The Real-World Use of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction Newly Initiated on Dapagliflozin: An EVOLUTION-HF CEE-BA Study (Results from the Baltic Cohort)

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Heart Failure with Reduced Ejection Fraction (HFrEF) (n=178). Intervention: Dapagliflozin. Primary outcome: Dapagliflozin discontinuation rate (13.2 per 100 patient-years, 95% CI 8.2-18.2).

Q: What does this research mean for the field?

In Baltic HFrEF patients newly initiated on dapagliflozin, the drug discontinuation rate is low at 13.2 per 100 patient-years, while overall guideline-directed medical therapy adherence remains suboptimal, falling to 42.3% at 12 months. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Diana Žaliaduonytė; Paulius Orda; Olar Pullisaar; Mai Blöndal; Roma Kavaliauskienė; Jolanta Laukaitienė; Natalija Pontaga; Vytė Maneikienė; Aldis Strēlnieks; Kārlis Trušinskis; Tiina Uuetoa; V Stirna; Anu Hedman

doi:10.3390/medicina62071310

July 7, 2026MedicinaOpen Access

The Real-World Use of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction Newly Initiated on Dapagliflozin: An EVOLUTION-HF CEE-BA Study (Results from the Baltic Cohort)

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Key result

Real-world dapagliflozin discontinuation reaches ~13 per 100 patient-years in HFrEF, alongside declining quadruple GDMT.

13.2 per 100 patient-years
95% CI 8.2-18.2
n=178

Figures

Why the study?

Adherence to guideline-directed medical therapy in patients with heart failure and reduced ejection fraction in the Baltics was unknown.

Key Points

To describe patient characteristics, treatment patterns, and adherence to guideline-directed medical therapy among patients with heart failure with reduced ejection fraction newly initiated on dapagliflozin in the Baltic region.
Conducted a longitudinal, real-world evidence study across 12 hospital-based study sites (four per country) in Estonia, Latvia, and Lithuania.
Enrolled 178 patients with heart failure with reduced ejection fraction (median left ventricular ejection fraction of 32%) who newly initiated 10 mg daily dapagliflozin, following them for 12 months.
Assessed patient profiles, dapagliflozin persistence, and adherence to core guideline-directed medical therapy (including RAASi, beta-blockers, and MRAs alongside dapagliflozin).
At baseline, 47.8% of patients (n = 85) received guideline-directed medical therapy (RAASi, beta-blockers, MRA, and dapagliflozin), with specific use at 94% for beta-blockers, 87% for RAASi, and 60% for MRAs.
The proportion of patients receiving guideline-directed medical therapy decreased from 47.8% at baseline to 46.1% at 6 months and 42.3% at 12 months.
Dapagliflozin was discontinued by 23 patients (12.9%), corresponding to an incidence rate of 13.2 discontinuations per 100 patient-years (95% CI: 8.2–18.2).

Study Design

Type

Cohort (n=178)

Multicenter

Yes

Structured PICO

P

Population

178 adults with HFrEF (LVEF ≤ 40%) newly initiated on dapagliflozin across the Baltics, followed for 12 months.

E

Exposure

Dapagliflozin 10 mg once daily added to standard heart failure therapy

O

Outcome

Baseline demographic and clinical characteristics, treatment patterns for dapagliflozin (including time to discontinuation), and treatment patterns for other HF and glucose-lowering medications over time at 6 and 12 months

Main Result

Effect estimate: 13.2 per 100 patient-years (95% CI 8.2-18.2)

Real-world data from the Baltic region reveals suboptimal implementation of guideline-directed medical therapy in HFrEF patients, with less than half receiving quadruple therapy despite a high-risk clinical profile.

Limitations

Secondary data collection study
Early prescriptions for dapagliflozin may have been selectively used in patients with more severe HF
Self-reporting of drug intake may overestimate adherence
LVEF status and NT-proBNP levels not reassessed during follow-up
No data collected on HF hospitalizations or readmissions
Secondary data collection study with potential for imprecise data
Lack of dapagliflozin reimbursement in two of the three countries
LVEF and NT-proBNP were not reassessed during follow-up

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Observed dapagliflozin discontinuation and GDMT decline in HFrEF highlight implementation gaps; leaves open whether targeted strategies can improve persistence.

Abstract

Background and Objectives: Guideline-directed medical therapy (GDMT) remains a challenge due to its low rates worldwide. Adherence to GDMT in patients with heart failure (HF) and reduced ejection fraction (rEF) in the Baltics (Estonia, Latvia, and Lithuania) has been unknown. This is the first study to describe the characteristics of patients with HFrEF and their treatment patterns in the Baltics. Materials and Methods: The EVOLUTION-HF study was a longitudinal, real-world evidence study that enrolled patients with HFrEF following newly initiated sodium–glucose cotransporter-2 inhibitor (SGLT2i) dapagliflozin therapy. In total, 12 study sites (four from each country) were included. Patients were followed up for 12 months. A pooled data set including adherence to GDMT, dapagliflozin’s usage, and patients’ profiles was evaluated. Results: Between April and December 2022, 178 patients with a median left ventricular ejection fraction of 32% were enrolled. At baseline, 155 (87%) patients received renin–angiotensin–aldosterone system inhibitors (RAASi), 168 (94%) received beta-blockers (BB), and 106 (60%) received mineralocorticoid receptor antagonists (MRA); however, only 47.8% of the study population were found to be treated with GDMT (including RAASi, BB, MRA, and dapagliflozin) at the beginning of the study. At the end of the follow-up, the percentage of GDMT users decreased to 42.3%. The number of dapagliflozin discontinuations per 100 patient-years was found to be 13.2 (95% CI 8.2–18.2). Conclusions: The findings indicate a low rate of dapagliflozin discontinuation (13%) and an overall suboptimal proportion of patients receiving GDMT for HFrEF (almost half of the patients). The low rate of GDMT use in the Baltics prompts great attention. Additional research and incremental joint efforts are needed to ensure an increase in GDMT use across diverse HF patient populations.

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Cite This Study

Žaliaduonytė et al. (2026) conducted a cohort in Heart Failure with Reduced Ejection Fraction (HFrEF) (n=178). Dapagliflozin was evaluated on Dapagliflozin discontinuation rate (13.2 per 100 patient-years, 95% CI 8.2-18.2). In a real-world Baltic cohort of patients with HFrEF, the dapagliflozin discontinuation rate was 13.2 per 100 patient-years, and quadruple GDMT use declined from 47.8% at baseline to 42.3% at 12 months.

synapsesocial.com/papers/6a4f3b382b81a944af575322 https://doi.org/10.3390/medicina62071310

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The Real-World Use of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction Newly Initiated on Dapagliflozin: An EVOLUTION-HF CEE-BA Study (Results from the Baltic Cohort)

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

The Real-World Use of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction Newly Initiated on Dapagliflozin: An EVOLUTION-HF CEE-BA Study (Results from the Baltic Cohort)

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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