Evidence, Controversies, and Practical Progress of Early Initiation of SGLT2 Inhibitors in Hospitalized Patients With Acute Heart Failure

Admission for acute heart failure (AHF) represents a critical therapeutic window for intervention. Conventional therapies centered on maintaining hemodynamic balance fail to improve patients' long-term prognosis. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) constitute a pivotal therapeutic agent for heart failure (HF), and the timing and dosing strategies for their early administration after hospitalization have become a major research focus. This review summarizes the evidence base, major controversies, and real-world clinical application regarding the early use of SGLT2is in patients with AHF. Our previous research demonstrated that early initiation of SGLT2i therapy following clinical stabilization significantly improves clinical outcomes and reduces HF readmission, representing an innovative therapeutic strategy. Prior work from our research group also indicated that kidney-tonifying and blood-activating prescriptions can ameliorate myocardial energy metabolism, alleviate inflammatory responses, and mitigate myocardial fibrosis, identifying a promising therapeutic target for HF treatment. Nevertheless, several debates persist in routine clinical practice, including the definition of the "early" initiation window, patient selection criteria (particularly assessment of hemodynamic stability), risks of hypovolemia, and diabetic ketoacidosis. Recent international guidelines recommend initiating SGLT2is promptly once patients with HF achieve clinical stability. Successful implementation relies on establishing a multidisciplinary in-hospital initiation pathway, enhancing patient education, and optimizing transitional care communication after hospital discharge. SGLT2i therapy yields substantial net clinical benefits when administered to patients with AHF. Future research priorities should include generating evidence for special populations such as elderly patients and those with multiple comorbidities, long-term evaluation of hard clinical endpoints, cost-effectiveness analyses, and the development of individualized precision diagnosis and treatment strategies.