Effects of SGLT2i in the perioperative care of cardiac surgery: a systematic review and meta-analysis of randomised controlled trials

Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated cardiovascular and renal protective effects in patients with heart failure and chronic kidney disease, beyond their glucose-lowering properties. In the perioperative setting of cardiac surgery, patients are at increased risk of complications such as cardiac arrhythmias and acute kidney injury (AKI), both of which are associated with worse short and long term outcomes. In this context, new studies have shown benefits of this use, including the association with reduced rates of acute kidney injury and cardiac arrhythmias. However, their impact in the perioperative period remains unclear due to limited and heterogeneous evidence. Purpose This systematic review and meta-analysis evaluated the effects of perioperative use of SGLT2i in patients undergoing cardiac surgery. Methods PubMed, Embase, Scopus and the Cochrane Library were systematically searched through February 2026 for randomised controlled trials (RCTs) comparing SGLT2 inhibitors with placebo or usual care. Eligible studies reported outcomes such as AKI, cardiac arrhythmias, ketoacidosis, and mortality. The results were expressed as risk ratios (RR) with 95% confidence intervals (CI) and were estimated using a random-effects model with the Restricted Maximum Likelihood estimator. All statistical analyses were performed using R (version 4.4.2). Results Four RCTs, comprising 1,234 participants, of whom 613 (49.6%) were assigned to SGLT2i, were included. The mean age was 64.7 years, with approximately 40% having diabetes. The most commonly performed surgery was coronary artery bypass grafting (CABG). Compared with controls, SGLT2i significantly reduced the incidence of AKI (RR 0.52; 95% CI 0.44, 0.62; P < 0.05; I² = 0%). There were no significant differences between groups in arrhythmia (RR 1.14; 95% CI 0.71, 1.81; P = 0.59; I² = 0%), ketoacidosis (RR 3.63; 95% CI 0.50, 26.44; P = 0.2; I² = 0%), and mortality (RR 0.69; 95% CI 0.03, 15.65; P = 0.82; I² = 52%). Conclusion In this meta-analysis, the perioperative use of SGLT2 inhibitors in patients undergoing cardiac surgery was associated with a significant reduction in acute kidney injury but did not demonstrate a significant impact on cardiac arrhythmias or mortality. These findings highlight a potent reno-protective effect of SGLT2 inhibitors in this high-risk population without increasing major adverse events.