical presentation and higher risk of poor clinical outcomes.2 SGLT2 inhibitors are associated with a reduction of NT-proBNP concentration and improvements in left ventricular function and volumes, functional capacity, and quality of life among patients with HFrEF but without diabetes mellitus.3,4
Educational grant support provided by: Boehringer Ingelheim Pharmaceuticals Inc. (BIPI) and Lilly USA, LLC (Lilly).
To visit the course page for the Heart Failure & SGLT2is: The New Pillar in Care grant, click here!
References
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol 2022;79:e263-e421.
- Ahmad T, Desai N, Velazquez E, et al. SGLT2 inhibitors should be considered for all patients with heart failure. J Am Coll Cardiol 2022;80:1311-13.
- Januzzi J, Zannad F, Anker S, et al. Prognostic importance of NT-proBNP and effect of empagliflozin in the EMPEROR-Reduced trial. J Am Coll Cardiol 2021;78:1321-32.
- Santos-Gallego C, Vargas-Delgado A, Requena-Ibanez J, et al. Randomized trial of empagliflozin in nondiabetic patients with heart failure and reduced ejection fraction. J Am Coll Cardiol 2021;77:243-55.
Log in to MyACC
