A 68-year-old woman with type 2 diabetes and a history of heart failure with reduced ejection fraction, BMI 27, HbA1c 70 mmol/mol. Select the most appropriate antidiabetic medication for intensified therapy.

• A. Dapagliflozin
• B. Sitagliptin
• C. Empagliflozin
• D. Liraglutide

Answer: (C)

In this situation, the key idea is to choose an antidiabetic agent that also improves heart failure outcomes. SGLT2 inhibitors do exactly that: they lower blood glucose and have proven benefits in heart failure with reduced ejection fraction, reducing heart failure hospitalizations and cardiovascular death.

Empagliflozin has particularly strong heart-failure-specific evidence from the EMPEROR-Reduced trial, which showed a clear reduction in the combined risk of cardiovascular death and heart failure events in patients with HFrEF, including those with diabetes. This makes it a preferred choice when heart failure is a prominent concern alongside diabetes.

Dapagliflozin also provides heart failure benefits (DAPA-HF), but in the context of selecting the most appropriate option among these choices for someone with HFrEF and diabetes, empagliflozin’s robust heart-failure outcome data and approvals make it the standout choice.

GLP-1 receptor agonists like liraglutide mainly reduce atherosclerotic cardiovascular events and have less demonstrated impact on heart failure outcomes. Sitagliptin has neutral cardiovascular effects and lacks HF-specific benefits. So they’re less optimal for addressing heart failure alongside diabetes in this scenario.

Therefore, initiating empagliflozin aligns best with the patient’s heart failure history while also improving glycemic control.