Early Initiation of Sodium-Glucose Cotransporter 2 Inhibitors in Acute Heart Failure: A Systematic Review and Meta-Analysis.

Summary

Across seven RCTs (n=2320), starting SGLT2 inhibitors before discharge or within 3 days significantly reduced all-cause mortality (OR 0.71) and heart failure rehospitalization (OR 0.73). Safety outcomes were inconclusive due to low event rates.

Key Findings

• Early SGLT2i reduced all-cause death (OR 0.71; 95% CI 0.55–0.92).
• Early SGLT2i reduced HF rehospitalizations (OR 0.73; 95% CI 0.57–0.94).
• Efficacy persisted in sensitivity analysis limited to pre-discharge initiation.
• Safety endpoints were underpowered due to low event rates; diabetic-status subgroup effects remain unclear.

Clinical Implications

Consider initiating SGLT2 inhibitors before discharge for most AHF patients (with usual contraindication checks), incorporating early-start pathways into inpatient heart failure care.

Limitations

• Safety endpoints inconclusive due to low event rates and wide confidence intervals
• Limited data to assess effect modification by diabetes status

Future Directions

Large, pragmatic RCTs with standardized early-start protocols and robust safety adjudication are needed, including subgroup analyses by diabetes status and AHF phenotype.