Early initiation of sodium–glucose co-transporter-2 inhibitors in heart failure patients: a nationwide study

Abstract Introduction While sodium–glucose co-transporter-2 inhibitors (SGLT-2i) have shown substantial benefit in heart failure (HF) across clinical trials and are now a cornerstone of HF guideline-directed medical therapy (GDMT), data on their use in Europe remains scarce. This study aimed to assess SGLT-2i initiation after a first HF hospitalization, identify its predictors, and evaluate between-hospital disparities. Methods Using the French National Healthcare Database (SNDS) between 2021 and 2023, SGLT-2i initiation was assessed in patients discharged from a first HF hospitalization, excluding patients with prior exposure to SGLT-2i. Multilevel logistic regression identified individual- and hospital-level predictors of SGLT-2i initiation and median odds ratio (MOR) estimated between-hospital variance in SGLT-2i initiation. Results Among 303 118 patients, 16.1% initiated SGLT-2is. Initiation rates were higher in patients ≤75 years (24.3% vs. 12.4%), males (19.7% vs. 12.4%), diabetics (18.9% vs. 14.8%), without chronic kidney disease (CKD) (17.4% vs. 11.4%), and with lower left ventricular ejection fraction (LVEF) (40%: 36.1%, 40%–49%: 19.7%, ≥50%: 11.7%, P for trend 0.001). Initiation rose from 4.8% in 2021 to 28.5% in 2023 (P for trend 0.001), with similar trends across subgroups. Positive predictors included male sex, critical care unit stay, diabetes, lower LVEF and background GDMT, while older age and CKD were negative predictors. Between-hospital variance in SGLT-2i initiation was high, with 25% of hospitals sharing more than half of SGLT-2i initiators (MOR 1.55, 95% CI 1.50–1.60). Conclusion In this nationwide study, SGLT-2i initiation increased over the years but remains suboptimal and highly variable across hospitals and patient phenotypes, highlighting opportunities to improve GDMT.