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2yr
Updated guideline for heart failure

The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure has been updated with new recommendations based on recent data.

Key updates

For heart failure with reduced ejection fraction (HFrEF), the guideline-directed medical therapy (GDMT) comprises 4 classes of medications (GDMT-4).

  1. renin-angiotensin system inhibition with the following:
  • angiotensin receptor-neprilysin inhibitors (ARNis);
  • angiotensin-converting enzyme inhibitors (ACEis);
  • angiotensin (II) receptor blockers (ARBs) alone;
  1. beta blockers;
  2. mineralocorticoid receptor antagonists (MRAs);
  3. the newly added group, SGLT2 inhibitors (SGLT2is).


For heart failure with mildly reduced LVEF, new medication recommendations include the utilization of SGLT2is. Importantly, SGLT2is have a Class of Recommendation (COR) 2a in HF with mildly reduced EF (HFmrEF), with weaker recommendations (i.e., COR 2b) issued for ARNi, ACEi, ARB, MRA and beta blockers.

For patients with HF with preserved EF (HFpEF), new drug recommendations include the utilization of SGLT2is (i.e., COR 2a); MRAs (i.e., COR 2b); and ARNis (i.e., COR 2b). Of note, a COR 1 is considered “strong,” with benefit >>> risk; COR 2a, “moderate,” with benefit >> risk; and COR 2b, “weak” with benefit > risk.

What role do SGLT2is play in your management of HF and does your use align with the 2022 heart-failure guideline? Which patients are particularly responsive to this class of medications?

  • 2yr
    Yes. I use SGLT2 inhibitors for heart failure associated risk reduction especially with patients with diabetes and/or patients at risk for kidney disease progression. Benefits include prevention of cardiovascular risks, decreasing risks in patients with diabetes as well as kidney disease, and weight loss. Unfortunately, the barrier to prescribing medication or having patients maintain therapy include cost. Careful with patients whom have recurrent UTIs and diabetes as they maybe at greater risk for urosepsis.
  • 2yr
    I would recommend the use of SGLT2 esp. in diabetics not only does it lower BP, some weight loss, CV and renal benefits as well
  • 2yr
    With recent trials SGLT2 suggesting a significant reduction in adverse cardiovascular outcomes in patients with HF with mildly reduced and preserved ejection, especially beneficial in patients with diabetes, recurrent HF and worsening kidney function
  • 2yr
    hopefully using sglt2 in type 2 diabetes will prevent patients from going into chf
  • 2yr
    This is great to see that SGLT2 inhibitors have been added to the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Now lets hope that insurance companies will cover the cost of this medication for this indication.
  • 2yr
    The patients who particularly benefit from SGLT2's are those with HFrEF and more specifically those with NYHA class II-IV symptoms. The DAPA-HF and EMPEROR-Reduced trials have demonstrated the efficacy of dapagliflozin and empagliflozin in reducing the risk of cardiovascular events and improving outcomes in HFrEF patients.

    It's important to note that SGLT2's are not recommended for all HF patients. The guideline suggests considering their use in patients with HFrEF who remain symptomatic despite optimal medical therapy, including guideline-directed medical therapy with beta-blockers, ACE inhibitors or ARBs, and mineralocorticoid receptor antagonists.
  • 2yr
    Definitely an add to the CHF med regimen and have been doing in but the challenge is the tolerance of the medicine with other meds on board , the room with BP when added to the others , cost of the meds and convincing the pts that they really need it , Ideally if one could take off the other ones and replace it with SGLT-2 inhibitors ,Pill burden remains an issue in particular when pt has been very well compensated !
  • 2yr
    I use the SGLT2 medications for patients in early diagnosis because they are more likely to be on newer dabetic medications that their diabetes will benefit as well. the cost of them is the biggest issue.
    barriers of use or risk of infection is also something to consider in this fragile population.
  • 2yr
    SGLT-2 Inhibitors reduce the risk of cardiovascular risks and hospitalization from heart failure in patient with reduced and preserved EF, patients with or without diabetes type 2 benefit from these medications
  • 2yr
    Yes. I tend to use SGLT2 inhibitors for HF but mainly Jardiance and Farxiga since they have the indications. I do not use Invokana. For some patient, the medicine can be too expensive.
  • 2yr
    I consider SGLT 2 inhibitors standard treatment in CHF, especially in diabetic patient with CHF. Cost is an issue.
  • 2yr
    I use them early In treatment of new patients and add to existing patients as they have excellent data-part of my standard of care
  • 2yr
    Not only does SGLT2 inhibitors treat heart failure, it is also good for patients with a comorbid diagnosis of diabetes. These medications overall improve cardiovascular health can help improve renal functioning as well.
  • 2yr
    it has been known for a while, and the benefit has been widely proven. the indication will encourage more utilization. Especially with diabetic pts with known cardiac condition much more likely to benefit
  • 2yr
    I consider this a standard in my care if HF patients. This aligns with the guidelines. Cost is still an issue for many patients
  • 2yr
    Such an exciting new class of medications. Rivals DOACs when they came out. I keep it in mind on Hospital rounds and clinic patients. So many patients qualify. More importantly supported by the guidelines. Very exciting.
  • 2yr
    I have been prescribing SGLT2is for awhile now for HFrEF and HFpEF. They are one of the first classes I prescribe due to their stronger recommendation. I find that insurance coverage has improved. For patients on limited income, they may qualify for the prescription assistance programs. Patients with symptomatic HF do seem to see some relief in symptoms with the SGLT2i class, in my experience.
  • 2yr
    Also , it is 700-800$ out of pocket cost
  • 2yr
    I previously had thought I should “stay in my lane” and not prescribe these but “recommend “to the pcp. I now realize this is standard care for HF and it is in my lane. My fear of side effects have dwindled as well.
  • 2yr
    They are now part of standard therapy for HFrEF and HFmEF and are generally easy to add to whatever existing regiment there is since there is no BP effect or negative renal effect. For most patients, however, with a new Dx, I will still start with beta blocker + ACEI/ARB to avoid the "sticker shock" of the more expensive drug immediately (which in some populations leads to patients stopping everything). Once stabilized on those agents, if still symptomatic (like most are), I will add in the "expensive" drugs including empagliflozin and entresto. Spironolactone is the last one to add due to complex interactions (potassium, BP, side effects, etc). For HFpEF, I start with BP control (often with BB, ACEI/ARB) and add empagliflozin when the patient has good BP control but still has symptoms.
  • 2yr
    drugs such as Dapa and Empa Are very beneficial to improving heart failure class. There is no question of the favorable effects. It is encouraging to see literature regarding their use and diastolic heart failure. There may well be a class effect on renal protection as well. I Use these drugs frequently.
  • 2yr
    I have been using SGLT2 Inhibitors routinely in both HFREF and HFPEF for some time. I usually initiate these in HFREF after BB and ARNI/ACEI/ARB and and before Spironolactone. In HFPEF I usually initiate SGLT2 inhibitors first line and use Spironolactone earlier in the algorithm. In patients with CKD as well Farxiga may be especially beneficial in prevention of worsening CKD.
  • 2yr
    SGLT-2 inhibitors is being more commonly used for a wide spectrum of HF patients irrespective of the EF range. They are useful for both non-diabetics and diabetics alike, in fact they are HF agents than anti-diabetics. They can be given in patients with mild to moderate CKD
  • 2yr
    sglt2 inhibitors have become a stanfard part of the 4 horseman of meds to treat chf
    particuarly usful in mild decreased lv function of preserved lv function
    interesting to see how the duel sglt1 and 2 inhibitorSotagliflozin fares since I know virtuslly nothing about it
    the nice part of sgpt2 meds is theycan be added seemlessly to other meds-- bad part is cost
  • 2yr
    I think that SGLT2 inhibitors have become standard of care for my inpatients with any heart failure regardless of EF ever since we added to inpatient formulary based on data showing reduced readmission rates. For outpatients, anyone with an EF of less than 50% gets them, along with anyone with diastolic dysfunction and shortness of breath or swelling. The hang up comes with type 1 diabetics, where PCPs often stop them :(
  • 2yr
    My colleagues and I are now adding SGLT2 inhibitors empagliflozin or dapagliflozin for some of our patients with HFrEF after beta blocker and ACEI/ARB/ANI, and sometimes before spironolactone if renal function is reasonably preserved. If patient is diabetic, then we prescribe it more often. We use it in a greater percentage in patients who require diuretics for HFrEF. In HFpEF, benefits of SGLT2 inhibitor use is predominantly for reducing hospitalization rates, with little reduction in mortality, but I use it in symptomatic HFpEF patients.
  • 2yr
    I have been using them for reduced EF for about a year with regularity .
    For hfpf about 6m .
    I have seen great results in terms of improving EF in the reduced EF patients many of whom are feeling dramatically better aS well
  • 2yr
    I do use SGLT 2 inhibitors. However, I tend use them earlier in heart failure with preserved EF and save them as the 4th medication in heart failure with reduced EF. They continue to be very expensive. This limits their use to some extent. I try to get patients with reduced EF on Entresto 1st as, of course, this is also an expensive medication.
  • 2yr
    We became part of the SGL T2 innovation, early with the first Dapa trials. We also had early believe that they would be value end diastolic dysfunction patients will be for the Paragon trial!
  • 2yr
    My practice has gotten in line with the guidelines for the most part. Using primarily COR 2a recommendations and higher. DATA really are strong for these newer agents, and it’s especially refreshing to have a therapy for HFPEF finally.
  • 2yr
    The SGLT2 inhibitors are an important part of the treatment of congestive failure. Hopefully their availability will expand on hospital formularies. They play an important part in the management of these patients and should be considered for each individual.
  • 2yr
    The practice has been different in bigger hospitals versus small hospitals. SGLT2 inhibitors are still non formulary in small hospitals unfortunately and patients have to wait until discharge.

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