Digital trial doubles heart-failure drug starts in Denmark

A letter arriving in Denmark’s governmental Digital Post system became the first step toward a specialist call for thousands of people living with heart failure. In the EMAIL-HF trial, a registry-based digital strategy identified patients not receiving SGLT2 inhibitors and more than doubled treatment initiation: 18.6% received dapagliflozin or empagliflozin within six months, compared with 8.2% under usual care.

The trial was led by Dr. Mariam Elmegaard at Herlev and Gentofte University Hospital in Copenhagen. It enrolled 5,996 patients with heart failure in Denmark’s Capital Region and the municipality of Roskilde. Their mean age was 71 years, 33% were women, and the mean duration of heart failure was around five years. Forty percent had previously been hospitalized for the condition.

The system’s intervention was deliberately simple. The registry located untreated patients; the digital letter explained SGLT2 inhibitors and offered a telephone consultation. During that call, a heart-failure specialist reviewed the patient’s electronic health record and decided whether starting treatment was appropriate under current ESC Guidelines. Patients assigned to usual care received no digital letter and continued with routine care. The difference in treatment initiation remained at 24 months.

Concretely, the strategy gives health systems a way to find patients who may not return to a specialist heart-failure clinic and put a clinical conversation in front of them before their next hospital visit. That matters for people whose care has shifted to general cardiology or primary care, and for clinicians trying to close the gap between proven treatments and everyday prescribing without waiting for a hospitalization.

The result is encouraging but narrower than a mortality claim. The combined outcome of hospitalization for heart failure or death from any cause occurred in 13.0% of the digital-strategy group and 14.0% of the usual-care group, a difference that was not statistically significant. Only 60% of invited patients responded and signed up, limiting the difference in SGLT2 inhibitor use between groups. Safety outcomes were infrequent, with no evidence of excess events in the digital group; a much larger study would have been needed to reliably detect an effect on clinical outcomes.