Cost-effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for Patients With Heart Failure and Preserved Ejection Fraction—Living on the Edge

The landscape of clinical trials for heart failure with preserved ejection fraction (HFpEF) is littered with failed therapies, in stark contrast to that for heart failure with reduced ejection fraction (HFrEF) in which multiple therapies improve survival and quality of life.Among therapies tested for HFpEF, the sodium glucose cotransporter-2 (SGLT2) inhibitors, empagliflozin and dapagliflozin, are the first two drugs to demonstrate benefit, by reducing the composite of cardiovascular death, heart failure hospitalization, and (in DELIVER) urgent heart failure visits in large-scale outcome trials. 1,2While these therapies have been appropriately seen as a breakthrough by the cardiology community, they come with a hefty price tag of >$4,000 annually.With over 6 million individuals affected by HFpEF, the potential impact on the healthcare spending is substantial. 3Therefore it is critical to understand the economic value of SGLT2 inhibitors for HFpEF by carefully comparing the costs with the expected clinical benefit.In this issue, Cohen and colleagues have performed a formal cost-effectiveness analysis of SGLT2 inhibitors for patients with heart failure with an ejection fraction > 40%. 4They developed a computer-simulation model to project the long-term clinical benefits and costs for patients with HFpEF with and without SGLT2 inhibition.Their model was based on pooled estimates of baseline risk and the effectiveness of SGLT2 inhibitors derived from the EMPEROR-PRESERVED and DELIVER trials. 5Because these trials followed patients for a median of only 2.3 years, the authors extrapolated long-term event rates under the assumption that the therapeutic benefits on mortality, quality of life, and heart failure hospitalization would persist over a patient's lifetime.In their primary analysis, they found that treatment with SGLT2 inhibitors led to an additional 0.19 quality-adjusted life-years (QALYs) at a cost of $26,312, with an incremental cost-effectiveness ratio of $141,200 per QALY gained.Based on current U.S. benchmarks of <$50,000/QALY for high