Skill Checkup: A 65-Year-Old Woman With Treated Type 2 Diabetes Presents With Shortness of Breath and Lightheadedness

Romesh Khardori, MD, PhD


February 23, 2023

Current practice in managing patients with T2D involves reducing hyperglycemia while also addressing cardiovascular and other risk factors. For patients with HF, the ADA recommends including an SGLT2 inhibitor with proven benefit in reducing HF progression.

As part of the SGLT2 inhibitor cardiovascular outcome trials, canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin led to significant reductions in hospitalization for HF, which was a secondary outcome in all trials but DECLARE-TIMI 58 with dapagliflozin, where it was a co-primary outcome. Subsequently, HF-specific trials that included patients with or without T2D were conducted with dapagliflozin (DAPA-HF and DELIVER) and empagliflozin (EMPEROR-Reduced and EMPEROR-Preserved).

Patients with HFrEF and NYHA class II-IV with/without diabetes were enrolled in DAPA-HF, and dapagliflozin 10 mg/day or placebo was added to existing care. On the primary outcome, treatment with dapagliflozin reduced risk of worsening of HF or death from cardiovascular causes by 26% (HR, 0.74; 95% CI, 0.65-0.85).

EMPEROR-Reduced also enrolled patients with HFrEF and NYHA class II-IV with or without diabetes. On the primary outcome, treatment with empagliflozin 10 mg/day vs placebo added to existing care reduced risk for cardiovascular death and hospitalization for worsening HF by 25% (HR, 0.75, 95% CI, 0.65-0.86).

In DELIVER and EMPEROR-Preserved, treatment with dapagliflozin 10 mg/day or empagliflozin 10 mg/day, respectively, was associated with significant reductions in cardiovascular death or worsening HF/hospitalization for HF in patients with HFpEF.

At present, only dapagliflozin and empagliflozin have received specific indications from the US Food and Drug Administration for reduction of HF risk in patients with or without diabetes. For reduction in risk for HF progression, patients should be started and maintained on 10 mg of dapagliflozin or empagliflozin.


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