Digital registry strategy doubles heart failure treatment uptake

A registry-based digital strategy that identified untreated patients and invited them to a telephone consultation more than doubled implementation of an effective type of heart failure treatment. These results from the EMAIL-HF trial were presented in a Hot Line session today at ESC Congress 2026.

Affecting more than 64 million individuals worldwide, heart failure is a major public health issue that is associated with high mortality and morbidity, poor quality of life and high healthcare utilization and costs.

Trial lead, Doctor Mariam Elmegaard from Herlev and Gentofte University Hospital, Copenhagen, Denmark, explained why the EMAIL-HF trial was carried out: "Sodium–glucose cotransporter 2 (SGLT2) inhibitors have proven benefits in the treatment of heart failure and yet, as with many evidence-based therapies, adoption in routine clinical practice is limited."

She noted that the implementation of new therapies such as SGLT2 inhibitors can be particularly challenging in patients with longstanding heart failure. 

Many of these patients are no longer followed in specialist heart failure clinics, but receive care in general cardiology, primary care or other nonspecialist settings."

Doctor Mariam Elmegaard, Herlev and Gentofte University Hospital, Copenhagen, Denmark

Doctor Elmegaard and collaborators tested a novel digital implementation approach, investigating whether SGLT2 inhibitor therapy could be increased by using nationwide health registries to identify untreated patients at the population level and proactively invite them for a specialist consultation.

In this investigator-initiated, registry-based randomized trial, all patients with heart failure in the Capital Region of Denmark and the municipality of Roskilde who were not receiving SGLT2 inhibitor therapy were identified. Eligible patients were assigned to a digital strategy or usual care. Patients randomized to the digital strategy were sent a letter through the governmental Digital Post system with information about SGLT2 inhibitors and were offered a telephone-based consultation with a heart failure specialist. During the consultation, the specialist reviewed the patient's electronic health record and determined whether initiation of an SGLT2 inhibitor was appropriate according to current ESC Guidelines. Patients assigned to usual care did not receive the digital letter and continued to receive routine care. 

A total of 5,996 patients were randomized who had a mean age of 71 years and 33% were women. The mean duration of heart failure was around five years and 40% of patients had previously been hospitalized for heart failure. Among patients assigned to the digital strategy, 60% responded to the invitation and signed up on the digital platform. 

The main finding was that initiation of SGLT2 inhibitor therapy more than doubled with the digital strategy. The primary outcome of initiation of dapagliflozin or empagliflozin within six months occurred in 18.6% of patients in the digital-strategy group and 8.2% in the usual-care group (p<0.001). The difference was maintained at 24 months. 

The secondary outcome of hospitalization for heart failure or death from any cause occurred in 13.0% of patients in the digital-strategy group and 14.0% in the usual-care group (p=0.276). Doctor Elmegaard said: "Because only a proportion of patients responded to the invitation and initiated treatment, the difference in SGLT2 inhibitor use between the groups was limited. Based on the observed effect on the clinical outcomes, a much larger study would have been needed to reliably detect a difference." 

Safety outcomes were infrequent, with no evidence of excess events in the digital-strategy group. 

Doctor Elmegaard ended by saying that the biggest challenge in cardiovascular medicine is often not discovering new treatments, but making sure patients receive proven therapies in a timely manner. "Our findings show that digital systems can be developed that proactively identify and contact patients who are missing out, helping more patients to receive guideline-recommended treatment in a timely manner, without relying on their next hospital visit or hospitalization," she noted, concluding, "If adopted more widely, this type of digital strategy could help narrow the gap between medical evidence and the care patients actually receive."