SGLT2i uptake among heart failure patients with reduced ejection fraction: ongoing prescriber hesitancy and how to address this

Background

The evidence of mortality benefit from sodium-glucose transport protein 2 inhibitors (SGLT2i) in the management of heart failure with reduced ejection fraction (HFrEF) has been observed since 2019. Its first-line use in HFrEF, regardless of diabetes status, has been recommended by The European Society of Cardiology (ESC) since September 2021. Yet prescriber hesitancy surrounding SGLT2i use is still an under investigated issue resulting in centres falling short of gold-standard care. A simple review of pharmacotherapy pattern can alert clinicians to under prescribing of SGLT2i inhibitors and respond by improving adherence to guidelines.

Purpose

To describe the pharmacotherapy pattern of HFrEF patients attending an outpatient (Heart Failure Support Unit) HFSU in Ireland.

Methods

A retrospective analysis was performed in HFrEF patients actively attending the HFSU. Active attendance was considered a single engagement with the service between 1st January 2021 and 31st December 2021, and patients who have not died, been transferred to another service, or loss to follow-up. Information collected from digital records included patient demographic, comorbidities, baseline investigations, and pharmacotherapy pattern. Sensitivity analysis was performed for patients with type 2 diabetes (T2DM).

Results

156 HFrEF patients were actively attending the HFSU. The mean age was 72.1 (±12.5) years and majority were male 114 (73.1%). The following pharmacotherapy pattern was revealed: angiotensin-converting enzyme inhibitors/ angiotensin II receptor blockers (ACEi/ARBs) 80 (51.3%), ARNi 55 (35.3%), β-blockers 142 (91.0%), mineralocorticoid receptor antagonist (MRA) 58 (37.2%), SGLT2i 9 (5.8%) and Ivabradine 9 (5.8%). Sensitivity analysis for T2DM patients (n=45) reveals a pattern of ACEi/ARBs 46.7%, ARNi 37.8%, β-blockers 95.6%, MRA 42.2%, SGLT2i 20.0% and Ivabradine 8.9%. All 9 instances of SGLT2i use were in T2DM patients. Since identification of SGLT2i under-prescribing, an interim review on 28th February 2022 revealed that total SGLT2i prescription had increased by 19 (211.1%), all of which were outside the T2DM population.

Conclusions

SGLT2i is still under prescribed for HFrEF management and prescriptions have the tendency to be restricted to T2DM patients. Identification of pharmacotherapy pattern can alert clinicians to prescriber hesitancy and increase new SGLT2i prescriptions outside the T2DM population.

Funding Acknowledgement

Type of funding sources: None.