SGLT2 Inhibitors in Heart Failure: 2025 Updates for SCE Cardiology Success

Why SGLT2 Inhibitors Dominate HF Discussions in 2025

Landmark trials (DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved, DELIVER) show robust reductions in cardiovascular death and HF hospitalizations across HFrEF and HFpEF.
International guidelines (ESC 2021, ACC/HFSA 2022, NICE) now give Class I recommendations for dapagliflozin or empagliflozin in symptomatic HFrEF, and strong support for HFpEF.
High-yield for SCE: expect OSCE stations, viva prompts, and MCQ questions on when to start, dosing, side effects, and safety in CKD/diabetes.

HFrEF (EF ≤40%): Dapagliflozin and empagliflozin reduce CV death/HF hospitalization by ~26% and improve QoL.
HFpEF (EF ≥50%): Empagliflozin (EMPEROR-Preserved) and dapagliflozin (DELIVER) reduce the composite endpoint by ~20–21%, with consistent benefits across EF spectrum, diabetes status, and background therapy.
Practical implication: SGLT2 inhibitors are no longer “diabetes drugs for HF”—they are foundational HF therapies.

Osmotic diuresis and natriuresis without neurohormonal activation.
Improved cardiac metabolism (more ketones and efficient fuel use).
Favorable effects on myocardial remodeling, vascular function, and kidney protection.
Why it matters to examiners: mechanism explains efficacy with minimal hypotension or electrolyte chaos.

HFrEF (NYHA II–IV, EF ≤40%): Dapagliflozin 10 mg daily OR empagliflozin 10 mg daily; up-titrate to 10 mg if tolerated (no need for routine up-titration).
HFpEF (EF ≥50%): Empagliflozin 10 mg daily (EMPEROR-Preserved) or dapagliflozin 10 mg daily (DELIVER).
CKD: Renoprotection with eGFR declines mitigated; safe down to eGFR ~20–25 mL/min/1.73 m² (per label) with some tolerability even lower.
Diabetes with HF: Both dapagliflozin and empagliflozin show CV and HF benefits; avoid in type 1 diabetes.
Background therapy: Add on top of ACEi/ARB/ARNI, beta-blocker, MRA—no mandatory sequencing; benefits accrue early (within weeks).
Quick-start checklist:
- Confirm EF category (echo).
- Check eGFR and K+.
- Counsel on genital mycotic infections and DKA awareness (rare without diabetes).
- No need for routine K+-sparing dose adjustment.

Common: Volume depletion (watch BP), genital mycotic infections (hygiene counseling), mild increase in hematocrit.
Rare but critical: Euglycemic DKA—teach patients to check ketones if symptomatic (nausea, abdominal pain, tachypnea).
Renal: Temporary eGFR dip is expected; continue unless a significant sustained fall or symptomatic hypotension.
Stop temporarily around surgery/major illness; restart when stable and eating/drinking.
Interactions: Limited; still review diuretics to avoid over-diuresis.

OSCE station (GP referral for breathless patient):
- Establish HF phenotype: HFrEF vs HFpEF.
- Initiate SGLT2i alongside standard therapy; counsel on side effects; safety netting for genital infection/DKA.
Viva prompt:
- “Compare DAPA-HF and EMPEROR-Preserved; what changes in practice?”
- Answer: Both dapagliflozin and empagliflozin cut CV death/HF hospitalization; now treat HFpEF with empagliflozin or dapagliflozin, not just HFrEF.
MCQ seeders:
- 70-year-old with EF 55%, NYHA III—best next step? Add empagliflozin 10 mg daily.
- eGFR 28—can you start? Yes, with monitoring; avoid in severe hepatic impairment.
- On furosemide with dizziness—adjust loop diuretic before stopping SGLT2i.

First-line in symptomatic HFrEF: ARNI/ACEi/ARB + beta-blocker + MRA + SGLT2i (dapagliflozin/empagliflozin).
HFpEF now has a disease-modifying option: empagliflozin/dapagliflozin.
Benefits are early and durable; monitor BP, eGFR, and for infection/DKA.