I read with great interest the article by Andrade et al. on real-world dapagliflozin treatment patterns in Portuguese patients with heart failure (HF) with reduced ejection fraction (HFrEF) (Rev Port Cardiol. 2026;45(1):13–21).1 The growing incorporation of sodium–glucose cotransporter-2 (SGLT2) inhibitors into routine HF care means these registry-based analyses are highly relevant, particularly as clinicians strive to translate randomized trial evidence into everyday practice.

The authors provide important descriptive data regarding prescribing patterns and tolerability. Nevertheless, certain aspects merit further reflection. While observational data appropriately capture pragmatic clinical decision-making, additional clarification regarding baseline functional class and comorbidity burden would strengthen interpretation. In the DAPA-HF trial, the magnitude of benefit with dapagliflozin varied across patient risk profiles.2 Without a clear stratification of New York Heart Association class or baseline natriuretic peptide levels, it is difficult to contextualize the external validity of the present findings relative to controlled trial populations.

Furthermore, the optimization status of background guideline-directed medical therapy deserves attention. Contemporary HF management emphasizes foundational quadruple therapy – including angiotensin receptor–neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors – initiated in a timely and coordinated fashion.3 Clarifying whether dapagliflozin was introduced before, during, or after titration of other agents would offer insight into therapeutic sequencing in real-world Portuguese practice.

Although tolerability outcomes were reassuring, a more granular discussion of renal function trajectories and volume-related adverse events would enhance clinical applicability. SGLT2 inhibitors exert modest diuretic and hemodynamic effects, and real-world renal dynamics sometimes differ from trial settings, particularly among elderly or multimorbid cohorts.4 This information would help clinicians anticipate and manage early physiological changes after initiation.

Finally, longer-term follow-up assessing hospitalization rates or cardiovascular mortality would provide complementary outcome data. While short-term registry observations are informative, outcome-oriented evidence remains central to evaluating therapeutic impact beyond surrogate or prescribing metrics.

Despite these considerations, the study represents an important national contribution. Real-world data remain essential to bridge the gap between controlled trial environments and heterogeneous patient populations encountered in daily cardiology practice. Further multicenter prospective registries with standardized data capture may consolidate understanding of treatment implementation patterns and outcome trajectories in HFrEF.