In-hospital initiation of SGLT2 inhibitors in acute heart failure significantly reduced all-cause death (RR 0.61; 95% CI 0.47-0.81) and worsening HF events (RR 0.67; 95% CI 0.48-0.94).
Meta-Analysis (n=4,096)
Does in-hospital initiation of SGLT2 inhibitors reduce all-cause death and worsening heart failure in patients with acute heart failure?
In-hospital initiation of SGLT2 inhibitors in patients with acute heart failure significantly reduces short-term all-cause mortality and worsening heart failure events without increasing adverse safety events.
Effect estimate: RR 0.61 (95% CI 0.47-0.81)
BACKGROUND: Acute heart failure (AHF) remains a leading cause of hospitalization and mortality despite therapeutic advances. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have shown benefits in chronic HF, but their role when initiated during hospitalization for AHF remains uncertain. METHODS: A literature search was conducted across main databases through September 10, 2025 to identify randomized controlled trials (RCTs) evaluating in-hospital initiation of SGLT2 inhibitors in patients with AHF. Primary outcomes were all-cause death and worsening HF; secondary outcomes included cardiovascular death, HF rehospitalization, and safety endpoints. Random-effects model was used to estimate risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS: Eight RCTs including 4,096 patients were analysed with a weighted median follow-up of 60 days. In-hospital initiation of SGLT2 inhibitors significantly reduced all-cause death (RR 0.61, 95% CI 0.47-0.81) and worsening HF events (RR 0.67, 95% CI 0.48-0.94) compared to control group. The risk of cardiovascular death was significantly lower with SGLT2 inhibitors (RR 0.68, 95% CI 0.47-0.99). No significant effect on HF rehospitalizations was observed (RR 0.87, 95% CI 0.70-1.09). Safety outcomes, including acute kidney injury, hypotension, hypoglycemia, urinary tract infection, and serious adverse events were comparable between groups. Trial sequential analysis confirmed firm evidence for mortality reduction, while further trials are needed for worsening HF. CONCLUSIONS: In-hospital initiation of SGLT2 inhibitors in patients with AHF lowers mortality and worsening HF without increasing adverse events. Further evidence from large scale RCTs with longer follow-ups is required to reach a definitive conclusion. LAY SUMMARY: Acute heart failure is a serious condition that often leads to repeated hospitalizations and a high risk of death. We reviewed all available clinical trials to understand whether starting a class of medications called SGLT2 inhibitors during the hospital stay can help these patients. Across eight trials involving more than 4,000 patients, in-hospital treatment with SGLT2 inhibitors lowered the chances of death and reduced episodes of worsening heart failure. Importantly, these medicines did not increase side-effects such as kidney problems, low blood pressure, or infections. Although they did not significantly reduce hospital readmissions, the overall benefits were consistent and appeared within weeks of treatment. These findings support starting SGLT2 inhibitors safely during hospitalization for acute heart failure to improve patient outcomes.
Ahmed et al. (Wed,) conducted a meta-analysis in Acute heart failure (n=4,096). SGLT2 inhibitors vs. Control group was evaluated on All-cause death (RR 0.61, 95% CI 0.47-0.81). In-hospital initiation of SGLT2 inhibitors in acute heart failure significantly reduced all-cause death (RR 0.61; 95% CI 0.47-0.81) and worsening HF events (RR 0.67; 95% CI 0.48-0.94).