Temporal trends and clinical predictors of GLP-1 receptor agonist and SGLT2 inhibitor use after myocardial infarction among patients with type 2 diabetes

Background Patients with myocardial infarction (MI) are at high risk of adverse outcomes, including mortality. Individuals with type 2 diabetes (T2D) are particularly vulnerable due to accelerated atherosclerosis, endothelial dysfunction, chronic inflammation and enhanced platelet activity, all of which contribute to an elevated risk of adverse events following MI. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated cardiovascular risk reduction in patients with T2D and established atherosclerotic cardiovascular disease. Purpose To assess temporal trends and clinical predictors of GLP-1 RA and SGLT2 inhibitor prescription among patients with T2D hospitalised for MI in a contemporary nationwide cohort. Methods Using the Swedish MI Registry (SWEDEHEART) and the National Diabetes Register, we identified patients with T2D admitted with MI between 1 January 2006 and 16 September 2025. Ongoing therapy prior to admission and new prescriptions for GLP-1 RAs and SGLT2 inhibitors dispensed from discharge up to one year thereafter were evaluated, including combination therapy. Trends were analysed by calendar year and stratified according to periods before and after the 2019 European Society of Cardiology (ESC) diabetes guideline update, which followed pivotal cardiovascular outcomes trials of GLP-1 RAs and SGLT2 inhibitors. Multivariable logistic regression was used to identify predictors of treatment, adjusting for demographics, socioeconomic factors, comorbidities, renal function and in-hospital characteristics. Results Among 78,719 patients with MI and T2D, use of both drug classes increased over time. GLP-1 RA use was <1% before 2010, increased modestly during 2015–2018, and rose after 2019, reaching 23% in 2025. SGLT2 inhibitor use was negligible before 2013, increased to 20–30% during 2018–2020, and reached 73% in 2025. Combination therapy with SGLT2 inhibitors and GLP-1 RAs also increased progressively, particularly after 2019 (Figure 1). Higher body mass index and younger age were associated with a greater likelihood of GLP-1 RA prescription, whereas reduced left ventricular systolic function was associated with SGLT2 inhibitor prescription (Figure 2). Conversely, older age and lower educational level were associated with lower prescription rates for both drug classes. Conclusions In this nationwide cohort of patients with MI and T2D, the uptake of GLP-1 RAs and SGLT2 inhibitors increased markedly following publication of cardiovascular outcome trials and subsequent ESC guideline updates. However, a substantial proportion of high-risk patients remain untreated with these drugs, and initiation of therapy appears to be influenced by age, educational level and comorbidity burden. Strategies to reduce residual gaps and inequities in cardioprotective diabetes therapies after MI are warranted with the potential to significantly reduce residual cardiovascular risk.Figure 1Figure 2