Are post-hoc analyses on subgroups sufficient to support new treatment algorithms of heart failure? The case of SGLT2 inhibitors associated with sacubitril/valsartan

The use of sodium glucose cotransporter 2 inhibitors (SGLT2i) in heart failure (HF) with reduced ejection fraction (HFrEF) has been strongly supported by the results of recent randomized clinical trials. Upon this evidence, international recommendations and consensus documents propose the inclusion of SGLT2i among the first-line classes for HFrEF management. Subsequent analyses of treatment subgroups have been performed to investigate the effects of SGLT2i in patients treated with first line classes including sacubitril/valsartan (Sac/Val), showing a consistent reduction of cardiovascular (CV) outcomes with a good safety profile of SGLT2i in combination with the other classes. Accordingly, SGLT2i are recommended also in combination with Sac/Val. This association, however, may require caution before being translated into guideline directed medical therapy (GDMT) in clinical practice, since the proportion of patients receiving Sac/Val and SGLT2i in the available studies was poorly represented. In order to support an effective and safe sequencing or a simultaneous initiation of these two drug classes, pragmatic and real world clinical studies would be helpful.