AS A PHARMACIST, you will hear buzz about the role of Jardiance (empagliflozin) in managing heart failure with PRESERVED ejection fraction (HFpEF). This is in addition to the growing evidence showing benefit of SGLT2 inhibitors in heart failure with REDUCED ejection fraction (HFrEF). But over half of HF patients have HFpEF, and to date, treatment options for HFpEF have been limited. Some data suggest an ACEI or ARB, Entresto (sacubitril/valsartan), or spironolactone might reduce HFpEF hospitalizations. But this evidence isn’t robust. It often hinges on rehashing data or digging into secondary endpoints or subgroups to find benefit.
Now stronger data suggest that Jardiance 10 mg/day prevents HF hospitalization in 1 in 31 patients with HFpEF over about 2 years, but doesn’t reduce CV death. This is in patients with OR without diabetes and most already taking an ACEI or ARB, beta-blocker, and often an aldosterone antagonist. Be aware, benefit seems greater with mildly reduced ejection fraction (EF), from 40% to 50% and tapers as EF increases, especially over 60%. Expect FDA to review Jardiance for HFpEF approval soon and stay tuned for data with other SGLT2 inhibitors. But weigh Jardiance downsides, such as genital or urinary tract infections, volume depletion.
First, focus on blood pressure (BP) control, it may slow HFpEF progression. Choose BP medications based on comorbidities. Optimize management of common conditions that may worsen HFpEF, such as atrial fibrillation, COPD, and obesity. And use loop diuretics if needed for fluid overload. But keep in mind, reducing preload too much can worsen HFpEF symptoms. Then evaluate what’s practical for your patient.
In many cases, consider adding Jardiance if HFpEF symptoms persist especially for patients with type 2 diabetes. Or think of spironolactone if cost is an issue or Entresto instead of an ACEI or ARB if additional BP lowering is needed. It’s also okay if patients need to combine Jardiance, spironolactone, and Entresto for HFpEF, but data are limited.
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