Care discrepancy in the management of the cardiorenal-metabolic syndrome: real-world analysis of SGLT2 inhibitor use in heart failure, chronic kidney disease, and type 2 diabetes
R Reibis, M Luedde, N Smetak, E Ziegler, F Roedicker, T Celer, S WassmannAbstract
Background
Heart failure (HF), chronic kidney disease (CKD), and type 2 diabetes mellitus (T2D) are key, frequently co-occurring components of the cardiorenal-metabolic syndrome. Affected patients are typically managed in primary care and have an increased risk of mortality, morbidity, and hospitalization. Despite the proven benefits of guideline-directed medical therapy, particularly treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2i), their use in Germany has thus far been insufficiently established. Structured, cross-sector care is essential to improve mortality, morbidity, and quality of life. Real-world data on implementation in primary care are currently limited.
Objective
The aim of this retrospective cross-sectional analysis was to examine the current care situation of patients with cardiorenal-metabolic syndrome in German primary care using electronic real-world data.
Methods
The AWAreness of prevalence, diagnosis and Treatment of CHronic Heart Failure (WATCH-HF) subanalysis of the InspeCKD study[1] is based on anonymized routine data from 1,244 general practices. Included were patients (≥18 years) with documented cardiovascular risk factors or diagnoses, including HF, CKD, and T2D. Identification was ICD-10-based, considering all HF phenotypes. The observation period covered January 2021 to June 2023.
Results
Of 448,837 included patients, 12.2% (n = 54,721) had a documented HF diagnosis. Of these, 1,891 (3.5%) had both CKD and T2D documented prior to the initial HF diagnosis. The mean age of this comorbid cohort was 77.5 years, and slightly more than half (51.6%) were female. NT-proBNP measurement prior to HF diagnosis was performed in only 2.6% (n = 50) of patients, with a markedly elevated mean value of 2,553.7 pg/mL; the maximum interval between measurement and HF diagnosis was 10 weeks. Despite multiple indications, only 32.4% (n = 612) of multimorbid patients (HF+CKD+T2D) received an SGLT2i prescription over the entire observation period. Among the 1,185 patients with at least 13 weeks of observation before and 26 weeks after HF diagnosis, only 162 (13.7%) had an SGLT2i prescribed prior to the HF diagnosis, while 1,023 (86.3%) were not treated. Within 26 weeks after HF diagnosis, 10.0% (n = 119) received an initial SGLT2i prescription; the mean time to therapy initiation was 8.5 weeks.
Conclusions
The analysis reveals substantial discrepancies between current guideline recommendations and real-world care for patients with HF, CKD, and T2D in German primary care. To optimize outcomes, improvements in diagnostics, therapy standardization, and closer cross-sector collaboration are required. In addition, knowledge and resources for managing this complex patient population should be made widely available in primary care and appropriately reimbursed.