Determinants and Prognostic Impact of In-Hospital Sodium-Glucose Cotransporter-2 Inhibitor Initiation in Patients with Heart Failure.

Abstract

Background and objectives: Initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients hospitalised for heart failure (HF) is crucial for improving long-term outcomes. However, in real-world practice, a considerable proportion of patients are discharged without initiation. This study aimed to evaluate the initiation rate of SGLT2i, identify clinical factors associated with non-initiation, and examine the impact on long-term prognosis in patients hospitalised for HF.

Methods: This single-centre, retrospective, observational analysis of a prospective registry included 781 consecutive patients who were hospitalised for HF between 2021 and 2024. The primary endpoint was the in-hospital initiation rate of SGLT2i. Secondary endpoints included clinical factors associated with non-initiation, assessed using multivariable logistic regression, and the incidence of the composite endpoint of all-cause mortality or HF rehospitalisation at 1 year according to SGLT2i prescription status at discharge, evaluated by log-rank test and Cox proportional hazards analysis.

Results: A total of 467 patients (median age 81 [74-87] years, 50.3% male) were included in the final analysis. The initiation rate of SGLT2i during hospitalisation was 37.3% (174/467), and treatment discontinuation after initiation occurred in 8.6% (15/174). Multivariable analysis revealed that older age, non-diabetes, impaired renal function, higher left ventricular ejection fraction, malnutrition, impaired mobility, and cognitive dysfunction were independently associated with non-initiation. Among 346 patients with available follow-up data, the incidence of the composite endpoint at 1 year was significantly higher in the non-initiation group than in the initiation group (37.5% vs 21.3%, log-rank p = 0.001). In multivariable Cox analysis, not prescribed SGLT2i at discharge remained independently associated with worse long-term outcomes (hazard ratio 1.70, 95% confidence interval 1.07-2.69, p = 0.02).

Conclusion: Both conventional clinical factors (e.g., diabetes, left ventricular ejection fraction) and aging-related factors (e.g., nutritional status, mobility, cognitive function) were independently associated with non-initiation of SGLT2i in hospitalised patients with HF. Importantly, non-initiation at discharge was significantly associated with worse long-term outcomes, underscoring the need to promote active initiation of SGLT2i in this population.