Utilization Patterns and Barriers to Sodium–Glucose Cotransporter-2 Inhibitor Prescription in Patients with Heart Failure: Real-World Evidence from Saudi Arabia

Sodium–glucose cotransporter-2 inhibitors (SGLT2i) are recommended as foundational therapy for patients with heart failure (HF) across all ejection fractions; however, real-world adoption remains inconsistent, and data from Middle Eastern health systems are limited. This study aimed to assess real-world utilization of SGLT2i among patients with HF in Saudi Arabia and to identify clinical factors associated with prescribing and outcomes. We conducted a multicenter retrospective cohort study of adult patients with HF receiving longitudinal care at tertiary cardiac centers between January 2016 and December 2024 in Saudi Arabia. HF phenotypes included reduced, mildly reduced, preserved, and improved ejection fraction. The primary outcome was SGLT2i use during follow-up. Multivariable logistic regression identified factors associated with prescribing. Exploratory outcomes included HF hospitalization and all-cause mortality. Among 1081 patients with HF (median age 66 years [IQR 56–76]; 50.8% women), 626 (57.9%) received an SGLT2i. Utilization uptake increased over time but was lower in HF with preserved versus reduced ejection fraction (adjusted odds ratio [aOR] 0.30; 95% CI 0.20–0.43). Diabetes mellitus (aOR 2.29; 95% CI 1.60–3.29) and greater baseline guideline-directed medical therapy optimization (aOR per additional class 1.31; 95% CI 1.13–1.51) were independently associated with use, whereas advanced chronic kidney disease (eGFR < 30 ml/min/1.73 m 2 ) was associated with lower prescribing (aOR 0.26; 95% CI 0.15–0.44). Exploratory analyses suggested lower rates of HF hospitalization and all-cause mortality among SGLT2i users; however, these findings are associative and should be interpreted cautiously. In this real-world cohort, SGLT2i use was heterogeneous and influenced by HF phenotype, renal function, comorbidity burden, and baseline therapy, highlighting persistent gaps in evidence-based HF care.