Study Highlights Rate of Sodium-Glucose Cotransporter 2 Inhibitor Use for Heart Failure

Sodium-glucose cotransporter 2 inhibitor (SGLT2i) use for heart failure in US ambulatory cardiovascular care is low, rises over time, and is shown to be highly variable across practices, according to new data, and efforts to make SGLT2i therapy use improvements may be warranted.1

These data resulted from a recent study published in JAMA looking into the temporal change, prevalence, and variability of SGLT2i implementation among individuals with heart failure held in ambulatory cardiovascular care.

Abdelghani El Rafei, MD, MS—from the University of Colorado, Anschutz Medical Campus’s Division of Cardiology—authored this analysis alongside a team of investigators.

“[We] sought to characterize (1) trends in use of SGLT2i therapy by different left ventricular ejection fraction (LVEF) categories (HFrEF vs HFmrEF or HFpEF), (2) factors underlying SGLT2i therapy prescription, and (3) variation across practices among patients with [heart failure],” El Rafei et al wrote.1

Design and Notable Findings

The investigative team's aim was to look into how frequently SGLT2i were prescribed to individuals with heart failure held in outpatient cardiology clinics. The team conducted their study using a retrospective cohort trial design, with the research spanning from July 2019 - June 2023. The study's population consisted of patients with heart failure enrolled in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry—a nationwide database established in 2008 within the US to systematically gather outpatient cardiovascular care quality metrics.

El Rafei and colleagues' data analysis took place between February 2024 - January 2025. Their primary focus was on both patient-level and practice-level prescription SGLT2i therapy rates among patients. Those deemed eligible to be participants were adults in the age range of 18 years or older who had at least a single clinical encounter for heart failure during the study period and had documented SGLT2i prescribing data.

759,915 individuals with heart failure were included in total from 191 clinical sites in the US. All subjects had a mean [SD] age of 70 [14] years. El Rafei et al noted that 47.3% had been women, 14.6% identified as Black, and 82.7% as White. Among these individuals, 10.1% were prescribed an SGLT2 inhibitor. Among those with available ejection fraction (EF) data, prescription rates were 17.9% for those with heart failure with reduced ejection fraction (HFrEF), and 8.9% for those with heart failure with mildly reduced EF (HFmrEF) or preserved EF (HFpEF).

Overall, the investigative team concluded that SGLT2i use rose from 4.6% in Q3 2019 to 16.2% in Q2 2023. Among those with HFrEF, the team found increases in usage from 5.1% to 28.5%, whereas for those with HFmrEF or HFpEF, such increases were from 4.5% to 12.8% over the same period (P < .001).

Prescriptions of SGLT2i therapy took place less frequently among those labeled as older adults (OR: 0.76; 95% CI: 0.75–0.77), among women (OR: 0.79; 95% CI: 0.77–0.81), and among subjects showing higher systolic blood pressure (OR: 0.78; 95% CI: 0.77–0.79). Patients with a history of type 2 diabetes, however, were shown by El Rafei and coauthors to be significantly more likely to be given an SGLT2i (OR: 3.21; 95% CI: 3.15–3.28).

After adjusting for both patient- and practice-level variables, the investigators found that substantial variation in SGLT2i prescribing patterns continued to appear among all clinical sites. Individuals given treatment at practices in the 90th percentile of prescribing had a 4.40-fold higher likelihood of receiving an SGLT2i compared to those at 10th percentile practices (adjusted OR: 4.40; 95% CI: 3.76–5.52).

“In a nationwide study of outpatients with [heart failure], a majority eligible for SGLT2i therapy did not receive it, particularly those who were older, female, or with higher blood pressure,” the investigators concluded.1 “There was a significant increase in SGLT2i use over the study period, less among patients with HFmrEF or HFpEF compared with those with HFrEF, with substantial variation in use across practices.”

El Rafei et al added that systematic efforts to make improvements to SGLT2i therapy use may be necessary in the future.

References

1. El Rafei A, Gosch K, Manning ES, et al. Sodium-Glucose Cotransporter 2 Inhibitor Use for Heart Failure in US Ambulatory Cardiovascular Care. JAMA Cardiol. Published online July 09, 2025. doi:10.1001/jamacardio.2025.2145.

2. Abdel Jawad M, Spertus JA, Ikeaba U, et al. Early adoption of sodium-glucose cotransporter-2 inhibitor in patients hospitalized with heart failure with mildly reduced or preserved ejection fraction. JAMA Cardiol. 2025;10(1):89-94. doi:10.1001/jamacardio.2024.4489.