SGLT2 inhibitor prescription at discharge in very old adults with heart failure irrespective of diabetes status

Figures

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  Fig. 1. Study flow chart. Of 1470 hospitalisations recorded in the institutional database, 1235 met inclusion criteria and constituted the main analysis study population (SGLT2i prescribed: n = 1016 [82.3%]; not prescribed: n = 219 [17.7%]). Two sensitivity analyses were prespecified: exclusion of hospitalisations with CKD stage 5 (n = 44) and exclusion of hospitalisations with palliative orientation (n = 243). Abbreviations: CKD, chronic kidney disease; SGLT2i, sodium–glucose cotransporter 2 inhibitor. Alt text: Study flow chart showing the selection of the main analysis study population. Among 1470 hospitalisations recorded in the institutional cardiogeriatric database, 1314 had a diagnosis of heart failure. After exclusion of 156 hospitalisations without heart failure and 79 with undocumented SGLT2i discharge status, 1235 hospitalisations were included in the main analysis study population: 1016 with SGLT2i prescribed and 219 without SGLT2i prescribed. Two sensitivity analyses excluded CKD stage 5 hospitalisations and palliative-oriented hospitalisations, resulting in analysis populations of 1191 and 992 hospitalisations, respectively.

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  Fig. 2. SGLT2 inhibitor prescription across HF phenotype and diabetes status. Overall prescription rate was 82.3%. Rates by LVEF category: HFrEF 78.9%, HFmrEF 85.3%, HFpEF 84.1% (p < 0.001 overall). Prescription did not differ significantly between diabetic and non-diabetic patients (80.4% vs 83.2%, p = 0.276). In the primary multivariable model, diabetes was not independently associated with non-prescription (aOR 1.35 [95% CI 0.92–1.99], p = 0.122). Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; EF, ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; NS, not significant; SGLT2i, sodium–glucose cotransporter 2 inhibitor. Alt text: Grouped bar chart showing SGLT2i prescription rates according to left ventricular ejection fraction category and diabetes status. Prescription rates were 79% in diabetic and 79% in non-diabetic patients with HFrEF, 77% and 88% in HFmrEF, 83% and 85% in HFpEF, and 80% and 83% overall, respectively.

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  Fig. 3. SGLT2 inhibitor prescription according to renal function. Prescription rates were high and stable across CKD stages 1 to 3B (86–91%), declined substantially at stage 4 (73%), and fell sharply at stage 5 (27%; p < 0.001 overall). CKD stages were defined according to the KDIGO classification: stage 1 (eGFR >90 mL/min/1.73m2), stage 2 (60–89), stage 3 A (45–59), stage 3B (30–44), stage 4 (15–29), stage 5 (<15 mL/min/1.73m2). Abbreviations: CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes; SGLT2i, sodium–glucose cotransporter 2 inhibitor. Alt text: Bar chart showing SGLT2i prescription rates according to chronic kidney disease stage at discharge. Prescription rates remained high across CKD stages 1 to 3B, ranging from 86% to 91%, then decreased to 73% in stage 4 and 27% in stage 5. Individual bars are distinguished by their fill patterns and labels, with diagonal hatching for CKD stage 4 and crosshatching for CKD stage 5.

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  Fig. 4. Guideline-recommended drug classes and combination therapy at discharge among patients with HFrEF (n = 361). Panel A: individual drug class prescription rates. Panel B: combination therapy rates. Absolute numbers and percentages are shown for each category. Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor. Alt text: Two-panel horizontal bar chart showing guideline-recommended heart failure therapy at discharge among patients with HFrEF. The upper panel shows individual drug-class prescription rates: SGLT2i 79%, beta-blocker 77%, ACEi/ARB/ARNi 53%, and MRA 34%. The lower panel shows combination-therapy rates: 53% received at least three classes and 18% received all four classes.