Sodium–glucose cotransporter 2 inhibitors: efficacious and safe in elderly patients with heart failure

In the developed world the prevalence of diagnosed heart failure with reduced ejection fraction (HFrEF) is estimated to be 1% of the general population.1 This group endures a reduced short to medium term survival, an increased rate of hospitalization and diminished quality of life.2 Guideline-directed medical therapy (GDMT), which includes beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB)/angiotensin receptor–neprilysin inhibitor (ARNi), mineralocorticoid receptor antagonists (MRA) and most recently, sodium–glucose cotransporter 2 inhibitors (SGLT2i), positively impacts this trifecta.1 An important clinical question is what role SGLT2i should occupy across the spectrum of HFrEF, especially in older cohorts. GDMT is underused and when used, rarely uptitrated in elderly patients with HFrEF;3 this has been demonstrated not only in real-world registries but also in contemporary randomized clinical trials.4–6 In this issue of the Journal, Filippatos et al.4 present an age-specific sub-analysis of the Empagliflozin Outcome Trial in Patients with Chronic Heart Failure and a Reduced Ejection Fraction (EMPERORReduced) trial. In 3730 symptomatic patients with HFrEF, empagliflozin when compared to placebo reduced the composite outcome of heart failure hospitalization and cardiovascular death by 25% (the majority of effect was via reduction in hospitalization). The investigators reassessed the effect of the drug after dividing their study population in three cohorts based on age (<65, 65–74 and >75 years). A total of 999 patients or 27% of the population were >75 years of age and this included some nonagenarians. Older patients (>75 years) had more comorbidities including hypertension, atrial fibrillation and lower estimated