Evaluating sglt2 inhibitor application in heart failure patients across the spectrum in a large multi-hospital healthcare network
P Darko, B Otchere, E Hama, P Berchie, E Vince, X Salazar, B Demoss, A Krishnamoorthy, R Singh, R Loungani, K Bauza, S Damle, E Molina, C MartiAbstract
Introduction
Sodium–glucose cotransporter-2 inhibitors (SGLT2-i) are guideline-recommended therapies across the heart failure (HF) spectrum, including patients with reduced and preserved ejection fraction. Despite strong evidence for morbidity and mortality benefit, real-world adoption remains inconsistent. Prior studies suggest variability in uptake by age, race, renal function, and health system characteristics, raising concerns regarding equity and implementation. However, contemporary multi-system evaluations assessing whether such patterns are consistent across distinct healthcare environments remain limited.
Purpose
To evaluate real-world utilisation of SGLT2 inhibitors among patients with heart failure and to assess consistency of prescribing patterns across age, race, renal impairment, and health systems.
Methods
We conducted a retrospective, multi-centre electronic medical record analysis using an AI-assisted query across three geographically distinct hospital systems between 2022 and 2025. Adult patients with a documented diagnosis of heart failure were identified. SGLT2-i prescription was ascertained from medication records. The primary outcome was SGLT2-i utilisation overall and stratified by age decade, race, and presence of renal impairment. Between-system consistency of subgroup-specific utilisation patterns was assessed descriptively to identify system-dependent versus system-independent trends.
Results
Among 36,196 patients with heart failure, 55% (n=19,908) received an SGLT2 inhibitor. Overall utilisation declined progressively with advancing age, a pattern that was consistent across all three health systems, with no material inter-system differences in age-stratified uptake. By race, Asian patients demonstrated the highest SGLT2-i utilisation, while Native American patients had the lowest uptake. These race-associated patterns were directionally consistent across systems. Among patients with documented renal disease, 60% received an SGLT2-i, with no meaningful variation in utilisation across health systems, suggesting that renal impairment was not a major barrier to prescribing in contemporary practice.
Conclusions
In this large, contemporary, multi-system cohort, SGLT2-i adoption in heart failure was moderate overall but declined substantially with increasing age, and race-associated disparities were evident, with highest uptake among Asian patients and lowest among Native American patients. Renal impairment was not a limiting factor for use. The consistency of these patterns across three distinct health systems suggests that underutilisation is driven by system-independent factors rather than local practice variation. These findings highlight opportunities for targeted, equity-focused implementation strategies, particularly among older adults and populations with the lowest observed uptake. Prospective interventions aimed at reducing age- and race-related gaps in SGLT2-i prescribing are warranted.For image description, please refer to the figure legend and surrounding text.