Effect of Empagliflozin on Left Ventricular Myocardial Perfusion and Systolic Wall Stress Among Patients with Type 2 Diabetes

Background Sodium-glucose cotransporter 2 inhibitors improve cardiovascular and heart failure outcomes. Prior studies using SPECT and PET showed SGLT2i did not alter myocardial flow reserve. We aimed to confirm these findings using cardiac MRI (cMRI) technology, building on the results of the EMPA-HEART CardioLink-6 trial. This post-hoc analysis used cMRI to determine whether empagliflozin improves resting left ventricular (LV) perfusion among patients with type 2 diabetes mellitus (T2DM) and established coronary artery disease (CAD). Secondary objectives were to assess for the effect of empagliflozin on LV wall stress. Methods Eighty adult patients with established coronary artery disease and type 2 diabetes were randomized to 6 months of empagliflozin 10 mg/day versus placebo. Using cardiac MRI, myocardial first pass perfusion global indices including: maximum slope, perfusion index, time to maximum slope and maximum signal intensity were measured by an independent reader. Results Six months of empagliflozin did not significantly alter maximum slope (p=0.27), perfusion index (p=0.210), time to maximum slope (p=0.96) or maximum signal intensity (p=0.17). There was no heterogeneity of effect in relation to baseline perfusion measurements. There was a significant reduction in end systolic wall stress in the empagliflozin group versus placebo (p=0.0098). Conclusion Six months of empagliflozin therapy in persons with T2DM and pre-existing CAD did not alter resting global LV myocardial perfusion but decreased wall stress, as assessed by CMR, confirming similar findings from prior studies using other imaging modalities.