The treatment approach to type 2 diabetes (T2D) should begin with an assessment of atherosclerotic cardiovascular disease (ASCVD). Sodium-glucose cotransporter-2 inhibitors (SGLT2i) should be considered in T2D with established ASCVD or heart failure (HF). In this study, we analyzed the prescription patterns of ant-diabetic treatment in T2D with ASCVD or HF in real-world clinical practice. During 1-year period (2018), we reviewed 1553 consecutive T2D patients with ASCVD or HF visiting an endocrinology outpatient clinic from four teaching hospitals in Seoul Capital Area after excluding patients aged โฅ85 years or estimated glomerular filtration rate (eGFR) โค30 ml/min/1.73m2. Mean age was 65 years, duration of diabetes 11 years, and duration of ASCVD 7 years; HbA1C 7.5%, eGFR 80 ml/min/1.73m2, and body mass index (BMI) 25.6 kg/m2. ASCVD characteristics were stroke 27%, coronary artery disease (CAD) 59%, stroke+CAD 5%, peripheral arterial occlusive disease 1%, and heart failure 8%. Over four years, the initiation of SGLT2i has increased (2015=9% vs. 2018=42%). Compared with SGLT2i non-users (80%, n=1249), SGLT2i users (20%, n=304) tended to be younger (60 vs. 67) and with significantly lower stroke (16% vs. 30%). They also had higher BMI (27 vs. 25), worse HbA1C levels (8.1 vs. 7.4), and higher eGFR (88 vs. 78). Non-users with HbA1C 8 โผ9% (n=245) who might be eligible for switching to SGLT2i showed a longer duration of diabetes (14 vs. 11 years) or ASCVD (7.4 vs. 6.5 years) compared to users. The most common prescription pattern in non-users was triple oral glucose-lowering drugs (OGLD) followed by dual OGLD while in users, dual OGLD followed by triple OGLD. Interestingly, 0.5% were on GLP-1RA in this study. In contrast to clinical guidelines, a small proportion of T2D with ASCVD or HF is currently treated with SGLT2i in real-world clinical practice. The limiting factors for failing to initiate SGLT2i are age, stoke, eGFR, and clinical inertia. Disclosure S. Jeong: None. I. Park: None. S. Lee: None. D. Shin: None. K. Kim: None.