Skill Checkup: A Woman With Long‐standing Hypertension and Worsening Dyspnea on Exertion

Yasmine S. Ali, MD; Jeffrey J. Hsu, MD


December 20, 2022

A clinical trial published in October 2021 found that empagliflozin — a sodium-glucose cotransporter 2 (SGLT2) inhibitor — reduced the combined risk for cardiovascular death or HF-related hospitalization in patients with HFpEF, regardless of the presence or absence of diabetes. This comes on the heels of evidence showing that SGLT2 inhibitors reduce the risk for HF-associated hospitalization or death in patients with HFrEF. A multinational randomized trial concluded that empagliflozin in patients hospitalized for acute HF is well tolerated and leads to significant clinical benefit in the 90 days after treatment initiation. According to the 2022 AHA/ACC/HFSA Heart Failure Guidelines, SGLT2 inhibitors have a Class 2a recommendation for the pharmacologic treatment of patients with HFpEF.

Loop diuretics have also been linked to reduced hospital readmission risk in the 30 days after an index hospitalization in patients who have HFpEF, according to a study published in 2020. However, loop diuretics have not been shown to reduce mortality in either HFrEF or HFpEF. Angiotensin receptor/neprilysin inhibitors (ARNIs) have a Class 2b recommendation in the 2022 AHA/ACC/HFSA Heart Failure Guidelines because they may be considered to decrease hospitalizations in patients with HFpEF, but not mortality.

In patients with HFrEF, combinations of drug therapies that may include angiotensin-converting enzyme (ACE) inhibitors; ARNIs, such as sacubitril-valsartan; beta-blockers; ivabradine; and mineralocorticoid receptor antagonists provide incremental benefit, with marked reductions in all-cause mortality, cardiovascular mortality, all-cause hospitalizations, and hospitalizations for HF.

Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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