Digital Strategy Doubles Heart Failure Drug
A digital strategy that identified and contacted heart failure patients not on guideline-recommended medication more than doubled treatment initiation
A digital strategy more than doubled the number of heart failure patients starting a proven medication. These findings from the EMAIL-HF trial were presented at the ESC Congress in August 2026, as reported by the European Society of Cardiology.
Trial lead Dr. Mariam Elmegaard from Herlev and Gentofte University Hospital in Denmark explained the problem. She said adoption of sodium-glucose cotransporter 2 (SGLT2) inhibitors in routine clinical practice is limited, despite their proven benefits. Many patients with longstanding heart failure are no longer followed in specialist clinics, receiving care in general cardiology or primary care instead.
The Digital Strategy Approach
The trial tested a novel digital implementation approach. Researchers used nationwide health registries to identify untreated patients at a population level. They then proactively invited them for a specialist consultation.
In this registry-based randomized trial, all heart failure patients in the Capital Region of Denmark and Roskilde municipality not on SGLT2 inhibitor therapy were identified. Eligible patients were assigned to either the digital strategy or usual care.
Patients in the digital strategy group received a letter via the governmental Digital Post system. It contained information about SGLT2 inhibitors and offered a telephone consultation with a heart failure specialist. During the call, the specialist reviewed the patient's electronic health record to determine if starting an SGLT2 inhibitor was appropriate per current guidelines. The usual care group received no such letter and continued with routine care.
Trial Results and Patient Outcomes
A total of 5,996 patients were randomized. Their mean age was 71 years, and 33% were women. The mean duration of heart failure was around five years, with 40% having a prior heart failure hospitalization. Among those assigned the digital strategy, 60% responded to the invitation and signed up on the platform.
The primary outcome was the initiation of dapagliflozin or empagliflozin within six months. The digital strategy more than doubled this rate.
| Outcome Measure | Digital Strategy Group | Usual Care Group |
|---|---|---|
| Initiation of SGLT2 inhibitor within 6 months | 18.6% | 8.2% |
| Hospitalization for heart failure or death from any cause | 13.0% | 14.0% |
The difference in medication initiation was maintained at 24 months. The secondary outcome of hospitalization for heart failure or death from any cause showed no statistically significant difference between the groups.
Elmegaard commented on the clinical outcomes. "Because only a proportion of patients responded to the invitation and initiated treatment, the difference in SGLT2 inhibitor use between the groups was limited," she said. She noted that a much larger study would have been needed to reliably detect a difference in clinical outcomes based on the observed effect. Safety outcomes were infrequent, with no evidence of excess events in the digital-strategy group.
Implications for Closing the Treatment Gap
Elmegaard stated that the biggest challenge in cardiovascular medicine is often ensuring patients receive proven therapies in a timely manner, not discovering new treatments. This is a common challenge across healthcare, similar to ensuring a team's squad has the right players or that a league's standings accurately reflect performance.
"Our findings show that digital systems can be developed that proactively identify and contact patients who are missing out," she noted. This approach helps more patients receive guideline-recommended treatment without relying on their next hospital visit. She concluded that if adopted more widely, this type of digital strategy could help narrow the gap between medical evidence and the care patients actually receive, much like how consistent stats can help identify areas for improvement in a team's performance.
