Sodium-Glucose Cotransporter 2 Inhibitor Use for Heart Failure in US Ambulatory Cardiovascular Care

Importance Sodium-glucose cotransporter 2 inhibitor (SGLT2i) therapy reduces risk of heart failure (HF) events and cardiovascular death among individuals with HF. Trends of SGLT2i use in cardiovascular ambulatory care in the US remain unknown. Objective To evaluate the rate of SGLT2i use among patients with HF in the cardiovascular ambulatory care setting. Design, Setting, and Participants This was a retrospective cohort study conducted from July 1, 2019, through June 30, 2023. Included for analysis were patients with HF enrolled in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry, a national ambulatory cardiovascular care quality improvement registry. Study data were analyzed from February 15, 2024, through January 15, 2025. Main Outcomes and Measures Patient-level and practice-level prescription of SGLT2i therapy. Results Of 759 915 patients (mean [SD] age, 70 [14] years; 359 270 women [47.3%]; 49 252 Black individuals [14.6%]; 278 303 White individuals [82.7%]) with HF at 191 US sites, 76 927 (10.1%) were prescribed SGLT2i. Among patients with available ejection fraction (EF) data, 20 544 (17.9%) with HF with reduced EF (HFrEF) and 36 615 (8.9%) with HF with mildly reduced EF (HFmrEF) or HF with preserved EF (HFpEF) were prescribed SGLT2i. Rates of SGLT2i use for all patients with HF increased from 4.6% in the third quarter of 2019 to 16.2% in the second quarter of 2023, from 5.1% to 28.5% for those with HFrEF, and from 4.5% to 12.8% for those with HFmrEF or HFpEF ( P for trend <.001). SGLT2i was less commonly used for older persons (IQR age, 80 years vs 63 years; OR, 0.76; 95% CI, 0.75-0.77), female sex (OR, 0.79; 95% CI, 0.77-0.81), and higher systolic blood pressure (OR, 0.78; 95% CI, 0.77-0.79), whereas history of type 2 diabetes was associated with markedly higher use (OR, 3.21; 95% CI, 3.15-3.28). After adjustment for patient- and practice-level characteristics, significant variation in SGLT2i use across sites was present (90th vs 10th percentile risk practice, adjusted OR, 4.40; 95% CI, 3.76-5.52). Conclusions and Relevance Although this study found that SGLT2i use had increased among ambulatory patients with HF during the study period, the majority of eligible patients did not receive this therapy. Older age, female sex, and higher blood pressures were associated with lower SGLT2i use with significant unexplained variation in use across practices. Systematic efforts to improve SGLT2i therapy use are warranted.