Mind The Gap
A CardioAdvocate Phenotype
Mind the Gap
How Lifesaving Heart Therapies Get Lost Between the Trial and the Exam Room
A note to the reader: This article is about a different kind of heart disease — not the one in your arteries, but the one in the system designed to protect them. It is the story of what happens after a drug is proven to save lives. How long does it take for that proof to reach your doctor’s prescription pad? How many committees, insurance forms, and institutional barriers stand between a landmark clinical trial and the patient who needs the drug today? If you have heart failure, type 2 diabetes, kidney disease, or cardiovascular disease, this article will explain why you may not yet be receiving a medication that was proven to help people like you years ago — and what you can do about it. (For the science behind these drugs, see our companion article: The Accidental Cardioprotectors.)
Case Presentation
Robert is a 67-year-old retired electrician with heart failure with preserved ejection fraction (HFpEF), type 2 diabetes, CKD stage 3a, and a BMI of 34. He has been managed by his primary care physician for diabetes (metformin and a sulfonylurea, A1c 7.4%) and by a cardiologist for his heart failure (a loop diuretic and a beta-blocker). He was hospitalized once for decompensated heart failure last year. His cardiologist has never prescribed an SGLT2 inhibitor. His primary care physician has never prescribed a GLP-1 receptor agonist. Neither physician has discussed these options with him. His sulfonylurea was started in 2016 and never reconsidered.
Robert is not an outlier. He is the norm.
By 2026, EMPEROR-Preserved, DELIVER, and the pooled EMPEROR/DELIVER meta-analysis have proven that SGLT2 inhibitors reduce heart failure hospitalization and cardiovascular death across the entire ejection fraction spectrum — including HFpEF, where Robert lives. The 2022 AHA/ACC/HFSA heart failure guidelines gave SGLT2 inhibitors a Class I recommendation (highest level). That was four years ago. Robert still doesn’t have one.
This is the gap.
Flying Under the Radar
Flying Under the Radar
The evidence is in. The patient is still waiting.
In 2011, researchers at the Journal of the Royal Society of Medicine published a landmark analysis asking a simple question: how long does it take for medical research to reach the patient? Their answer — drawn from multiple studies measuring different points in the translational pipeline — was 17 years. On average, it takes 17 years from a research discovery to its implementation in routine clinical practice.
Seventeen years. Not because the science is uncertain. Not because the trials are small. Because the system between the trial and the patient is broken.
The story of SGLT2 inhibitors and GLP-1 receptor agonists is a case study in this failure. These are not marginal drugs with questionable benefit. They are among the most rigorously validated cardiovascular therapies of the past three decades — proven across multiple megatrials, in tens of thousands of patients, for heart failure, atherosclerotic disease, kidney protection, and mortality reduction. They represent a paradigm shift comparable to statins. And yet, as of 2024, fewer than 20% of eligible heart failure patients were receiving an SGLT2 inhibitor, and cardiologists accounted for fewer than 5% of prescriptions for either drug class — despite the primary benefit being cardiovascular.
The patients flying under the radar are everywhere: the heart failure patient whose cardiologist doesn’t prescribe “diabetes drugs.” The diabetic patient whose endocrinologist doesn’t prescribe “heart drugs.” The primary care patient whose physician isn’t familiar with the trial data. The patient whose insurance requires prior authorization and whose prescription was never filled because the process took too long. The patient who was never told these drugs existed.
CardioAdvocate Checklist
For Patients: Are You in the Gap?
For Clinicians: Are You Contributing to the Gap?
Questions to Ask Your Clinician
Deep Dive: The Five Layers of Delay
Layer 1 — Trial to Guideline: The Committee Bottleneck
The EMPA-REG OUTCOME trial reported in September 2015 at the European Association for the Study of Diabetes annual meeting. The results stunned both the diabetes and cardiology communities: empagliflozin reduced cardiovascular death by 38%, heart failure hospitalization by 35%, and all-cause mortality by 32% in patients with type 2 diabetes and established cardiovascular disease. Published simultaneously in the New England Journal of Medicine, it was one of the most striking cardiovascular outcomes of the decade.
The European Society of Cardiology moved fastest, incorporating SGLT2 inhibitors into its 2019 ESC/EASD diabetes and cardiovascular guidelines. But the American guidelines lagged. The AHA/ACC did not issue a Class I recommendation for SGLT2 inhibitors in heart failure until the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — seven years after EMPA-REG.
To be fair, the guideline committees had reasonable arguments for waiting. EMPA-REG was a diabetes trial, not a heart failure trial. The dedicated HF trials — DAPA-HF (2019), EMPEROR-Reduced (2020), EMPEROR-Preserved (2021), DELIVER (2022) — came later and confirmed the benefit directly in heart failure populations. Guidelines are meant to reflect the totality of evidence, not react to single trials.
But here is the question Robert’s story forces us to ask: what happened to the patients between 2015 and 2022? How many people with heart failure were hospitalized — or died — during the seven years that guideline committees deliberated? The trials were positive. The signal was consistent across studies, across molecules, and across populations. And still, the formal endorsement that gives clinicians “permission” to prescribe took seven years to arrive.
Layer 2 — Guideline to Formulary: The Authorization Bottleneck
Even after the 2022 guidelines gave SGLT2 inhibitors a Class I recommendation, insurance barriers remained formidable. A 2026 study from NYU Langone Health examining prescription fill patterns for heart failure medications found that patients whose SGLT2 inhibitor prescriptions required prior authorization were twice as likely to never fill them, and those who did fill them took six times as long to do so compared to patients without prior authorization requirements.
The same study documented that prior authorization was more common among patients living in lower socioeconomic-status neighborhoods and among those who identified as Black or Hispanic. Patients facing these requirements were more likely to have Medicaid insurance. In other words, the very populations who bear the highest burden of heart failure and diabetes — and who would benefit most from these medications — face the greatest barriers to receiving them.
For years, many insurance plans classified SGLT2 inhibitors as “diabetes drugs” and required documented failure of metformin or a sulfonylurea before approving them — even for patients whose primary indication was heart failure, not blood sugar control. Some plans required A1c documentation even for non-diabetic heart failure patients, creating an absurd Catch-22: the drug was prescribed for the heart, but the insurance company wanted proof that the patient’s blood sugar was high enough to justify it.
The cost barrier compounds the problem. Without insurance coverage, brand-name SGLT2 inhibitors can cost $500–600 monthly out-of-pocket. For a retiree like Robert on a fixed income, this is prohibitive. Generic dapagliflozin has improved access since 2025, but many patients were lost during the years when cost was a wall.
Layer 3 — Formulary to EHR: The Alert Bottleneck
In modern medicine, the electronic health record is where care decisions are made. Epic, Cerner, and other EHR systems have the capability to fire Best Practice Alerts (BPAs) — clinical decision support tools that notify a physician when a patient meets criteria for a specific intervention. A well-designed BPA might say: “This patient has heart failure with EF <40% and is not on an SGLT2 inhibitor. Consider initiating dapagliflozin or empagliflozin.”
The technology exists. The guidelines support it. But implementation has been glacial. Building, validating, and deploying BPAs requires institutional buy-in from IT departments, pharmacy committees, quality officers, and clinical leadership. Each health system makes its own decisions about which alerts to build. There is no national mandate. The result is a patchwork: some academic medical centers have implemented SGLT2i BPAs; many community hospitals have not. Many primary care practices — where the majority of diabetic patients receive care — have no such alerts at all.
The irony is that EHR systems already fire alerts for far less consequential things. Physicians are bombarded with alerts about drug–drug interactions that rarely matter, duplicate order warnings, and documentation reminders. Alert fatigue is real — clinicians dismiss the majority of alerts they receive. But the solution is not fewer alerts; it is better alerts. An alert for a Class I therapy in an eligible patient who isn’t receiving it is exactly the kind of alert that should exist.
Layer 4 — EHR to Prescription Pad: The Inertia Bottleneck
This is perhaps the most uncomfortable layer, because it implicates the physicians themselves.
A 2020 survey of cardiology, endocrinology, and primary care providers at Duke University Health System found that over 80% of cardiology providers had never prescribed an SGLT2 inhibitor or GLP-1 receptor agonist. The stated reasons were revealing: lack of knowledge about the medications, concerns about “introducing confusion into the diabetes care plan,” and — most tellingly — a sentiment that it is not a cardiologist’s responsibility to prescribe “diabetes medications.”
A parallel survey of 103 consultant cardiologists in the United Kingdom found that only 30% felt very familiar with SGLT2 inhibitor cardiovascular outcomes data, and only 11% believed that cardiologists were best suited to deliver diabetes treatment to a patient with acute coronary syndrome and type 2 diabetes. Only 5% would initiate a guideline-recommended SGLT2 inhibitor or GLP-1 RA for that patient. The rest preferred to refer to a diabetes specialist.
The ACC’s 2021 expert analysis by Adhikari and Blaha put the numbers starkly: among patients with type 2 diabetes and cardiovascular disease at the University of Mississippi Medical Center, only 1.4% received an SGLT2 inhibitor and only 1.6% a GLP-1 RA. Cardiologists accounted for just 6% of SGLT2i prescriptions and 1% of GLP-1 RA prescriptions. Primary care physicians wrote the majority — but even they were prescribing at extremely low rates.
The problem is a specialty silo. Cardiologists think these are “diabetes drugs” and therefore someone else’s responsibility. Endocrinologists think heart failure management belongs to cardiology. Primary care physicians may not be following the cardiovascular outcomes trial literature closely enough to recognize the paradigm shift. The patient falls through the crack between three specialties, each assuming the other will act.
As the ACC authors noted: a patient with T2D and CVD is four times less likely to encounter an endocrinologist than a cardiologist in a given year. Cardiologists see these patients regularly. They are positioned to prescribe. They simply choose not to.
Layer 5 — Prescription to Patient: The Last Mile
Even when a physician writes the prescription, the patient may never take the drug. Cost remains a barrier even with insurance: copays, deductibles, and coverage gaps create out-of-pocket burdens. Side effects — real or feared — drive discontinuation. GLP-1 receptor agonists require weekly subcutaneous injection, which some patients resist. Gastrointestinal side effects (nausea, diarrhea) during dose titration cause early dropouts. And perhaps most importantly, many patients simply do not understand why the drug was prescribed. A patient told “this is for your diabetes” when their A1c is 6.8% may reasonably wonder why they need another medication. Without understanding the cardiovascular rationale, adherence falters.
Patient education is the final bridge. If a physician says: “This drug was proven in a trial of 17,000 people to reduce your risk of dying from heart disease by 20%, independent of what it does to your blood sugar” — that is a fundamentally different conversation than “I’m adding another diabetes medication.” Framing matters. Context matters. And in the 12-minute appointment that defines modern medicine, this conversation is often the first thing cut.
The Statin Parallel: We Have Done This Before
If the SGLT2i/GLP-1RA story sounds familiar, it should. Statins traveled the same road.
The Scandinavian Simvastatin Survival Study (4S), published in The Lancet in November 1994, was the first trial to prove that a statin reduced mortality. Simvastatin lowered LDL cholesterol by 35% and reduced total mortality by 30% in patients with coronary heart disease. It was landmark. It should have changed practice overnight.
It did not. A 2001 analysis in the Canadian Medical Association Journal examined whether the major statin trials actually changed prescribing behavior. The authors found that while simvastatin prescribing increased after 4S, the magnitude was modest — approximately 4,200 additional prescriptions per month. In the years following 4S, CARE (1996), and LIPID (1998), surveys revealed a “wide therapeutic gap” between the scientific evidence and clinical practice in secondary prevention of coronary heart disease. Most eligible patients were not receiving statins.
A study of statin prescribing trends from 1994 to 2001 in the UK documented a gradual, multi-year ramp-up that only accelerated after repeated guideline updates, generic availability, and sustained educational campaigns. The pattern — landmark trial, slow uptake, specialty resistance, gradual adoption over a decade — mirrors exactly what we are seeing with SGLT2 inhibitors and GLP-1 receptor agonists today.
The statin story eventually had a happy ending. By the mid-2000s, aggressive lipid lowering became standard of care, driven by guidelines (ATP III, then the 2013 ACC/AHA cholesterol guidelines), generic availability, and a generation of clinicians who grew up with the evidence. But it took more than a decade. How many patients suffered cardiovascular events during those lost years?
The Numbers: Where We Stand Now
As of mid-2023 — the most recent nationally representative data available — the prescribing picture for SGLT2 inhibitors in heart failure looks like this:
| Setting | Time Period | SGLT2i Use Rate | Source |
|---|---|---|---|
| Ambulatory cardiovascular care | Q3 2019 | 4.6% | US Pharmacist 2024 |
| Ambulatory cardiovascular care | Q2 2023 | 16.2% | US Pharmacist 2024 |
| Hospitalized heart failure | Jul–Sep 2021 | 4.2% | Medscape 2024 |
| Hospitalized heart failure | Jul–Sep 2023 | 23.5% | Medscape 2024 |
| T2D + CVD (academic center) | Jan 2013–Jun 2019 | 1.4% | ACC/Blaha 2021 |
Progress is real. The trend line is moving in the right direction. But consider the denominator: these are patients with Class I indications — meaning the guidelines say they should be on this drug. Reaching 16–24% adoption more than eight years after EMPA-REG and four years after a Class I guideline recommendation is not a success story. It is a measure of how much work remains.
For comparison, statin use among eligible secondary prevention patients eventually exceeded 70–80% — but it took well over a decade to get there. If SGLT2 inhibitors follow the same trajectory, we may not reach optimal prescribing rates until the 2030s. That is patients lost, hospitalizations not prevented, and money spent on avoidable acute care.
Why This Matters: The Mission of CardioAdvocate
This article exists because the problem it describes is the reason CardioAdvocate exists.
Our mission is to close the gap between what medical science has proven and what patients actually receive. Every article on this site — from The Accidental Cardioprotectors (the science) to The Sweet Spot (diabetes management) to See No Evil (obesity) — is written because the evidence says one thing and the average patient’s care says another.
The five layers of delay described in this article are not abstract. They are the reason your father is still on a sulfonylurea instead of an SGLT2 inhibitor. They are the reason your mother’s cardiologist has never mentioned semaglutide despite her obesity and HFpEF. They are the reason a 67-year-old retired electrician named Robert has been hospitalized for heart failure when a $15-per-month generic could have prevented it.
Advocacy is not a political word. It is a medical one. It means making sure the patient gets what the evidence says they deserve.
The Bottom Line
The Bottom Line
The gap between what clinical trials have proven and what patients actually receive is the defining failure of modern medicine. It is not a failure of science. The trials have been done. The evidence is overwhelming. SGLT2 inhibitors and GLP-1 receptor agonists save lives, prevent hospitalizations, protect kidneys, and reduce cardiovascular events — and they do it across the board, in diabetics and non-diabetics alike.
The failure is in the pipeline between the evidence and the patient. It is in guidelines that take seven years to update. It is in insurance companies that require prior authorization for drugs that guideline committees call mandatory. It is in electronic health records that lack the alerts to prompt physicians. It is in specialty silos where cardiologists won’t prescribe “diabetes drugs” and endocrinologists won’t prescribe “heart drugs.” It is in a 12-minute office visit that leaves no time to explain why a new medication matters.
You do not have to accept this. If you have heart failure, diabetes, CKD, or obesity with cardiovascular risk — and you are not on an SGLT2 inhibitor or GLP-1 receptor agonist — ask why. Bring this article. Bring the checklist. Ask for the peer-to-peer appeal if insurance says no. The evidence is on your side.
Mind the gap. Then close it.
CardioAdvocate helps people understand what matters — and how to speak up about it.
