Early in-hospital initiation of SGLT2 inhibitors in acute decompensated heart failure and after myocardial infarction: A narrative review

Sodium–glucose cotransporter 2 (SGLT2) inhibitors reduce cardiovascular death and heart failure (HF) events across the whole spectrum of ejection fraction, and their benefit emerges within weeks of the first dose. This has moved the clinical question from whether to use them to when to start them. Hospitalization for acute decompensated HF and the early period after acute myocardial infarction (AMI) are the moments of highest absolute risk, and also the moments when a drug that is not prescribed is most likely never to be prescribed at all. This narrative review examines the randomized evidence for starting SGLT2 inhibitors during the index admission. In acute decompensated HF, the EMPA-RESPONSE-AHF, SOLOIST-WHF, EMPULSE and DICTATE-AHF trials show consistently that in-hospital initiation is safe, improves decongestion and diuretic efficiency, improves symptoms and health status and, in the larger trials, reduces subsequent HF events. DAPA ACT HF-TIMI 68, the largest dedicated trial, did not significantly reduce cardiovascular death or worsening HF at two months, although its prespecified meta-analysis of patients hospitalized for HF showed a significant reduction in both that composite and all-cause death. After AMI, EMMY showed a greater fall in N-terminal pro-B-type natriuretic peptide and more favourable left ventricular remodelling, DAPA-MI improved a hierarchical cardiometabolic composite without affecting death or HF hospitalization, and EMPACT-MI did not meet its primary endpoint, although first and total HF hospitalizations were reduced. Taken together, the evidence supports initiation before discharge in patients hospitalized for HF once they are haemodynamically stable, and an indication-driven rather than infarction-driven approach after AMI. Practical aspects of initiation are also reviewed.