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Shamliyan et al. Vessel Plus 2020;4:35 I http://dx.doi.org/10.20517/2574-1209.2020.34 Page 9 of 13

in these patients [92,93] . Diabetes care should be provided by multidisciplinary teams of endocrinologists,
cardiologists and nephrologists and include assessment of HFpEF and consequent decisions of the best
treatment choices [5,6,94,95] .

Inconsistency in clinical research and practice policies, market approval, and coverage decisions across
countries preclude universal patient access to the optimal treatment options [96-98] . Harmonization of health
technology assessments methodology and data sharing across the countries would improve the quality of
care in patients with heart failure and specifically HFpEF [99,100] . The International Network of Agencies for
Health Technology Assessment calls for transparency in evidence collection, data sharing, and consistent
[101]
evidence appraisal to improve patient outcomes across the globe .
Our work has implications for future research. The emerging epidemic of diabetes, arterial hypertension
and HFpEF requires international efforts in improving the quality of evidence and the quality of
healthcare [10,26,40] . Professional associations and health technology assessment groups need to collaborate in
the development of consensus definitions of HFpEF, in prospective design of high quality powered RCTs
in adults with various phenotypes and underlying causes of HFpEF. Individual patient data meta-analyses
of completed RCTs and registries of medical records can shed light on optimal treatment choices in adults
with HFpEF [102-105] .

In conclusion, existing evidence is insufficient to support definitive clinical recommendations for use of
SGLT2- Inhibitors in adults with HFpEF. Future research should employ consistent definitions of HFpEF
and examine the effects from SGLT2- Inhibitors in patients with various HFpEF phenotypes and underlying
causes.

DECLARATIONS
Authors’ contributions
Designed review protocol, research questions and performed data analysis and interpretation: Shamliyan
TA
Conceptualized study objectives and goals and contributed to data analysis and interpretation: Aronow WS
Contributed to study design and execution, data analysis and interpretation: Avanesova AA
Made substantial contributions to the writing of the manuscript: Shamliyan TA, Avanesova AA, Aronow
WS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020.