Introduction Complex Heart Failure with reduced Ejection Fraction (HFrEF) causes left ventricle dysfunction and global cardiovascular morbidity and mortality. Type 2 Diabetes Mellitus (T2DM) increases cardiovascular risk, requiring early detection, self-management, blood pressure, glucose, and cholesterol treatment. SGLT2i may improve cardiovascular outcomes and diabetes treatment in the elderly. Over three months to two years, this trial examined the efficacy and safety of SGLT2i in older patients with HFrEF, including those with and without T2DM.

Method This retrospective observational study involved patients aged 65 and older with an EF of ≤ 40% from cardiology clinics. Patient medical records from 2018–2023 provided data for analysis, including demographics, comorbidities, hospitalisation, changes in EF, New York Heart Association (NYHA) shifts, estimated Glomerular Filtration Rate (eGFR) reduction, and mortality.

Results Our study focused on 167 elderly HFrEF patients (65+ years) treated with SGLT2i, split into T2DM (125) and non-T2DM (42) groups. While both groups had similar demographics, 80.6% of T2DM patients had hypertension compared to 37.2% of non-T2DM patients (p < 0.001). Empagliflozin was the predominant treatment, with significant differences in prescription rates between groups (p = 0.045). Both groups demonstrated similar improvements in EF and NYHA classification. Although cardiovascular events, hospitalisation, and mortality were higher in T2DM patients, these differences were not statistically significant. Non-T2DM patients experienced a more notable reduction in eGFR (p = 0.018).

Discussion The difference in comorbidities between the two groups likely reflects the strong connection between diabetes and hypertension, which often coexist due to shared mechanisms like insulin resistance. Empagliflozin was more commonly prescribed to T2DM patients, likely due to its proven benefits in diabetes management, as highlighted in the EMPEROR-Reduced trial. While SGLT2 inhibitors improved heart function and symptoms in both groups, the greater reduction in eGFR among non-diabetics indicates a need for closer monitoring of kidney function in these patients.

Conclusion In elderly HFrEF patients, SGLT2i improved EF and NYHA classification regardless of T2DM status. However, the combination of T2DM and CKD was linked to higher hospitalisation and mortality rates.