Discussion about this post

User's avatar
Mary Braun Bates, MD's avatar

Slightly off topic. In the US one big barrier to getting heart failure patients on SGLT2is is cost. The other meds are relatively inexpensive and I can get people on them. I've even failed to get insurance coverage for an SGLT2i when a patient has both HFrEF and diabetes.

One of the main reasons trials differ from real life is the relative ease of getting the pharmaceutical agents.

Expand full comment
Steve Cheung's avatar

I’m less pessimistic than you about this trial and its actual utility in clinical practice.

The “guidelines” (which are with every passing day progressively becoming more full of bunk) promote ‘4 pillars for everyone as soon as yesterday’ in the absence of evidence. This trial actually (indirectly) suggests that, “IF” you can get pts quickly titrated on all 4 drugs, it does in fact provide a benefit (even if driven primarily, though not entirely, by HHF reductions). That’s more than could be said before this study (and more than could be said for the basis of the guidelines themselves). That’s a useful thing to have some confirmation for.

And it to me actually serves as a brake for the mindless enthusiasm for “all 4 drugs ASAP for everyone and even in the water supply”….cuz if you can’t replicate the conditions of this trial (which most in Canada and North America cannot)….then such promotion remains in the absence of evidence. I also focus on the fact that the average age was 63. It tells me that, in young HFrEF pts for whom I have the good fortune to be able to provide this degree of intensive follow up, this rapid uptitration of “4 pillars” stuff is worth trying; but for most people, there is no evidence to compel me to deviate from the progressive titration style of yore.

I agree it “makes sense” that intensive follow up care “should help”. But this actually proves it. That someone went out to prove a motherhood statement to be correct should be celebrated.

Expand full comment
8 more comments...

No posts