J Card Fail. 2021 Nov 13:S1071-9164(21)00470-X. doi: 10.1016/j.cardfail.2021.11.010. Online ahead of print.
BACKGROUND: The sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear effective across a range of patient profiles. There is increasing interest around initiation of SGLT-2 inhibitor during hospitalization, yet little is known about the putative benefits of this implementation strategy.
METHODS: We evaluated Medicare beneficiaries with HFrEF (≤40%) hospitalized at 228 sites in the Get With The Guidelines®-Heart Failure (GWTG-HF) Registry in 2016 who had linked claims data for ≥1 year post-discharge. We identified those eligible for dapagliflozin under the latest US Food and Drug Administration label (excluding eGFR<25 mL/min per 1.73 m2, dialysis, or type 1 diabetes). We evaluated 1-year outcomes overall and among key subgroups (age≥75 years, sex, race, hospital region, kidney function, diabetes status, triple therapy). We then projected the potential benefits of implementation of dapagliflozin based on risk reductions from DAPA-HF.
RESULTS: Among 7,523 patients hospitalized for HFrEF, 6,576 (87%) would be dapagliflozin candidates (mean age 79±8 years, 39% women, 11% Black). Among eligible candidates, discharge use of β-blockers, ACEi/ARB, MRA, ARNI, and triple therapy (ACEi/ARB/ARNI+β-blocker+MRA) was recorded in 88%, 64%, 29%, 3%, and 20%, respectively. Among treatment-eligible patients, 1-year incidence (95% CI) of mortality was 37% (36-38%) and of HF readmission was 33% (32-34%), and each exceeded 25% across all key subgroups. Among 1,333 beneficiaries eligible for dapagliflozin who were already on triple therapy, 1-year incidence of mortality was 26% (24-29%) and 1-year HF readmission was 30% (27-32%). Applying the relative risk reductions observed in DAPA-HF, absolute risk reductions with complete implementation of dapagliflozin among treatment-eligible Medicare beneficiaries are projected to be 5% (1-9%) for mortality and 9% (5-12%) for HF readmission by 1 year. The projected number of Medicare beneficiaries that would need to be treated for 1 year to prevent 1 death is 19 (11-114) and 12 (8-21) would need to be treated to prevent 1 HF readmission.
CONCLUSIONS: Medicare beneficiaries with HFrEF eligible for dapagliflozin after HF hospitalization, including those well-treated with other disease-modifying therapies, face high risks of mortality and HF readmission by 1 year. If benefits in reduction in death and HF hospitalization observed in clinical trials can be fully realized, absolute benefits of implementation of SGLT-2 inhibitors among treatment eligible candidates are anticipated to be substantial in this high-risk post-discharge setting.