SGLT2 Inhibitors in Geriatric Heart Failure: Evidence, Safety, and Clinical Implementation

This review summarizes the rationale, efficacy, safety, and implementation of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in older adults with heart failure (HF). SGLT2i have become an integral part of contemporary HF therapy, with benefits demonstrated across the ejection fraction spectrum. Age subgroup analyses from randomized trials, frailty analyses, meta-analyses, and real-world cohorts suggest that benefits on HF hospitalization and cardiovascular outcomes are largely preserved in older and frail patients. Observational data in patients aged ≥ 75 and > 80 years further support potential effectiveness in very old and multimorbid populations. However, geriatric vulnerability modifies clinical implementation, particularly regarding volume status, renal function, risk of falling, genitourinary infections, nutritional status, cognition, polypharmacy, and self-care capacity. Available evidence suggests that SGLT2i remain effective and are generally well tolerated in older patients with HF. Older age alone should therefore not preclude SGLT2i therapy. In geriatric HF, treatment decisions should be individualized according to frailty, comorbidity burden, safety risks, functional status, self-care capacity, and goals of care.