Early initiation of sodium–glucose co-transporter-2 inhibitors in heart failure patients: a nationwide study

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Abstract
Introduction: While sodium–glucose co-transporter-2 inhibitors (SGLT-2i) have shown substantial benefit in heart failure (HF) across clinical trials and are now a cornerstone of HF guideline-directed medical therapy (GDMT), data on their use in Europe remains scarce. This study aimed to assess SGLT-2i initiation after a first HF hospitalization, identify its predictors, and evaluate between-hospital disparities. Methods: Using the French National Healthcare Database (SNDS) between 2021 and 2023, SGLT-2i initiation was assessed in patients discharged from a first HF hospitalization, excluding patients with prior exposure to SGLT-2i. Multilevel logistic regression identified individual- and hospital-level predictors of SGLT-2i initiation and median odds ratio (MOR) estimated between-hospital variance in SGLT-2i initiation. Results: Among 303 118 patients, 16.1% initiated SGLT-2is. Initiation rates were higher in patients ≤75 years (24.3% vs. 12.4%), males (19.7% vs. 12.4%), diabetics (18.9% vs. 14.8%), without chronic kidney disease (CKD) (17.4% vs. 11.4%), and with lower left ventricular ejection fraction (LVEF) (<40%: 36.1%, 40%–49%: 19.7%, ≥50%: 11.7%, P for trend <0.001). Initiation rose from 4.8% in 2021 to 28.5% in 2023 (P for trend <0.001), with similar trends across subgroups. Positive predictors included male sex, critical care unit stay, diabetes, lower LVEF and background GDMT, while older age and CKD were negative predictors. Between-hospital variance in SGLT-2i initiation was high, with 25% of hospitals sharing more than half of SGLT-2i initiators (MOR 1.55, 95% CI 1.50–1.60). Conclusion: In this nationwide study, SGLT-2i initiation increased over the years but remains suboptimal and highly variable across hospitals and patient phenotypes, highlighting opportunities to improve GDMT.

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