The majority of ambulatory patients with heart failure (HF) eligible for SGLT2 inhibitor therapy did not receive it, despite increasing rates of SGLT2 inhibitor use in this patient population and high variability across sites, according to a study recently published in JAMA Cardiology.

Using data from the Veradigm Cardiology Registry, formerly the PINNACLE Registry, Abdelghani El Rafei, MD, MS, et al., included 759,915 patients (mean age 70 years, 47% women, 15% Black individuals) with HF from 191 ambulatory sites between July 1, 2019 and June 30, 2023. They evaluated both patient- and site-level prescription of SGLT2 inhibitors.

Overall, 10% of patients analyzed were prescribed SGLT2 inhibitors and therapy use increased over the course of the study period: 5% in the third quarter of 2019 to 16% in the second quarter of 2023. When broken down by ejection fraction (EF) data, 18% of patients with HF with reduced EF (HFrEF) and 9% of patients with mildly reduced EF (HFmrEF) or preserved EF (HFpEF) were prescribed SGLT2 inhibitors. This increase was especially pronounced among patients with HFrEF (5% to 29%) compared to those with HFmrEF or HFpEF (5% to 13%, p for trend<0.001).

Patients who were older, female or had higher systolic blood pressure were associated with lower SGLT2 inhibitor use while type 2 diabetes was associated with higher use. The authors also note significant variation in SGLT2 inhibitor use across sites (90th vs. 10th percentile risk practice, adjusted odds ratio, 4.40; 95% CI, 3.76-5.52).

"Variability in performance across practices indicates opportunities for improvement at low-performing sites," write the authors. "High-performing sites may be using care processes that could be emulated by low-performing sites, including quality improvement efforts around key steps for SGLT2i therapy prescription such as clinician recognition of patient candidacy, meaningful communication between patients and clinicians, and patients' interest in medication adherence."