EMAIL-HF Trial: Registry Digital Outreach Doubles SGLT2 Inhibitor Initiation to 18.6% in Untreated Heart Failure Patients

Investigators used nationwide Danish health registries to identify all untreated heart failure patients in two regions, randomizing them to usual care or a proactive digital invitation via governmental post offering a telephone review by a heart failure specialist. Of those invited, 60% engaged, leading to guideline-directed starts of dapagliflozin or empagliflozin. The primary endpoint of therapy initiation within six months more than doubled, with the gap persisting at 24 months and no safety signals.

Clinical outcomes showed no significant difference in heart failure hospitalization or death (13.0% digital versus 14.0% usual care), consistent with the modest absolute uptake gain and the trial's limited power. This highlights the persistent implementation gap for SGLT2 inhibitors despite clear benefits established in trials such as DAPA-HF, where adoption lags especially outside specialist clinics.

The approach addresses a key barrier: many chronic heart failure patients receive care in primary or general settings without routine specialist review. Similar registry-driven nudges have succeeded in other cardiovascular domains but rarely at population scale for longstanding disease.

Larger multicenter trials powered for hard endpoints and cost-effectiveness analyses are required before broad rollout; replication in systems without centralized registries will test generalizability.