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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline noted previously, these analyses were performed in all patients with type 2 diabetes rather than specifically in patients with CCD, but these results appear to be robust to a range of assumptions regarding underlying risk and are likely applicable to patients with CCD. 4. Among patients with HF with reduced ejection fraction (with or without type 2 diabetes), SGLT2 inhibitors reduce the risk of cardiovascular death and HF hospitalization19–22 and improve functional capacity and QOL.23,24 These effects were independent of cause of cardiomyopathy, because approximately half of enrolled patients across the trials had CCD. SGLT2 inhibitors should be avoided or used with caution in patients with type 1 diabetes or with advanced CKD (eg, eGFR <30 mL/min/1.73 m2). 5. Among patients with HF with reduced ejection frac- tion (with or without type 2 diabetes), the use of SGLT2 inhibitors is projected to be of intermediate value ($50 000 to <$150 000 per QALY gained) from a US health care sector perspective and a lifetime horizon. One modeling-based study compared dapagliflozin and GDMT with GDMT alone in a hypothetical cohort of adults in the United States with similar clinical characteristics as participants of the DAPA-HF (Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction) trial.25 Assuming the cost of dapagliflozin to be $4192 annually, dapagliflozin was projected to add 0.63 (95% uncertainty interval, 0.25-1.15) QALYs at an incremental lifetime cost of $42 800 (95% uncertainty interval, $37 100-$50 300), for an incremental cost-effectiveness ratio of $68 300 per QALY gained (95% uncertainty interval, $54 600- $117 600 per QALY gained; cost-effective in 94% of probabilistic simulations at a threshold of $100 000 per QALY gained).25 Findings were similar among individuals with or without diabetes but were sensitive to drug cost. Similar findings were independently reported by another group of investigators.26 6 Among patients with HF with preserved ejec- tion fraction (with or without type 2 diabetes), SGLT2 inhibitors reduced the risk of HF hospitalization or cardiovascular death in the EMPEROR- PRESERVED (Evaluation of the effects of sodium-glucose co-transporter 2 inhibition with empagliflozin on morbidity and mortality in patients with chronic heart failure and a preserved ejection fraction) trial27 and the risk of worsening HF or cardiovascular death in the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure), with the primary endpoints driven by significant reductions in HF hospitalization in both trials. SGLT2 inhibitors also improved functional capacity and QOL in the PRESERVED-HF and DELIVER trials.28,29 CCD was diagnosed in 35% of enrolled patients in EMPORER-PRESERVED and 20% of enrolled patients in PRESERVED-HF (Effects of Dapagliflozin on Symptoms and Functional Status in Patients with Heart Failure and Preserved Ejection Fraction), with no significant difference in risk of HF hospitalization (subgroup was not tested in the QOL study); the CCD rate was not reported in DELIVER. 7. Among patients with HF with preserved ejection frac- tion (with or without type 2 diabetes), the economic value of SGLT2 inhibitors is sensitive to the effect of SGLT2 inhibitors on cardiovascular mortality. The reduction in cardiovascular mortality was not statistically significant in the EMPEROR-PRESERVED or DELIVER trials, or in a pooled analysis of the 2 trials. If one were to assume no reduction in cardiovascular mortality and minimal improvement in QOL among patients with HF with preserved ejection fraction, the use of empagliflozin is of low value (incremental cost-effectiveness ratio $437 000).30 However, if one were to assume a 9% reduction in cardiovascular mortality (as consistent with the point-estimate of EMPEROR-PRESERVED), the incremental cost-effectiveness ratio is lowered to $174 000 (which the authors defined as intermediate value after adjusting the ACC/AHA thresholds for interval change in per capita GDP). Although the trials included patients with and without CCD, it is likely that patients with CCD have a higher risk of events (including cardiovascular mortality) and therefore derive a larger-than-average benefit from SGLT2 inhibitors. Additional clinical studies that examine the effect of SGLT2 inhibitors on cardiovascular and noncardiovascular mortality, and additional economic evaluations that synthesize the available clinical evidence and consider a range of costs and risks, are needed to ascertain the value of SGLT2 inhibitors in patients with CCD and HF with preserved ejection fraction. 4.2.9 Weight Management Recommendations for Weight Management Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 C-EO 1 In patients with CCD, assessment of BMI with or without waist circumference is recommended during routine clinical follow-up.1–6 1 B-NR 2 Patients with CCD and overweight or obesity should receive counseling on diet, lifestyle, and goals for weight loss.7–10 2a B-R 3 For patients with CCD and overweight or obesity in whom pharmacologic therapy is warranted for further weight reduction, a GLP-1 receptor agonist can be beneficial in addition to counseling for diet and physical activity,11,12 and it is reasonable to choose semaglutide over liraglutide.13,14 Downloaded from http://ahajournals.org by on October 7, 2026