NICE Heart Failure Update (NG106): SGLT2 Inhibitors Now Span the Ejection-Fraction Spectrum

NICE updated NG106, its guideline on chronic heart failure in adults, on 3 September 2025. It is a more substantial update than it first looks. NICE amended the treatment of heart failure with reduced ejection fraction and, for the first time, added drug recommendations for mildly-reduced and preserved ejection fraction.

The through-line is SGLT2 inhibitors. A class that arrived in heart failure care as an add-on for reduced ejection fraction now has a place across the whole ejection-fraction spectrum. For preserved ejection fraction — long the hardest form to treat — there is finally something to offer beyond managing comorbidities and congestion.

This post is a plain-English summary for busy clinicians. The authoritative source is the NICE guideline itself. We summarise; we do not replace NICE, and nothing here substitutes for clinical judgement on an individual patient.

The headline change

Heart failure is classified by left ventricular ejection fraction: reduced (40% or below), mildly reduced (41 to 49%), and preserved (50% or above). Until this update, NICE's disease-modifying drug recommendations sat almost entirely with the reduced group. The 2025 update changes that.

• Reduced ejection fraction keeps its four-drug foundation, now stated as a single combination to offer rather than a sequence to build.
• Mildly-reduced ejection fraction (41 to 49%) — consider the same four drugs: an ACE inhibitor, a beta-blocker, an MRA and an SGLT2 inhibitor.
• Preserved ejection fraction (50% or above) — consider an MRA and an SGLT2 inhibitor.

The preserved-ejection-fraction recommendation is the one to notice. It is a large group, common in older and multimorbid patients, and one that previous guidance left with little to change the natural history. An SGLT2 inhibitor and an MRA is now a concrete offer.

The essentials, refreshed

Diagnosis

NICE diagnoses heart failure on NT-proBNP plus specialist assessment and echocardiography, with the referral urgency set by the NT-proBNP level.

• Above 2,000 ng/L — refer urgently; specialist assessment and echocardiography within 2 weeks.
• 400 to 2,000 ng/L — refer for specialist assessment and echocardiography within 6 weeks.
• Below 400 ng/L in an untreated person makes heart failure less likely, though it does not exclude it — and levels can be lower in obesity and with some drugs.

Treatment by ejection fraction

• Reduced (≤40%) — offer all four: an ACE inhibitor, a beta-blocker, an MRA and an SGLT2 inhibitor. If the ACE inhibitor is not tolerated, an ARNI takes its place; with angioedema, offer a beta-blocker, MRA and SGLT2 inhibitor and consider an ARB.
• Mildly reduced (41 to 49%) — consider the same four-drug combination.
• Preserved (≥50%) — consider an MRA and an SGLT2 inhibitor.

The SGLT2 inhibitors licensed in heart failure are dapagliflozin and empagliflozin; confirm the current licensed indication and dose against the BNF before prescribing.

Monitoring

• Renal function and electrolytes — before starting an ACE inhibitor, ARB, ARNI or MRA; again 1 to 2 weeks after starting and after each dose increase; then every 3 to 6 months when stable. Act on a creatinine rise over 50% or a potassium above 5.5 mmol/L.
• Beta-blockers — a 12-lead ECG before starting; review heart rate and clinical status after each increment.
• A comprehensive review at least every 6 months for stable patients: functional capacity, fluid status, rhythm, medication, renal function, and iron status.

What it means in practice

For primary and community care, the practical shift is the preserved-ejection-fraction group. A patient with breathlessness, a preserved ejection fraction on echocardiography, and no disease-modifying therapy is now a patient for whom NICE suggests considering an SGLT2 inhibitor and an MRA — with the usual renal and potassium monitoring.

It also confirms where SGLT2 inhibitors have landed: no longer a diabetes drug that turned out to help the heart and kidney, but a cross-cutting cardio-renal-metabolic therapy. The same class runs through our summaries of SGLT2 inhibitors in chronic kidney disease and the 2026 NICE NG28 diabetes update, where the same drugs do overlapping work. When one class earns a place in three guidelines at once, the monitoring and the contraindications are worth knowing cold.

A one-line guideline change — "consider an SGLT2 inhibitor for preserved ejection fraction" — is exactly the kind of update that reshapes a common consultation without making headlines. A weekly read of what actually changed is how it becomes practice rather than a note you meant to act on. That is what we built The Monday Clinical Brief to do.