In the DAPA-HF trial, dapagliflozin was added to guideline-recommended therapies, reducing the risk of mortality and heart failure (HF) hospitalization. In this study, the significance and frequency of outpatient HF episodes worsening were examined, requiring the implementation of oral therapy, and the effects of dapagliflozin on these events.

Patients in New York Heart Association functional class II to IV, with a left ventricular ejection fraction of greater than or equal to 40% and elevation of NT-proBNP, were eligible. Among the 4744 patients, the primary episode of worsening was the outpatient augmentation of treatment in 8.6% of participants, cardiovascular death in 6.2%,  HF hospitalization in 10.3%, and an urgent HF visit with intravenous therapy in 0.4%. The adjusted risk of death from any cause (in comparison with no event) after an outpatient worsening was hazard ratio, 2.67; after an urgent HF visit, the adjusted risk of death was hazard ratio, 3.00; and after an HF hospitalization, the adjusted risk of death was hazard ratio, 6.21.

In summary, the outpatient episodes of HF worsening were widespread, and reduced by dapagliflozin. A focus on HF hospitalization underestimates HF’s frequency worsening and ignores other preventable events of prognostic importance.