Perioperative dapagliflozin in diabetic patients undergoing cardiac surgery: the DAPA-CS trial

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated profound cardioprotective and renoprotective effects in chronic disease management.1,2 Theoretically, their pleiotropic effects, including inflammation modulation, oxidative stress reduction, and metabolic reprogramming, may confer perioperative benefits in cardiac surgery.2 However, whether SGLT2i provide rapid cardiorenal protection in the acute perioperative setting remains unexplored. Current guidelines recommend discontinuing SGLT2i 3–4 days before surgery to prevent diabetic ketoacidosis (DKA),3 based on case reports submitted to the FDA rather than systematic perioperative data.4 However, abrupt withdrawal may lead to adverse outcomes and deprive high-risk patients of potential organ protection.5 The necessity and timing of perioperative discontinuation remain controversial.5 We initiated the DAPA-CS (Dapagliflozin Therapy in Cardiac Surgery) randomized, open-label, blinded-endpoint trial to provide the first evaluation of the efficacy and safety of perioperative dapagliflozin in diabetic patients undergoing on-pump cardiac surgery. Eligible participants were adults with type 2 diabetes scheduled for elective on-pump cardiac surgery. Key exclusion criteria included current or recent use of SGLT2i, a history of DKA, and severe renal impairment.