Sodium-glucose cotransporter 2 (SGLT2) inhibitors may reduce the risk of death and hospitalization in patients over 80 years of age with heart failure with preserved ejection fraction (HFpEF), a new expert commentary suggests. Published in JACC: Heart Failure, and authored by Abdulla A. Damluji, MD, PhD, MBA, from the Cleveland Clinic Foundation, and colleagues, the commentary noted that while SGLT2 inhibitors carry guideline recommendations for HFpEF, evidence in very old patients with complex comorbidities has been lacking. Indeed, they noted that very old adults remain largely underrepresented in randomized trials, which limits generalizability to this population despite potential benefits. Real-world evidence The commentary highlights an observational study by Hacil et al., also published in JACC: Heart Failure, that enrolled 298 consecutive patients over 80 years of age hospitalized with HFpEF at three geriatric centers in France. The population was notably advanced, the commentators reported. The mean age was 90 years, more than half were at least 90 years old and 7% were centenarians. At discharge, half of patients received an SGLT2 inhibitor. Use of the drug class was associated with a lower adjusted risk of the composite outcome, with a hazard ratio of 0.43 (95% confidence interval, 0.29 to 0.66), the authors reported. The commentators acknowledged limitations including potential selection bias, as clinicians may have preferentially started SGLT2 inhibitors in more robust patients. Age should not be a barrier Despite these limitations, the commentators emphasized that the findings support SGLT2 inhibitor use in real-world older adults with HFpEF. “The study highlights that age alone, even in the setting of multicomplexity, should not be used to deny older patients effective therapies,” wrote Damluji and colleagues. For very old patients whose goals include improving quality of life or survival, initiating an SGLT2 inhibitor is reasonable given the totality of evidence, they said. But the first step remains eliciting goals of care and personal preferences. The commentators called for pragmatic trials enrolling complex patients 80 years and older, reporting outcomes meaningful to this population including days alive free of major disability, home time, and quality of life. “We need many more observational studies and clinical trials in very old patients to enable evidence-based care decisions that align with what matters most to individual patients,” they concluded. Source: Damluji AA, Nanna MG, Rich MW. Optimal Management of HFpEF in Very Old Patients, Where Do We Stand? JACC Heart Fail. 2025;13(12):102758. Image Credit: Jo Panuwat D – stock.adobe.com