SGLT2 Inhibitor Prescription Rates Lag Behind in HFrEF, with Stephen Greene, MD

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Stephen Greene, MD, discusses the results of a recent GWTG-HF registry analysis, which concluded just 1 in 5 hospitalized patients with HFrEF were discharged with an SGLT2 inhibitor prescription and less than 10% were receiving all 4 classes of guideline-directed medical therapy.

An analysis of data from nearly 500 US hospitals suggests, despite inclusion in national and international guidelines, the uptake of SGLT2 inhibitors continues to be a sticking point for heart failure specialists.

Using data from more than 49,000 patients treated from 2021-2022 within the Get With The Guidelines-HF (GWTG-HF) registry, results of the study suggest just 1 in 5 adults with heart failure with reduced ejection fraction (HFrEF) were receiving SGLT2 inhibitors at discharge, with some hospitals reporting no patients receiving SGLT2 inhibitors at discharge and less than 10% receiving the full complement of guideline-directed medical therapy.

“in this nationwide analysis, we saw that 1 in 5 eligible patients were discharged on an SGLT2 inhibitor and there was modest variation across different demographic subgroups,” explained study investigator Stephen Greene, MD, a heart failure cardiologist with Duke University Medical Center, in an interview with HCPLive Cardiology. “But what was also striking was that even patients with a triple indication for this drug—those with HFrEF, [chronic kidney disease], and type 2 diabetes—still had use below 30%”

The rise of SGLT2 inhibitors from an oral glycemic control agent with modest glucose-lowering effects to a class boasting agents touting indications for glycemic control, chronic kidney disease (CKD), and heart failure has been nothing short of historic. Still, despite the fervor and clinical trial data, the rate of uptake for these agents has been a sticking point for many in endocrinology, nephrology, and cardiology.

In the current study, Greene and a team of investigators sought to examine the prevalence of SGLT2 inhibitor use among patients with heart failure with reduced ejection fraction (HFrEF) following the inclusion of SGLT2 inhibitors as part of guideline-directed medical therapy in HFrEF in the 2021 European Society of Cardiology heart failure guidelines and 2022 joint guidelines from the American Heart Association, American College of Cardiology, and Heart Failure Association of America.2,3

With this in mind, investigators designed their study as a retrospective analysis of data recorded from July 1, 2021-June 30, 2022 at sites from the American Heart Association’s Get With The Guidelines-HF (GWTG-HF) registry. From 489 sites within the registry, investigators obtained data related to 49,399 patients hospitalized with HFrEF during the aforementioned period of interest. The 49,399-person cohort had a median age of 67 (Interquartile range, 56-78) years and 33.5% were female. The primary outcomes of interest for the analysis were the patient-level and hospital-level prescription of SGLT2 inhibitors at hospital discharge.1

For inclusion in the analysis, patients were required to be 18 years of age or older, have a left ventricular ejection fraction of 40% or less, and have full data related to age, sex, disposition, or SGLT2 inhibitor status at discharge. Investigators noted patients with an estimated glomerular filtration rate (eGFR) less than 20 mL/min/1.73m2, type 1 diabetes, and a documented intolerance to SGLT2 inhibitors were excluded from the analysis.1

Upon analysis, results suggested just 20.2% (n=9988) were prescribed an SGLT2 inhibitor at discharge. Analysis of patient characteristics revealed SGLT2 inhibitor prescription was less common among those with CKD (18.6% vs 21.8%; P < .001) but more common in those with type 2 diabetes (26.2% vs 15.5%; P < .001) and those with both type 2 diabetes and CKD (23.7% vs 19.1%; P < .001). Further analysis of pharmacotherapy use at discharge found patients who were prescribed an SGLT2 inhibitor were more likely to be prescribed triple therapy with an ACE/ARB/ARNi, beta-blocker, and MRA (46.3% vs 27.6%; P < .001), but investigators underline just 9.4% of the overall cohort was prescribed quadruple medical therapy at discharge.1

When assessing between-hospital variation, results pointed to high between-hospital variance in the rate of SGLT2i prescription in both unadjusted models (median odds ratio, 2.53; 95% CI, 2.36-2.74) and following adjustment for patient and hospital characteristics (median odds ratio, 2.51; 95% CI, 2.34-2.71). Of the 489 reporting sites included in the analysis, 461 had 10 or more eligible discharges. Among these 461 hospitals, 4.1% (n=19) discharged 50% or more of patients with an SGLT2 inhibitor. In contrast, 74.6% (n=344) reported discharging less than 25% of eligible patients with an SGLT2 inhibitor prescription, including 6.3% (n=29) reporting 0 patients with SGLT2 inhibitor prescriptions at discharge.1

With an interest in learning more about the study, the editorial team of HCPLive Cardiology sat down with Greene for a deep dive during coverage of The Metabolic Institute of America’s 7th Heart in Diabetes meeting.

Greene reports having received funds for consulting or research grants from Amgen, AstraZeneca, Bayer Healthcare Pharmaceuticals, Boehringer Ingelheim Pharmaceuticals, Cytokinetics, and others. Here is a full list of relevant disclosures.


  1. Pierce JB, Vaduganathan M, Fonarow GC, et al. Contemporary Use of Sodium-Glucose Cotransporter-2 Inhibitor Therapy Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in the US: The Get With The Guidelines–Heart Failure Registry. JAMA Cardiol. Published online May 22, 2023. doi:10.1001/jamacardio.2023.1266
  2. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure [published correction appears in Eur Heart J. 2021 Oct 14;:]. Eur Heart J. 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
  3. 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 [published correction appears in J Am Coll Cardiol. 2023 Apr 18;81(15):1551]. J Am Coll Cardiol. 2022;79(17):e263-e421. doi:10.1016/j.jacc.2021.12.012