Effects of empagliflozin versus placebo on cardiac sympathetic activity in acute myocardial infarction patients with type 2 diabetes mellitus: the EMBODY trial

Efficacy and safety of empagliflozin for the acute myocardial infarction: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aims to evaluate the efficacy and safety of empagliflozin in acute myocardial infarction (AMI) treatment by synthesizing evidence from published randomized controlled trials (RCTs).

METHODS

PubMed, Web of Science, Embase, and Cochrane databases were thoroughly retrieved from inception to November 30, 2024, to identify eligible RCTs comparing empagliflozin with placebo in AMI treatment. The Cochrane Risk of Bias tool was leveraged to detect potential bias. The robustness of the results was examined via sensitivity analyses. Publication bias was evaluated via funnel plots and Egger's test.

RESULTS

Data from 9 RCTs involving 7,237 AMI patients were analyzed. Meta-analysis revealed that empagliflozin significantly reduced the total hospitalization rate for heart failure (HF) in AMI patients in comparison to placebo (relative risk [RR] = 0.70, 95% confidence interval [CI] = 0.57-0.85). Additionally, empagliflozin significantly improved their ejection fraction (EF) (standard mean difference [SMD] = 1.01, 95% CI = 0.63-1.38), left ventricular global longitudinal strain (LVGLS) (SMD = -0.27, 95% CI = -0.48 to -0.06), body weight (SMD = -0.80, 95% CI = -1.15 to -0.45), and systolic blood pressure (SBP) (SMD = -0.54, 95% CI = -0.88 to -0.20). Statistically significant differences were not noted in other parameters (all p > 0.05). The incidence of adverse events (AEs), such as hepatic dysfunction, contrast-induced nephropathy, and urinary tract infections, did not differ significantly across groups (all p > 0.05). The GRADE rating indicated the evidence for HF hospitalization rate and body weight was of high certainty.

CONCLUSION

Empagliflozin lowers the total hospitalization rate for HF in AMI patients and significantly improves EF, LVGLS, body weight, and SBP without raising the likelihood of AEs.

Cardiovascular therapeutic targets of sodium-glucose co-transporter 2 (SGLT2) inhibitors beyond heart failure

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are oral antidiabetic agents that have shown significant improvements in cardiovascular and renal outcomes among patients with heart failure (HF), regardless of diabetic status, establishing them as a cornerstone therapy. In addition to glycemic control and the osmotic diuretic effect, the inhibition of SGLT2 improves endothelial function and vasodilation, optimizing myocardial energy metabolism and preserving cardiac contractility. Moreover, SGLT2 inhibitors may exhibit anti-inflammatory properties and attenuate acute myocardial ischemia/reperfusion injury, thereby reducing cardiac infarct size, enhancing left ventricular function, and mitigating arrhythmias. These pleiotropic effects have demonstrated efficacy across various cardiovascular conditions, ranging from acute to chronic coronary syndromes and extending to arrhythmias, valvular heart disease, cardiomyopathies, cardio-oncology, and cerebrovascular disease. This review provides an overview of the current literature on the potential mechanisms underlying the effectiveness of SGLT2 inhibitors across a wide range of cardiovascular diseases beyond HF.

Comparative efficacy and safety of SGLT2 inhibitor class members in patients with heart failure and type 2 diabetes: A systematic review and network meta-analysis of randomized controlled trials

We conducted a systematic review with pairwise (PMA) and network meta-analyses (NMA) to evaluate sodium-glucose transport protein 2 inhibitor (SGLT2i) effects in patients with both heart failure (HF) and type 2 diabetes mellitus (T2DM). Five databases were searched up to April 15, 2025. Primary outcomes were all-cause mortality (ACM), cardiovascular death (CVD), all-cause hospitalization (ACH), and hospitalization for heart failure (HHF). SGLT2i class effects versus control were assessed via PMA and individual SGLT2i comparative efficacy via NMA plus ranking using p-scores. Seventeen randomized controlled trials (n = 17,809) were included. Arms included canagliflozin (n = 2), dapagliflozin (n = 6), empagliflozin (n = 6), ertugliflozin (n = 1), ipragliflozin (n = 1), sotagliflozin (n = 1), placebo (n = 13), and standard of care (n = 4). Compared to control, SGLT2i significantly reduced ACM (HR 0.87, 95 %CI 0.78 to 0.98, low quality of evidence [QoE]), ACH (HR 0.74, 95 %CI 0.62 to 0.88, high QoE), and HHF (HR 0.70, 95 %CI 0.63 to 0.77, low QoE); but not CVD (HR 0.87, 95 %CI 0.76 to 1.00, very low QoE). Canagliflozin ranked highest in decreasing ACM (p-score = 0.86), CVD (p-score = 0.82), and HHF (p-score = 0.88). In patients with HF and T2DM, SGLT2i class effects include ACM, ACH, and HHF reduction. Among SGLT2i, canagliflozin showed greatest ACM, CVD, and HHF benefit.

Early prescription of SGLT2i for acute patient care: from current evidence to future directions

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have emerged as transformative therapies in the management of chronic heart failure (HF), offering substantial reductions in mortality and hospitalizations. Beyond their initial classification as diuretics, SGLT2i exert a spectrum of cardioprotective effects that extend far beyond renal modulation. By activating autophagic pathways and mimicking a starvation-like state, SGLT2i enhance cellular bioenergetics and mitigate acute injury, potentially underpinning both their immediate and sustained cardiometabolic benefits when administered early in acute care settings. In acute decompensated HF, early initiation of SGLT2i enhances clinical decongestion by increasing diuresis, improving diuretic efficiency, and mitigating diuretic resistance, translating to shorter hospitalizations and reduced readmissions and mortality. In acute myocardial infarction, SGLT2i reduce the incidence of first and total HF hospitalizations, arrhythmic events, adverse cardiac remodelling, and contrast-induced acute kidney injury, while mitigating stent failure and atherosclerotic progression. Furthermore, they demonstrated efficacy in preventing new-onset and recurrent supraventricular and ventricular arrhythmias. However, the evidence remains inconclusive regarding their impact on sudden cardiac death or outcomes following cardiac arrest. In critically ill patients, SGLT2i use is associated with reduced rates of acute kidney injury and the need for renal replacement therapy, with promising implications for the management of sepsis and multi-organ dysfunction. Importantly, adverse effects such as renal impairment, electrolyte disturbances, acid-base imbalances, urinary tract infections, and dysglycemia appear infrequently in this population. This narrative review synthesizes the underlying pathophysiological mechanisms, current clinical evidence, and potential future applications of early SGLT2i therapy in acute care settings, providing insights into their expanding role in contemporary cardiovascular medicine.

SGLT2 inhibitors across the acute cardiac care spectrum: insights and perspectives

This review examines the evolving role of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in acute cardiac care. Originally developed as antidiabetic agents, SGLT2i have demonstrated significant and early benefits in chronic heart failure by reducing hospitalizations and cardiovascular mortality across all the ejection fraction spectrum. Recent evidence now suggests that these agents may also offer advantages in acute settings, including acute decompensated heart failure (ADHF) and post - acute myocardial infarction (AMI). Several clinical trials have explored early SGLT2i initiation during hospitalization, reporting improvements in diuretic efficiency, cardiac biomarkers, and favorable remodeling, without notable safety concerns. The present review discusses the multifaceted mechanisms underlying these benefits, which include osmotic diuresis, modulation of neurohormonal activation, anti-inflammatory effects, and direct myocardial protection. Together, these actions not only facilitate decongestion and renal preservation but also enhance cardiac energetics. Current data are promising and support a pivotal role of a SGLT2i as a therapeutic strategy in the whole acute cardiac care setting for their short and long-term benefit. Future research is essential to validate these findings and refine the best patients to be treated with early SGLT2i implementation in the acute cardiac care spectrum.

Interaction between SGLT2 and the sympathetic nervous system in normal and various cardiovascular metabolic disease states

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to suppress cardiovascular events and are widely used for treating diabetes, chronic heart failure and chronic kidney disease. Although the underlying mechanisms by which SGLT2 inhibitors suppress cardiovascular events are not entirely clear, several mechanisms have been proposed to explain the cardiorenal protective effects of SGLT2 inhibitors. One of these involves sympathoinhibition. In vitro, SGLT2 expression is upregulated by norepinephrine, and SGLT2 inhibitors have been shown to attenuate SGLT2 expression and normalize the diuretic response to volume expansion with isotonic saline in rats with heart failure. These findings suggest that inhibition of renal sympathetic nerve activity is the mechanism underlying the beneficial effects of SGLT2 inhibitors on heart failure. Increased resting afferent renal nerve activity has been observed in several disease models, including models of hypertension, heart failure, and kidney disease, and might induce augmented sympathetic outflow via the central nervous system. SGLT2 inhibitors may suppress afferent renal nerve activity via intrarenal environmental modifications such as renal tissue hypoxia, inflammation, oxidative stress, mitochondrial function, and congestion, thereby inhibiting sympathetic outflow to the peripheral organs, including the heart and kidneys. On the other hand, SGLT2 is also expressed in the brain, and electrophysiological techniques in rats have shown that SGLT2 inhibitors suppress the activities of the rostral ventrolateral medulla neurons which project to the sympathetic preganglionic nuclei of the spinal cord to control sympathetic outflow, suggesting decreased sympathetic nerve activities. This mini review focuses on the bidirectional interaction between SGLT2 and the sympathetic nervous system and introduces recent related findings from Hypertension Research and other journals.

Impact of sodium-glucose co-transporter 2 inhibitors on cardiovascular outcomes in patients with acute myocardial infarction: Systematic review and meta-analysis

BACKGROUND

The role of sodium-glucose co-transporter inhibitors (SGLT2i) in heart failure is well-established. However, evidence supporting their use in acute myocardial infarction remains limited.

METHODS

Two independent researchers conducted a comprehensive literature review on PubMed and Embase until April 2024. They identified 14 articles, consisting of randomized controlled trials and observational studies, investigating the use of SGLT2i in acute myocardial infarction. The analysis focused on cardiovascular outcomes, including all-cause mortality, cardiovascular mortality, major adverse cardiovascular events (MACE), heart failure exacerbation, strokes, and recurrence of acute coronary syndrome.

RESULTS

Our pooled analysis of 19,319 participants revealed a significant reduction in MACE [OR 0.50, 95 % CI [0.36; 0.70], p-value = 0.0001] and hospitalization due to heart failure [OR 0.59 (0.43-0.79), P < 0.0004] in the SGLT2i group compared to the control group. In contrast, there were no statistically significant differences between the SGLT2i and control groups regarding all-cause mortality, cardiovascular mortality, recurrence of acute coronary syndrome, or new-onset arrhythmia.

CONCLUSIONS

Our study highlights that among patients with acute myocardial infarction, the use of SGLT2i reduces MACE and hospitalizations due to heart failure. However, there was no significant reduction in mortality, recurrence of acute coronary syndrome, or arrhythmia in the SGLT2i group.

The efficacy and safety of Empagliflozin on outcomes of patients with myocardial infarction undergoing primary PCI: a systematic review and meta-analysis

Empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, has garnered significant interest due to its potential cardiovascular benefits, particularly in patients experiencing acute myocardial infarction (AMI) who are undergoing primary percutaneous coronary intervention (PCI). This systematic review aims to evaluate the effectiveness of Empagliflozin in improving clinical outcomes in this patient population. A systematic review of randomized controlled trials (RCTs) was conducted to assess the effects of Empagliflozin on clinical outcomes in patients with AMI undergoing primary PCI. Electronic databases, including PubMed, Scopus, Web of Science, Cochrane, and the Scientific Information Database, were searched up to July 31, 2024. The risk of bias in the included studies was evaluated using the Cochrane Collaboration criteria. Data analysis was performed using Comprehensive Meta-Analysis software version 3, with outcomes expressed as risk ratios (RR) and 95% confidence intervals (CI). Seven studies were included in the meta-analysis. The results demonstrated that Empagliflozin significantly reduced the risk of heart failure hospitalization compared to placebo, with a risk ratio of 0.48 (95% CI: 0.23-0.99; P = 0.049), indicating a 52% reduction in hospitalization risk. However, secondary outcomes showed that Empagliflozin was associated with a reduction in cardiovascular mortality (RR = 0.45; 95% CI: 0.06-3.02; P = 0.415) and the need for coronary revascularization (RR = 0.75; 95% CI: 0.15-3.59; P = 0.717), although these results did not achieve statistical significance. Empagliflozin is associated with a significant reduction in heart failure hospitalizations among patients with AMI undergoing primary PCI, while its effects on cardiovascular mortality and the necessity for coronary revascularization were not statistically significant. Despite these secondary outcomes, the favorable safety profile of Empagliflozin supports its use as a treatment option for high-risk patients following acute coronary events. Further research is warranted to investigate the long-term impact of Empagliflozin on cardiovascular outcomes in this population.

SGLT-2 inhibitors on cardiac autonomic function in individuals with and without type 2 diabetes mellitus

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have emerged as key therapeutic agents in managing type 2 diabetes mellitus (T2DM) and obesity, offering benefits that extend beyond glycemic control. This review examines the role of SGLT-2 inhibitors in modulating cardiac autonomic function, with a particular focus on heart rate variability (HRV) as a biomarker of autonomic balance. These agents improve metabolic profiles through enhanced glucosuria, natriuresis, and weight loss, while concurrently reducing blood pressure. Importantly, they also attenuate sympathetic nervous system overactivity and promote parasympathetic modulation, which may lower the risk of adverse cardiovascular events. The underlying mechanisms include not only the metabolic effects but also anti-inflammatory and antioxidative actions, which together contribute to improved endothelial function and vascular health. Advanced HRV analyses, encompassing traditional time and frequency domain methods as well as nonlinear approaches, have proven valuable in detecting early autonomic dysfunction in high-risk populations. Some studies suggest that SGLT-2 inhibitors may be associated with improvements in HRV parameters, such as increased SDNN and RMSSD and a reduced LF/HF ratio. However, findings are inconsistent across studies, and further research is needed to determine the extent and mechanisms of these potential effects. Although these findings are promising, further standardized, long-term studies are essential to clarify the mechanisms and optimal therapeutic strategies involving SGLT-2 inhibitors in the management of autonomic dysfunction. Future research should also explore the synergistic potential of combining SGLT-2 inhibitors with other cardiometabolic therapies to enhance cardiovascular outcomes in individuals with and without T2DM.

The Impact of Metformin on BNP Levels: A Potential Cardioprotective Role in Type 2 Diabetes

Background/Objectives: Cardiovascular complications are the most common cause of mortality and morbidity in diabetic patients. Therefore, the aim of antidiabetic therapy should not only be to provide glucose regulation but also to protect patients from complications and related mortality. Brain natriuretic peptide (BNP) is a peptide secreted as a result of myocardial stress. BNP levels increase under conditions of increased myocardial stress, such as heart failure. It is an important marker not only at the time of diagnosis but also during follow-up. In our study, we aimed to evaluate BNP levels and thus, the factors affecting the risk of developing heart failure during the course of diabetes. Methods: This study was conducted at the diabetes outpatient clinic of the University of Health Sciences, Haseki Training and Research Hospital. A total of 252 patients met the inclusion criteria and were enrolled in the study. All study participants were patients with a confirmed diagnosis of type 2 diabetes. Laboratory parameters, including BNP values, comorbidities, and anamnesis data, were recorded. Results: The mean BNP levels were significantly lower in patients using metformin and pioglitazone. Other antidiabetic medications were not associated with BNP levels. BNP levels were positively correlated with age and diabetes duration and negatively correlated with hemoglobin levels. According to regression analysis, age, metformin use, and hemoglobin levels were found to independently affect BNP levels. Conclusions: Our findings suggest that metformin could potentially play a significant role in preventing the development of heart failure in diabetic patients currently not experiencing this complication owing to its favorable effects on myocardial stress. This suggests metformin's potential in preventing heart failure in type 2 diabetic patients.

Effect of Dapagliflozin on Ventricular Arrhythmic Events in Heart Failure Patients With an Implantable Cardioverter Defibrillator

Background

The aim of our study was to evaluate the effects of dapagliflozin on the ventricular arrhythmia burden (VAb) in patients with heart failure with reduced ejection fraction (HFrEF) and an implantable cardioverter defibrillator (ICD), correlating the possible reduction in arrhythmic events and ICD therapies with the basal functional capacity, as well as the remodeling parameters induced by treatment.

Methods

A total of 117 outpatient ICD patients with a known diagnosis of HFrEF who underwent treatment with dapagliflozin were evaluated according to a prospective observational protocol. VAb (including sustained ventricular tachycardia, non-sustained ventricular tachycardia, ventricular fibrillation, and total ventricular events) and specific ICD therapies (anti-tachycardia pacing (ATP) and ICD shocks) were extrapolated from the devices' memory (events per patient per month) by comparing events in the observation period before and after the introduction of dapagliflozin.

Results

The VAb was significantly reduced after dapagliflozin introduction (2.9 ± 1.8 vs. 4.5 ± 2.0, P = 0.01). The burden of appropriate ATPs was significantly reduced (0.57 ± 0.80 vs. 0.65 ± 0.91, P = 0.03), but not for ICD shocks. In patients with a more advanced functional class, a greater reduction in VAb was observed than in patients with a better initial functional capacity (2.2 ± 0.8 vs. 5.5 ± 1.8, P = 0.001 in the New York Heart Association (NYHA) III/IV group; 3.5 ± 2.1 vs. 4.5 ± 2.2, P = 0.02 in the NYHA I/II group). Considering two independent groups according to reverse remodeling (Δleft ventricular ejection fraction (LVEF) > 15%), a significant reduction in VAb was observed only in those patients who presented significant reverse remodeling (2.5 ± 1.1 vs. 5.1 ± 1.6, P = 0.01). A statistically significant interaction between the variation of total ventricular arrhythmias (VTA) and the basal NYHA class (F(1,115) = 142.25, P < 0.0001, partial η2 = 0.553), as well as between the variation of VTA and the ΔLVEF (F(1,115) = 107.678, P < 0.0001, partial η2 = 0.484) has been demonstrated using a two-way analysis of variance (ANOVA) test.

Conclusions

In ICD outpatients with HFrEF, dapagliflozin treatment produces a reduction in arrhythmic ventricular events. This improvement is more evident in patients who have a worse functional class and thus a more precarious hemodynamic state, and in patients who present with significant ventricular reverse remodeling. Therefore, we can hypothesize that the hemodynamic and structural improvements induced by treatment represent, at least in the short-medium term, some of the principal elements justifying the significant reduction in VAb.

Emerging horizons: clinical applications and multifaceted benefits of SGLT-2 inhibitors beyond diabetes

SGLT-2 inhibitors, initially developed for type 2 diabetes, demonstrate profound cardiorenal and metabolic benefits. This review synthesizes evidence from clinical trials and mechanistic studies to elucidate their roles in cardiovascular diseases, chronic kidney disease, and non-alcoholic fatty liver disease. Key findings include a notable reduction in cardiovascular death/heart failure hospitalization, a marked decrease in heart failure hospitalization risk, and significant improvements in renal and hepatic outcomes. Emerging mechanisms, such as autophagy induction, ketone utilization, and anti-inflammatory effects, underpin these benefits. Ongoing trials explore their potential in non-diabetic populations, positioning SGLT-2 inhibitors as transformative agents in multisystem disease management.

Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a specific class of drugs originally developed for treating type 2 diabetes mellitus. Subsequently, studies demonstrated that their action was not limited to glycemic control but could also have positive effects on other specific outcomes, particularly at the cardiovascular level. Indeed, due to their diuretic effect, SGLT2i improve the clinical control of chronic heart failure and reduce the risk of rehospitalization. In addition, other studies reported a protective effect on major cardiovascular events and mortality. More recently, it has been suggested that the prescription of SGLT2i after an acute myocardial infarction may have positive effects due to their possible effect on inflammation, arrhythmias, and ventricular remodeling. Here, we reviewed studies focused on SGLT2i after an acute myocardial infarction in patients treated with percutaneous coronary intervention.

AlBarakat M, Elewidi M, Abuelazm M, Turkmani M, Abdelazeem B, Laeeq R. The effect of sodium-glucose co-transporter 2 inhibitors on clinical outcomes after acute myocardial infarction: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce cardiovascular events, especially in diabetic patients. However, the cardioprotective effects of early SGLT2i administration following acute myocardial infarction (AMI) remain unclear.

OBJECTIVE

This study aims to investigate the impact of SGLT2is on clinical outcomes in patients post-AMI.

METHODS

A comprehensive search was conducted in PubMed, CENTRAL, WOS, Scopus, and EMBASE up to April 2024. Risk ratio (RR) was used for dichotomous outcomes and mean difference (MD) for continuous outcomes, with 95% confidence intervals (CI).

RESULTS

Seven studies with 11,407 patients were included. SGLT2is did not significantly reduce the incidence of major adverse cardiovascular events (MACE) (RR = 0.94, 95% CI [0.68, 1.29], p = 0.69), all-cause mortality (RR = 1.01, 95% CI [0.84, 1.21], p = 0.93), or stroke (RR = 0.61, 95% CI [0.29,1.28], p = 0.19). However, SGLT2is significantly reduced the risk of heart failure (RR = 0.76, 95% CI [0.63, 0.91], p < 0.01) and improved left ventricular ejection fraction (MD = 1.86, 95% CI [1.58, 2.14], p < 0.01).

CONCLUSION

In post-AMI patients, SGLT2is do not significantly affect MACE or mortality but are associated with reduced heart failure risk and improved ejection fraction.

PROTOCOL REGISTRATION

PROSPERO identifier number: CRD42024506806.

Impact of sodium‒glucose cotransporter-2 inhibitors in patients with recent versus previous myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Sodium‒glucose cotransporter 2 (SGLT2) inhibitors have been included in heart failure (HF) guidelines because of their benefits in reducing mortality and hospitalization rates. However, the timing and benefits of initiating SGLT2 inhibitors in patients after myocardial infarction (MI) remain controversial. Therefore, we aimed to perform a systematic review and meta-analysis comparing SGLT2 inhibitors with placebo in patients with MI.

METHODS

We performed a systematic review and meta-analysis to determine the impact of SGLT2 inhibitors in patients with recent or previous MI. We systematically searched PubMed, Cochrane, and Embase for RCTs comparing SGLT2 inhibitors versus placebo in patients with MI. The primary outcome was (1) HF hospitalization. In this analysis, we also included the following secondary outcomes: (2) major adverse cardiovascular events (MACE) defined as a composite of cardiovascular (CV) death, MI or stroke; and (3) all-cause mortality. A subgroup analysis was conducted for the primary outcome, comparing patients who had experienced an MI more than 8 weeks prior to study enrolment (previous MI) versus those who had experienced an MI within the preceding 8 weeks (acute MI). Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled with a random effects model.

RESULTS

Our meta-analysis included 10 RCTs comprising 22,266 patients, of whom 11,339 (51.2%) had type 2 diabetes. The mean age was 62 years, and the median follow-up was 21 months. According to the pooled analysis, HF hospitalization rates were lower in patients on SGLT2 inhibitors compared with placebo (RR 0.77; 95% CI 0.69, 0.85; p < 0.001)). Differences in MACE were also observed in favor of SGLT2 inhibitors versus placebo (RR 0.88; 95% CI 0.79, 0.97; p = 0.012). There was no statistically significant difference in all-cause mortality between the groups (RR 0.88; 95% CI 0.78, 1.00; p = 0.058). Benefits of SGLT2 inhibitors for the primary outcome were consistent regardless of the timing of last MI, with no treatment by subgroup interaction (p for interaction = 0.56).

CONCLUSION

In this meta-analysis of patients who experienced MI, the administration of SGLT2 inhibitors was associated with lower rates of hospitalization for HF. In addition, the treatment effect of SGLT2 inhibitors was consistent regardless of whether they were started in the recent versus previous MI setting.

Investigating the Relationship Between Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors and Blood Pressure

Sodium-glucose cotransporter-2 (SGLT2) inhibitors were originally approved for use in type 2 diabetes, but in recent years, these medications were found to also have significant cardiovascular benefits in patients with heart failure with reduced and preserved ejection fraction and chronic kidney disease. Part of the cardiovascular benefits of SGLT2 inhibitors likely comes from their antihypertensive effect in addition to other unknown effects, but the mechanism by which these medications reduce blood pressure has not been identified yet. Multiple mechanisms have been proposed to describe SGLT2 inhibitors' antihypertensive effect, including their associated weight loss and diuretic effect. However, studies have shown that these indirect mechanisms alone do not account for the antihypertensive effect seen with this medication, with more recent studies identifying a new potential mechanism by which SGLT2 inhibitors may derive their direct antihypertensive and cardiovascular benefits. In animal models, SGLT2 receptors were identified in parts of the brain responsible for regulating the sympathetic nervous system and adjusting blood pressure. In these studies, SGLT2 inhibitors suppressed the neuronal activity in these brain regions, reducing the sympathetic nervous system activity and blood pressure of the animals. Further investigation is needed to identify whether there are SGLT2 receptors in the central nervous system of humans and whether SGLT2 inhibitors can suppress neuronal activity in these brain regions. This information could be significant in learning more about the susceptibility and severity of primary hypertension in certain patient populations, as well as identifying whether SGLT2 inhibitors can be considered as a primary antihypertensive agent.

Redefining outcomes of ventricular arrhythmia for SGLT2 inhibitor medication in heart failure patients: a meta-analysis of randomized controlled trials

BACKGROUND

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to lower the risk of re-hospitalization and cardiovascular mortality among heart failure (HF) patients. Nevertheless, the impact of these agents on ventricular arrhythmias (VAs) has not been thoroughly investigated. To assess the beneficial impact of SGLT2 inhibitors on VAs in patients at various stages of HF, a systematic review and meta-analysis of randomized controlled trials involving SGLT2 inhibitors in this patient population was performed.

METHODS

A comprehensive search of the PubMed, Embase, Ovid, ProQuest, Scopus, and Cochrane databases was performed for clinical trials published up to November 21, 2024. The primary outcomes of interest were incidences of VAs and sudden cardiac death (SCD) between the groups receiving SGLT2 inhibitors and the control drugs. For the outcomes observed in the populations of the included trials and in specific subgroups, hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled and meta-analysed across the analyses.

RESULTS

A total of 23 randomized trials (22 placebo-controlled trials and 1 active-controlled trial) involving 74,380 patients (37,372 receiving SGLT2 inhibitors and 37,008 in the control group) were included. The analysed SGLT2 inhibitors included canagliflozin, dapagliflozin, empagliflozin, bexagliflozin, sotagliflozin, and ertugliflozin. The participants were non-advanced HF patients, including at-risk for HF, pre-HF, and symptomatic HF, with follow-up duration ranging from 12 to 296 weeks. Compared with the control, treatment with SGLT2 inhibitors was associated with significantly reduced risk of VAs (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.74-0.98; P = 0.02) and SCD (RR 0.79, 95% CI 0.64-0.98; P = 0.03). Subgroup analyses indicated that longer follow-up (≥ 1 year) taking SGLT2 inhibitors can still reduce the risk of VAs (RR 0.79, 95% CI 0.65-0.96; P = 0.02) and SCD (RR 0.80, 95% CI 0.65-0.99; P = 0.04).

CONCLUSION

SGLT2 inhibitors have beneficial effects on lowering risks of VAs and SCD in patients with type 2 diabetes, cardiovascular diseases, heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and heart failure with mildly reduced ejection fraction (HFmrEF), with longer follow-up duration reinforcing these findings. However, future prospective trials are needed to verify the effects of SGLT2 inhibitors on VAs and SCD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42024601914).

Bidirectional interplay of sleep apnea syndrome and cardio-vascular disorders in diabetes

Although often overlooked sleep apnea has emerged as a significant public health concern. Obstructive sleep apnea (OSA) and diabetes commonly co-exist with a vicious cycle worsening the incidence and severity of both conditions. OSA has many implications including cardiometabolic disorders and impaired cardiovascular (CV) prognosis. OSA combined with diabetes generates a cumulative effect on CV outcomes. The association of OSA with several comorbidities including CV disease and heart failure is bi-directional meaning that some of them are likely to contribute to OSA. In patients with diabetes, OSA treatment should be integrated in a holistic strategy of prevention of CV and microvascular complications. This article provides some clues to advance the understanding of the interplay between OSA and CV disorders in diabetes and to consider the role of some CV risk markers like cardiac autonomic neuropathy and artery stiffness and of novel metrics for hypoxic-related events in CV risk stratification, and offers a discussion on the effects of medical approaches including weight loss strategies, GLP1-receptor agonists and sodium-glucose cotransporter 2 inhibitors. It provides a guidance to improve screening and diagnosis of OSA, and adherence to OSA treatment in patients with diabetes.

Sodium-dependent glucose transporter 2 inhibitors improve heart function in patients with type 2 diabetes and heart failure

This article discusses the study by Grubić Rotkvić et al on the mechanisms of action of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus (T2DM) and heart failure (HF). T2DM and HF are highly comorbid, with a significantly increased prevalence of HF in patients with T2DM. SGLT2i exhibit potential in reducing hospitalization rates for HF and cardiovascular mortality through multiple mechanisms, including improving blood glucose control, promoting urinary sodium excretion, reducing sympathetic nervous system activity, lowering both preload and afterload on the heart, alleviating inflammation and oxidative stress, enhancing endothelial function, improving myocardial energy metabolism, and stabilizing cardiac ion homeostasis. Further research and clinical practice will help optimize the use of SGLT2i in HF patients.

Antiarrhythmic Effects of SGLT2 Inhibitors on Supraventricular Tachyarrhythmias in Patients with HFrEF

Background: In recent years, sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated significant cardiovascular and renal benefits in patients with heart failure (HF), in addition to their established antidiabetic effects. However, their role in arrhythmia prevention remains unclear. This study aimed to assess the effect of SGLT2 inhibitors on the incidence of supraventricular tachycardia (SVT) and ventricular tachycardia (VT) in patients with HF with reduced ejection fraction (HFrEF) during an extended follow-up period. Methods: This retrospective cohort study was conducted between January 2019 and November 2024 at the Ulm University Heart Center. All patients exhibited severely reduced left ventricular function and underwent primary prophylactic implantable cardioverter-defibrillator (ICD) implantation. Half of the cohort initiated SGLT2 inhibitor therapy alongside optimal medical HF treatment (the SGLT2 group). Patients were followed for approximately three years (846.2 ± 520.0 days) and the incidence of SVT and VT was analyzed using intracardiac Holter records of the ICD. Results: The study population consisted of 78 patients with a mean age of 66.6 ± 12.9 years. Over the follow-up period, a significant prolongation in the time to first occurrence of SVT was observed in the SGLT2 group (Log-Rank p = 0.03), suggesting a potential protective effect of SGLT2 inhibitors. However, regarding VT, additional SGLT2 inhibitor therapy did not show an additional benefit to optimal medical HF treatment. Conclusions: This study suggests that SGLT2 inhibitors may play a beneficial role in reducing the incidence of SVT in patients with HFrEF. These results highlight the importance of further investigating the antiarrhythmic potential of SGLT2 inhibitors through large-scale, prospective studies to better understand their clinical implications and mechanisms of action.

Association of sodium-glucose cotransporter-2 inhibitors with mortality across the spectrum of myocardial infarction: a systematic review and meta-analysis

BACKGROUND

The impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors on mortality following myocardial infarction (MI) remains uncertain. Additionally, the role of type 2 diabetes mellitus (T2DM) and heart failure (HF) in modulating the effectiveness of these drugs post-MI are not fully understood. This meta-analysis aimed to assess the association of SGLT2 inhibitors with all-cause mortality in post-MI patients and to explore key moderators influencing this benefit.

METHODS

PubMed, Embase, and Scopus were searched for randomized controlled trials (RTCs) and propensity score-matched (PSM) observational studies assessing SGLT2 inhibitors' impact on post-MI mortality. The primary outcome was all-cause mortality. We pooled hazard ratios (HRs) to estimate the intervention's effect on the overall population and stratified studies into early (SGLT2 inhibitors administered within eight weeks post-MI) and delayed treatment trials. Meta-regression assessed the moderating effects of T2DM and HF.

RESULTS

 A total of five RCTs and four PSM observational studies involving 26,753 patients (mean [SD] age, 62.9 [10.5] years; 6,406 female [24.0%]; 16,369 T2DM [61.2%]; 13,933 HF [52.1%]) were included. Early and delayed treatment trials comprised 16,165 (60.4%) and 10,588 (39.6%) patients, respectively. SGLT2 inhibitors reduced all-cause mortality following MI (HR 0.79, 95% CI [0.68, 0.91]; p = 0.001; I2 = 59%). Stratified analysis demonstrated consistent effects in both early (HR 0.76, 95% CI [0.59, 0.98]; p = 0.03; I2 = 65%) and delayed (HR 0.81, 95% CI [0.67, 0.98]; p = 0.03; I2 = 60%) treatment. Meta-regression identified T2DM as a significant moderator of the mortality benefit (β = - 0.0049; p = 0.0006).

CONCLUSION

In this meta-analysis, early and delayed treatment with SGLT2 inhibitors following MI was associated with a significant reduction in all-cause mortality. Furthermore, the presence of T2DM was associated with a greater mortality reduction, while HF was not significantly associated with the outcome.

Effects of dapagliflozin on heart rate variability, cardiac function, and short-term prognosis in early-onset post-myocardial infarction heart failure

Objective

To investigate the effects of dapagliflozin, in addition to standard therapy, on heart rate variability (HRV), soluble growth stimulation expressed gene 2 protein (sST2), N-terminal pro B-type natriuretic peptide (NT-proBNP), and echocardiographic parameters in patients with early-onset post-myocardial infarction heart failure (HF).

Methods

A total of 98 patients with early-onset post-myocardial infarction HF were enrolled and randomly divided into a control group (n = 48, receiving standard therapy) and an observation group (n = 50, receiving standard therapy plus dapagliflozin 10 mg daily). HRV, cardiac function, and echocardiographic parameters were measured at baseline and after 24 weeks of treatment. Short-term prognosis and adverse events were also monitored.

Results

Compared with the control group, the observation group showed significantly greater improvements in SDNN and SDANN (P < 0.05). Significant improvements were also observed in sST2 and NT-proBNP levels in the observation group compared to the control group (P < 0.05). Additionally, echocardiographic parameters, including EF, LVESD, LVEDD, IVST, LVMI, and E/e', showed greater improvement in the observation group (P < 0.05). The incidence of major adverse cardiovascular events was lower in the observation group (P < 0.05). Multivariate logistic regression model revealed that dapagliflozin use was independently associated with a reduced risk of MACE (OR = 0.265, 95% CI: 0.097-0.724, P = 0.010).

Conclusion

Early administration of dapagliflozin 10 mg, in addition to standard therapy, can improve autonomic function, cardiac function, and short-term prognosis in patients with early-onset post-myocardial infarction heart failure.

Central SGLT2 mediate sympathoexcitation in hypertensive heart failure via attenuating subfornical organ endothelial cGAS ubiquitination to amplify neuroinflammation: Molecular mechanism behind sympatholytic effect of Empagliflozin

BACKGROUND

Sodium/glucose co-transporter 2 (SGLT2) inhibitors have transformed heart failure (HF) treatment, offering sympatholytic effects whose mechanisms are not fully understood. Our previous studies identified Cyclic GMP-AMP synthase (cGAS)-derived neuroinflammation in the Subfornical organ (SFO) as a promoter of sympathoexcitation, worsening myocardial remodeling in HF. This research explored the role of central SGLT2 in inducing endothelial cGAS-driven neuroinflammation in the SFO during HF and assessed the impact of SGLT2 inhibitors on this process.

METHODS

Hypertensive HF was induced in mice via Angiotensin II infusion for four weeks. SGLT2 expression and localization in the SFO were determined through immunoblotting and double-immunofluorescence staining. AAV9-TIE-shRNA (SGLT2) facilitated targeted SGLT2 knockdown in SFO endothelial cells (ECs), with subsequent analyses via immunoblotting, staining, and co-immunoprecipitation to investigate interactions with cGAS, mitochondrial alterations, and pro-inflammatory pathway activation. Renal sympathetic nerve activity and heart rate variability were measured to assess sympathetic output, alongside evaluations of cardiac function in HF mice.

RESULTS

In HF model mice, SGLT2 levels are markedly raised in SFO ECs, disrupting mitochondrial function and elevating oxidative stress. SGLT2 knockdown preserved mitochondrial integrity and function, reduced inflammation, and highlighted the influence of SGLT2 on mitochondrial health. SGLT2's interaction with cGAS prevented its ubiquitination and degradation, amplifying neuroinflammation and HF progression. Conversely, Empagliflozin counteracted these effects, suggesting that targeting the SGLT2-cGAS interaction as a novel HF treatment avenue.

CONCLUSION

This study revealed that SGLT2 directly reduced cGAS degradation in brain ECs, enhancing neuroinflammation in the SFO, and promoting sympathoexcitation and myocardial remodeling. The significance of the central SGLT2-cGAS interaction in cardiovascular disease mechanisms is emphasized.

Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cardiovascular disease is on the rise globally, with ischemic heart disease being the leading cause of mortality and morbidity. While sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to improve cardiovascular outcomes in patients with heart failure, evidence is limited in guiding initiation in post-acute myocardial infarction (post-AMI) patients. Hence, this study aimed to appraise the current literature on the effect of SGLT2i on the clinical outcomes of post-AMI patients.

METHODS

A comprehensive search of PubMed, EMBASE, SCOPUS, and ClinicalTrials.gov was conducted up to 1 May 2024. Only randomized controlled trials studying the use of SGLT2i in post-AMI patients were included. We included adult patients aged 18 years old and older diagnosed with AMI and initiated on SGLT2i in the acute post-AMI setting. SGLT2i studies solely in heart failure settings were excluded.

RESULTS

Eight clinical trials were included in the systematic review, comprising 11,436 patients. Compared with placebo, SGLT2i initiation in post-AMI patients significantly reduced total number of heart failure hospitalizations (risk ratio [RR] 0.74, 95% confidence interval [CI] 0.62-0.90) and was associated with a lower N-terminal pro-B-type natriuretic peptide (NT-proBNP) level (- 26.67 pg/ml, 95% CI - 41.74 to - 11.59). There was no difference in all-cause mortality (RR 1.02, 95% CI 0.81-1.28), cardiovascular mortality (RR 1.03, 95% CI 0.83-1.28), change in left ventricular ejection fraction, and glycated hemoglobin (HbA1c), as compared with placebo.

CONCLUSION

SGLT2i use in patients with AMI was associated with a reduction in heart failure hospitalizations and a decrease in NT-proBNP. There were no significant differences in mortality outcomes.

REGISTRATION

PROSPERO identifier number CRD42024540843.

Sodium-glucose cotransporter-2 inhibitors in acute myocardial infarction: a systematic review and meta-analysis of randomized controlled trials

We aimed to assess the efficacy and safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) versus placebo, initiated within the hospitalization period, in addition to habitual treatment, for treating adult patients with confirmed acute myocardial infarction (AMI). We also conducted subgroup analysis by diabetes mellitus (DM) status and type of AMI. We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs). The primary outcome was hospitalization for heart failure (HF). The secondary outcomes were all-cause death, cardiovascular death, and serious adverse events (AEs). We pooled risk ratios (RR) with a 95% confidence interval (CI) for binary outcomes. The between-study variance was assessed using tau2 statistics. We included five RCTs, encompassing 11,211 patients. SGLT2i significantly reduced the risk of hospitalization for HF compared to placebo (RR 0.73; 95% CI [0.61, 0.88]). However, the risk of all-cause death (RR 1.05; 95% CI [0.78, 1.41]) and cardiovascular death (RR 1.04; 95% CI [0.84, 1.29]) was similar between the groups, as well as the risk of serious AEs (RR 1.01; 95% CI [0.90, 1.14]). In the subgroup analysis by DM status and type of AMI, there were no significant subgroup differences for the outcomes of hospitalization for HF and all-cause death. In patients with AMI, treatment with SGLT2i is safe and significantly reduces the risk of hospitalization for HF, but it has no impact on all-cause death and cardiovascular death compared to placebo.

Cardiovascular Therapy Benefits of Novel Antidiabetic Drugs in Patients With Type 2 Diabetes Mellitus Complicated With Cardiovascular Disease: A Network Meta-Analysis

OBJECTIVE

Provide an evidence-based basis for the selection of cardiovascular benefit drugs in Type 2 diabetes mellitus (T2DM) patients with cardiovascular disease (CVD).

METHODS

Conduct a comprehensive search of all relevant literature from PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials.gov from their establishment until December 13, 2023, and select randomized controlled trials (RCTs) that meet the pre-established inclusion and exclusion criteria. Use the Cochrane bias risk assessment tool to evaluate the quality of the included literature. Use R 4.3.2 software to conduct network meta-analysis for drug category comparison.

RESULTS

A total of 24 large-scale randomized controlled trials (RCTs) were included, including 19 intervention measures, and 172 803 patients participated in the study. The results of the network meta-analysis show that: GLP1RA (OR 0.89, 95% CI 0.81-0.97) and SGLT2i (OR 0.91, 95% CI 0.83-0.99) can reduce the occurrence of major adverse cardiovascular events (MACE), GLP1RA (OR 0.88, 95% CI 0.79-0.97) and SGLT2i (OR 0.89, 95% CI 0.81-0.99) reduced the risk of cardiovascular death. SGLT2i (OR 0.68, 95% CI 0.62-0.75) reduced the occurrence of hospitalization for heart failure, GLP1RA (OR 0.88, 95% CI 0.81-0.97) and SGLT2i (OR 0.89, 95% CI 0.80-0.97) reduced the occurrence of all-cause death.

CONCLUSION

In the comparison of new hypoglycemic drug classes, GLP1RA and SGLT2i reduced MACE, cardiovascular mortality and all-cause mortality in T2DM patients with CVD, with no significant difference in efficacy, and DPP4i was noninferior to placebo. Only GLP1RA reduced the risk of nonfatal stroke, and only SGLT2i reduced the risk of HHF.

Modulating Sympathetic Nervous System With the Use of SGLT2 Inhibitors: Where There Is Smoke, There Is Fire?

Heart failure (HF) has become even more prevalent in recent years, because of improved diagnostics and an increase in the risk factors predisposing to its pathology. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) emerged as one of the key pharmacotherapy options for both reduced and preserved ejection fraction, providing cardio- and renoprotection and improving mortality and cardiovascular (CV) outcomes. The pleiotropism of SGLT2i has led to multiple efforts to understand their distinct pathophysiologic interactions with various pathways, including microcirculation, endothelial dysfunction, and inflammation. More recently, the role of SGLT2i on the sympathetic nervous system (SNS) is starting to be recognized, especially because observations of retained or reduced heart rate despite volume contraction have been noted by investigators in the large clinical trials testing the safety and efficacy of these agents. Both preclinical and clinical studies have been performed, with conflicting results. Interestingly, in both settings, although there are indications of SNS modulation by SGLT2i, other studies contradict such findings, without showing, however, worsening of the autonomic homeostasis. Given the importance of neuromodulation in HF, in both pharmacologic and interventional therapies, in this review, we aim to describe the role of SNS in CV disease, focusing on HF, analyze preclinical and clinical data regarding the efficacy of SGLT2i in modulating autonomic dysfunction by examining various markers of SNS activation, and provide the most plausible theoretical backgrounds on the mechanism of benefit of SNS from the inhibition of SGLT2 receptors.

Influence of sodium-glucose cotransporter 2 inhibitors on the triglyceride-glucose index in acute myocardial infarction patients with type 2 diabetes mellitus

Background

As a novel oral anti-hyperglycemic agent, sodium-glucose cotransporter 2 inhibitors (SGLT2-i) have been demonstrated to improve cardiovascular outcomes in acute myocardial infarction (AMI) patients with type 2 diabetes mellitus (T2DM). However, the mechanism responsible for the beneficial effects remains unclear. Recently, extensive studies have demonstrated a close relationship between elevated fasting triglyceride-glucose (TyG) index and the risk of AMI. Additionally, research has identified that SGLT2-i can reduce the TyG index in T2DM patients. However, it remains ambiguous whether the benefit of SGLT2-i in patients with AMI and T2DM is due to an improvement in the TyG index. Consequently, we aimed to assess the impact of SGLT2-i on the TyG index in AMI patients with T2DM.

Methods

A retrospective and cross-sectional study was conducted on 180 AMI patients with T2DM admitted to the chest pain center of the Second Affiliated Hospital of Anhui Medical University from January 2020 to January 2023. Based on the hypoglycemic regimens administered after admission, the patients were categorized into a control group (79 cases treated with sulfonylureas, α-glycosidase inhibitors, metformin, etc.) and a SGLT2-i group (101 cases administered with dapagliflozin or empagliflozin). Propensity score matching (PSM) was adopted to balance the baseline characteristics of patients and minimize selection bias to confirm the robustness of the results. After PSM, control group remained 32 patients, and SGLT2-i group remained 37 patients. All patients underwent regular follow-up after discharge, and comparisons were made between the two groups in terms of clinical indicators and major adverse cardiovascular events (MACEs) in 1 year. Univariate and Multivariate Cox regression analysis was performed to identify the predictors of MACE.

Results

Significant differences were observed between the two groups in terms of various parameters before PSM, included age, proportion of insulin use, Gensini score, serum creatinine (Cr), total cholesterol (TC), and cardiac troponin I (cTnI). After PSM, there were no statistically significant differences in baseline clinical indicators and laboratory tests. The median follow-up period was 11 months in both cohorts. The comparison of follow-up results between the two groups after matching confirmed statistically significant differences in triglyceride (TG) reduction index reduction, left ventricular end-diastolic diameter (LVDD) reduction, and white blood cell (WBC) reduction in the SGLT2-i group (all P<0.05). Additionally, a higher incidence of MACEs was observed in the control group (P=0.01). Univariate analysis showed that usage of SGLT2-i, Cr, low-density lipoprotein cholesterol (LDL-C), TyG index at baseline, and changes of TyG index (TyG at follow-up minus TyG at baseline) were associated with the risk of MACE. However, multivariate analysis showed only usage of SGLT2-i was associated with the risk of MACE [hazard ratio (HR) =0.077; 95% confidence interval (CI): 0.009-0.682; P=0.02].

Conclusions

In AMI patients with T2DM, the use of SGLT2-i was associated with a lower risk of MACE and an improvement of TyG index during 11 months follow-up. Our findings offer new insights into the cardio-protective mechanisms of SGLT2-i in the context of AMI.

Effects of Sodium-Glucose Cotransporter-2 Inhibitors on Body Composition and Fluid Status in Cardiovascular Rehabilitation Patients with Coronary Artery Disease and Heart Failure

Background and Objectives: Sodium glucose cotransporter-2 (SGLT-2) inhibitors have emerged as integral therapeutic tools in the management of patients with cardiovascular-kidney-metabolic (CKM) syndrome. In addition to their well-documented effects on lowering glucose levels and cardiovascular- and reno-protective actions, SGLT-2 inhibitors, through a reduction in body weight (BW), generate changes in the body composition and volume status that have not been clearly studied. Materials and Methods: This retrospective, observational longitudinal cohort, single-center study analyzed and compared body composition and fluid status measured by bioelectrical impedance analysis (BIA) from weeks 0 to 12 after the initiation of the cardiac rehabilitation (CR) program for coronary artery disease and heart failure in 59 patients who started treatment with SGLT-2 inhibitors (SGLT-2iG) and 112 patients without SGLT-2 inhibitors (non-SGLT-2iG). Results: Changes between the baseline and week 12 in the SGLT-2iG and non-SGLT-2iG were -0.3 L (p = 0.003) and -0.03 L (p = 0.82) in extracellular water (ECW) (p = 0.05), -0.39 L (p < 0.001) and -0.14 L (p = 0.33) in intracellular water (ICW) (p = 0.12), -0.69 (p < 0.001) and -0.16 (p = 0.52) in total body water (TBW) (p = 0.08), and -0.01 (p = 0.37) and -0.001 (p = 0.25) in the ECW/TBW ratio, respectively. After 3 months of exercise therapy in the CR program, patients in the SGLT-2iG showed a greater decrease than the non-SGLT-2iG in weight (-1.34 kg, p < 0.001 vs. -0.99, p = 0.02), body mass index (BMI) (-0.45 kg/m2, p < 0.001 vs. -0.38, p = 0.004), arm circumference (-0.57 cm, p = 0.008 vs. -0.12 cm, p = 0.21), waist circumference (-1.5 cm, p = 0.04 vs. -0.11 cm, p = 0.83), systolic blood pressure (SBP) (-8.9 mmHg, p = 0.049 vs. -4.19, p = 0.08), and diastolic blood pressure (DBP) (-5.15, p = 0.03 vs. -2.85, p = 0.01). The bioelectrical impedance analysis (BIA) revealed a significant decrease in body fat mass (BFM) and visceral fat area, without a loss of lean body mass (LBM) or skeletal muscle mass in the SGLT-2iG. Conclusions: SGLT-2 inhibitors exert beneficial effects on body compartments and volume status. Although they induce modest weight loss, this appears to be mainly directed at ECW, BFM, and visceral fat, without a loss of LBM nor skeletal muscle mass, which could contribute to the observed CKM benefits.

Impact of SGLT2 inhibitors on cardiovascular outcomes and metabolic events in Chinese han patients with chronic heart failure

OBJECTIVE

This study aimed to evaluate the real-world impact of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on the efficacy, safety, and metabolic profiles of patients with chronic heart failure (CHF), both with and without type 2 diabetes mellitus (T2DM).

METHODS

A cohort of 1,130 patients with reduced ejection fraction chronic heart failure (HFrEF) was recruited from Zhongnan Hospital of Wuhan University, spanning January 2021 to August 2023. Among these, 154 patients received SGLT2i therapy, while 131 patients were assigned to a non-SGLT2i group, following specified inclusion and exclusion criteria. The association between SGLT2i therapy and the risk of primary and secondary endpoints was analyzed, alongside the effect of guideline-recommended heart failure medications at varying dosages on Major Adverse Cardiovascular Events (MACE).

RESULTS

SGLT2i treatment led to reductions in blood pressure, uric acid, NT-proBNP, and pulmonary artery pressure, while increasing body mass index (BMI) and left ventricular ejection fraction (LVEF) in CHF patients. Multivariate Cox regression analysis revealed that SGLT2i therapy reduced the primary endpoint risk by 40.3% (HR 0.597, 95% CI 0.356-0.973, p = 0.047). Univariate Cox regression indicated that SGLT2i might also reduce the incidence of new diagnoses of atrial fibrillation, non-fatal acute myocardial infarction, and MACE in CHF patients. Moreover, the use of a four-drug combination for heart failure management was associated with a lower risk of MACE compared to monotherapy.

CONCLUSION

SGLT2i therapy not only enhances LVEF but also significantly reduces ambulatory blood pressure, uric acid, fasting blood glucose, pulmonary artery pressure, and NT-proBNP levels in CHF patients. Additionally, SGLT2i improves prognosis by lowering the risk of both primary and secondary endpoints. Compared to monotherapy, a four-drug regimen for CHF substantially reduces the risk of MACE, supporting the effectiveness of comprehensive treatment strategies.

Effect of sodium glucose cotransporter 2 inhibitors on all cause death and rehospitalization for heart failure in patients with acute myocardial infarction

The impact of sodium-glucose co-transporter 2 inhibitors (SGLT2-i) on reducing the risk of all-cause mortality and rehospitalization for heart failure (HF) in patients with acute myocardial infarction (AMI) remains unclear. This study aims to evaluate the effect of SGLT2-i on all-cause mortality and rehospitalization for HF in patients diagnosed with AMI. A comprehensive search was conducted in PubMed, Web of Science, the Cochrane Library, and Embase for relevant studies published up to May 2024, following the PICOS principle. Eligible studies included randomized clinical trials and cohort studies comparing SGLT2-i with placebo regarding all-cause mortality, rehospitalization for HF, cardiovascular mortality, and the incidence of nonfatal MI in AMI patients. Patient-level data from each trial were synthesized into a pooled dataset and analyzed using a mixed-effects or random-effects model based on the I2 statistic. Ten clinical trials enrolling 15,748 participants (6913 in the SGLT2-i group and 8835 in the placebo group) were included. The follow-up duration ranged from 12 weeks to 2.1 years. SGLT2-i significantly reduced rehospitalization for HF (RR: 0.69, 95% CI 0.60-0.81, P < 0.00001, I2 = 39%) compared to placebo. However, SGLT2-i did not significantly reduce the risk of all-cause death (RR: 0.85, 95% CI 0.72-1.00, P = 0.05, I2 = 46%), cardiovascular death (RR: 0.96, 95% CI 0.78-1.18, P = 0.67, I2 = 24%) or nonfatal MI (RR: 0.71, 95% CI 0.44-1.14, P = 0.16, I2 = 64%) during follow-up. Compared to placebo, SGLT2-i significantly reduced rehospitalization for HF in patients with AMI, but did not reduce the risk of all-cause death, cardiovascular death and nonfatal MI.

ANRIL's Epigenetic Regulation and Its Implications for Cardiovascular Disorders

Cardiovascular disorders (CVDs) are a major global health concern, but their underlying molecular mechanisms are not fully understood. Recent research highlights the role of long noncoding RNAs (lncRNAs), particularly ANRIL, in cardiovascular development and disease. ANRIL, located in the human genome's 9p21 region, significantly regulates cardiovascular pathogenesis. It controls nearby tumor suppressor genes CDKN2A/B through epigenetic pathways, influencing cell growth and senescence. ANRIL interacts with epigenetic modifiers, leading to altered histone modifications and gene expression changes. It also acts as a transcriptional regulator, impacting key genes in CVD development. ANRIL's involvement in cardiovascular epigenetic regulation suggests potential therapeutic strategies. Manipulating ANRIL and its associated epigenetic modifiers could offer new approaches to managing CVDs and preventing their progression. Dysregulation of ANRIL has been linked to various cardiovascular conditions, including coronary artery disease, atherosclerosis, ischemic stroke, and myocardial infarction. This abstract provides insights from recent research, emphasizing ANRIL's significance in the epigenetic landscape of cardiovascular disorders. By shedding light on ANRIL's role in cellular processes and disease development, the abstract highlights its potential as a therapeutic target for addressing CVDs.

Cardiovascular autonomic neuropathy in diabetes: an update with a focus on management

Cardiovascular autonomic neuropathy (CAN) is an under-recognised yet highly prevalent microvascular complication of diabetes. CAN affects approximately 20% of people with diabetes, with recent studies highlighting the presence of CAN in prediabetes (impaired glucose tolerance and/or impaired fasting glucose), indicating early involvement of the autonomic nervous system. Understanding of the pathophysiology of CAN continues to evolve, with emerging evidence supporting a potential link between lipid metabolites, mitochondrial dysfunction and genetics. Recent advancements, such as streamlining CAN detection through wearable devices and monitoring of heart rate variability, present simplified and cost-effective approaches for early CAN detection. Further research on the optimal use of the extensive data provided by such devices is required. Despite the lack of specific pharmacological interventions targeting the underlying pathophysiology of autonomic neuropathy, several studies have suggested a favourable impact of newer glucose-lowering agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, where there is a wealth of clinical trial data on the prevention of cardiovascular events. This review delves into recent developments in the area of CAN, with emphasis on practical guidance to recognise and manage this underdiagnosed condition, which significantly increases the risk of cardiovascular events and mortality in diabetes.

Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Acute Coronary Syndrome: A Modern Cinderella?

PURPOSE

Atherosclerotic cardiovascular disease remains a prominent global cause of mortality, with coronary artery disease representing its most prevalent manifestation. Recently, a novel class of antidiabetic medication, namely sodium-glucose cotransporter-2 (SGLT2) inhibitors, has been reported to have remarkable cardiorenal advantages for individuals with type 2 diabetes mellitus (DM), and they may reduce cardiorenal risk even in individuals without pre-existing DM. Currently, there is no evidence regarding the safety and efficacy of these drugs in acute coronary syndrome (ACS), regardless of diabetes status. This review aims to comprehensively present the available preclinical and clinical evidence regarding the potential role of SGLT2 inhibitors in the context of ACS, as adjuncts to standard-of-care treatment for this patient population, while also discussing potential short- and long-term cardiovascular benefits.

METHODS

A literature search was performed through MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, and Scopus until February 26, 2024. Eligible were preclinical and clinical studies, comprising randomized controlled trials (RCTs), real-world studies, and meta-analyses.

FINDINGS

Evidence from preclinical models indicates that the use of SGLT2 inhibitors is associated with a blunted ischemia-reperfusion injury and decreased myocardial infarct size, particularly after prior treatment. Although RCTs and real-world data hint at a potential benefit in acute ischemic settings, showing improvements in left ventricular systolic and diastolic function, decongestion, and various cardiometabolic parameters such as glycemia,body weight, and blood pressure, the recently published DAPA-MI (Dapagliflozin in Myocardial Infarction without Diabetes or Heart Failure) trial did not establish a clear advantage regarding surrogate cardiovascular end points of interest. SGLT2 inhibitors appear to provide a benefit in reducing contrast-induced acute kidney injury events in patients with ACS undergoing percutaneous coronary intervention. However, data on other safety concerns, such as treatment discontinuation because of hypotension, hypovolemia, or ketoacidosis, are currently limited.

IMPLICATIONS

Despite the well-established cardiovascular benefits observed in the general population with type 2 DM and, more recently, in other patient groups irrespective of diabetes status, existing evidence does not support the use of SGLT2 inhibitors in the context of ACS. Definitive answers to this intriguing research question, which could potentially expand the therapeutic indications of this novel drug class, require large-scale, well-designed RCTs.

The effect of Empagliflozin on echocardiographic parameters in diabetic patients after acute myocardial infarction: A systematic review and meta-analysis with trial sequential analysis

Patients with diabetes mellitus (DM) are at higher risk of cardiovascular events, particularly acute myocardial infarction (MI). Sodium-glucose cotransporter 2 inhibitors (SGLT2i) can improve cardiac outcomes among heart failure individuals, however, the effects on acute myocardial infarction remain unclear. This meta-analysis investigates the impact of empagliflozin in diabetic patients following acute myocardial infarction. We comprehensively searched PubMed, Scopus, Cochrane, and Web of Science through August 10th, 2023. We included studies comparing empagliflozin versus placebo in diabetes patients with acute myocardial infarction. We used Revman to report the data as mean difference (MD) and 95% confidence interval (CI), and our effect size with a random effects model. Additionally, we performed Trial Sequential Analysis (TSA) to test the robustness of the results. The study protocol was published on PROSPERO with ID: CRD42023447733. Five studies with a total of 751 patients were included in our analysis. Empagliflozin was effective to improve LVEF% (MD: 1.80, 95% CI [0.50, 3.10], p = 0.007), left ventricular end-diastolic volume (LVEDV) (MD: -9.93, 95% CI [-16.07, -3.80], p = 0.002), and left ventricular end-systolic volume (LVESV) (MD: -7.91, 95% CI [-11.93, -3.88], p = 0.0001). However, there was no difference between empagliflozin and placebo groups in terms of NT-pro BNP (MD: - 136.59, 95% CI [-293.43, 20.25], p = 0.09), and HbA1c (MD: -0.72, 95% CI [-1.73, 0.29], p = 0.16). Additionally, empagliflozin did not prevent hospitalization due to heart failure (RR: 0.59, 95% CI [0.16, 2.24], p = 0.44, I-squared = 0%), and mortality (RR: 1.34, 95% CI [0.15,11.90], p = 0.79, I-squared = 25%). Empagliflozin initiation in diabetic patients following acute MI may improve echocardiographic parameters. However, empagliflozin might not be effective in heart failure prevention and optimal glycemic control in this patient population. Further large-scale trials are warranted to ascertain our findings.

EMMY trial: What we know and what we need to know

SGLT-2 inhibitors are a class of antidiabetic drugs with additional cardiovascular benefits. Though initially developed for glycemic control, subsequent studies in the heart failure (HF) population also demonstrated positive outcomes. Currently, they are approved for use in HF with both reduced and preserved ejection fraction. More recently, encouraging data have emerged on acute HF. Following an episode of acute myocardial infarction, patients are also at high risk for developing HF and experiencing recurrent events despite optimal therapy. The PARADISE MI study failed to demonstrate any benefits of ARNI in this scenario. The EMMY trial explored the role of SGLT-2i in >450 odds patients with acute MI. At 26 weeks SGLT-2i (empagliflozin) use led to a higher fall in NT-pro-BNP levels compared to standard treatment. There was additional improvement in left ventricular echocardiographic parameters with empagliflozin too. However, it was a small trial, had a short follow-up and there were no clinical endpoints. But none the least, it attested to the safety of SGLT-2i in the post-MI scenario. Because the primary care physician frequently encounters patients in the post-MI scenario, the manuscript provides insights into their practice. Based on contemporary evidence, the universal use of SGLT-2 inhibitors in patients following acute MI is not warranted. A further role of these drugs in post-MI HF will be clarified in ongoing trials.

Protective Mechanisms of SGLTi in Ischemic Heart Disease

Ischemic heart disease (IHD) is a common clinical cardiovascular disease with high morbidity and mortality. Sodium glucose cotransporter protein inhibitor (SGLTi) is a novel hypoglycemic drug. To date, both clinical trials and animal experiments have shown that SGLTi play a protective role in IHD, including myocardial infarction (MI) and ischemia/reperfusion (I/R). The protective effects may be involved in mechanisms of energy metabolic conversion, anti-inflammation, anti-fibrosis, ionic homeostasis improvement, immune cell development, angiogenesis and functional regulation, gut microbiota regulation, and epicardial lipids. Thus, this review summarizes the above mechanisms and aims to provide theoretical evidence for therapeutic strategies for IHD.

Assessing the Sympatholytic Effects of SGLT2 Inhibitors in Anuric Haemodialysis Patients Using Microneurography: Study Protocol for a Mechanistic Proof-of-Concept Trial

INTRODUCTION

Sodium-glucose co-transporter 2 inhibitors (SGLT2is) have been shown to provide effective cardiorenal protection, reducing mortality in conditions such as heart failure and chronic kidney disease. While several mechanisms have been identified, recent research has shed light on the drug's ability to attenuate sympathetic nervous system (SNS) activity. Controversy exists on whether this is due to the extra-renal effects of the drug, or simply due to its renoprotective effects. However, recent trials have highlighted the persistent efficacy of SGLT2i despite declining renal function. Therefore, investigating the ability of SGLT2i to attenuate the SNS independently of the kidney could lead to more insight into its mechanism of action. So far, there has been limited research done on investigating the extra-renal effects of SGLT2i in human subjects on dialysis where the glycosuric renal effects of SGLT2i are negligible. This current study therefore aims to investigate the effects of SGLT2i on the SNS in anuric haemodialysis patients.

METHODS

We developed a protocol for a mechanistic study to investigate the extra-renal effects of SGLT2i on the SNS. The study will be an investigator-led, open-label, prospective study involving 20 adult (aged ≥18 years) haemodialysis patients with a residual urine output of ≤250 mL/day. Participants will be administered empagliflozin 25 mg/day for 6 weeks. Baseline SNS activity will be measured before and after administration by microneurography to assess central SNS outflow. Secondary outcomes such as changes from baseline in SNS stressor response, heart rate variability, and endothelial function will also be examined. We hypothesize that the use of empagliflozin will result in reduced sympathetic drive in anuric haemodialysis patients.

DISCUSSION

This will be the first study evaluating the effects of SGLT2i on the SNS in haemodialysis subjects. This study aims to enhance our understanding of the potential role of SGLT2i-induced SNS reduction in the setting of markedly reduced renal function. The study has received ethics approval from the Royal Perth Hospital Human Research Ethics Committee (RGS0000003840) (Australian New Zealand Clinical Trials Registry [ANZCTR] ID: ACTRN12623001237673).

Efficacy of Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Acute Myocardial Infarction: A Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors improve cardiovascular (CV) outcomes in patients with or without Type 2 diabetes and heart failure (HF). However, studies have shown conflicting evidence regarding their efficacy in patients following acute myocardial infarction (MI). We conducted a pilot systematic review and meta-analysis to synthesise the available evidence regarding the effectiveness of SGLT2 inhibitors in MI.

METHODS

A systematic literature search was conducted using PubMed/MEDLINE, the Cochrane Library and Embase databases to identify randomised controlled trials (RCTs) that compared clinical outcomes of SGLT2 inhibitors with placebo following MI. We conducted the statistical analysis using RevMan, version 5.4 and pooled risk ratios (RRs) along the corresponding 95% confidence interval (CI) for all outcomes.

RESULTS

Five RCTs reporting data for 11,211 patients were included in our study. The mean follow-up duration was 43.8 weeks. Our pooled analysis showed that SGLT2 inhibitors significantly reduced the risk of hospitalisations for heart failure (HHF) (RR = 0.76, 95% CI: 0.61-0.88, p = 0.001) in patients with MI. However, the risk of all-cause mortality (RR = 1.05, 95% CI: 0.78-1.41, p = 0.76), CV mortality (RR = 1.04, 95% CI = 0.84-1.29, p = 0.73) and all-cause hospitalisations (RR = 1.06, 95% CI: 0.96-1.17, p = 0.25) remained comparable across the two groups.

CONCLUSION

SGLT2 inhibitors reduce HHF without affecting all-cause mortality, CV mortality and all-cause hospitalisations. However, further evidence is required to reach a definitive conclusion.

Effect of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on N-terminal pro-B-type natriuretic peptide (NT-proBNP) level and structural changes following myocardial infarction: A systematic review and meta-analysis

BACKGROUND

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are anti-hyperglycemic drugs and have been proven to have cardiovascular protective effects for patients with heart failure regardless of their diabetes status. However, the benefit of SGLT2i following myocardial infarction (MI) remains incompletely established. This review aimed to investigate the impact of SGLT2i on NT-proBNP levels and structural changes post-MI.

METHOD

Medline, ClinicalTrial.gov, Scopus, and Directory of open-access journals were searched to retrieve the relevant articles. Eligible studies were randomized clinical trials that assessed NT-proBNP and cardiac structural changes in patients who received SGLT2i compared to placebo following MI. Two reviewers independently screened articles, extracted data, and assessed study quality.

RESULT

Four studies were included in this review, including patients with and without diabetes. While two studies showed no marked decrease from the baseline in NT-proBNP levels between the SGLT2i group and the control group, two studies reported a substantial reduction. The meta-analysis included three of these studies, with a total of 238 participants. The meta-analysis did not find a statistically significant drop in NT-proBNP levels post-MI in the SGLT2 inhibitors group compared to placebo (pooled SMD = 0.16, 95% CI 0.57-0.26, P 0.45). Furthermore, different echocardiographic parameters were reported in the included trials, yet no meta-analysis could be conducted to assess the influence of SGLT2i on cardiac remodeling post-MI.

CONCLUSION

SGLT2i did not result in a statistically significant reduction of NT-proBNP level subsequent to myocardial infarction. A knowledge gap exists regarding the impact of these agents on cardiac remodeling post-MI. Future high-quality clinical trials are needed to provide more robust evidence.

The benefits of oral glucose-lowering agents: GLP-1 receptor agonists, DPP-4 and SGLT-2 inhibitors on myocardial ischaemia/reperfusion injury

Myocardial infarction (MI) is a life-threatening cardiovascular disease that, on average, results in 8.5 million deaths worldwide each year. Timely revascularization of occluded vessels is a critical method of myocardial salvage. However, reperfusion paradoxically leads to the worsening of myocardial damage known as myocardial ischaemia/reperfusion injury (MI/RI). Therefore, reducing the size of myocardial infarction after reperfusion is critical and remains an important therapeutic goal. The susceptibility of the myocardium to MI/RI may be increased by diabetes. Currently, some traditional antidiabetic agents such as metformin reduce MI/RI by decreasing inflammation, inhibiting oxidative stress, and improving vascular endothelial function. This appears to be a new direction for the treatment of MI/RI. Recent cardiovascular outcome trials have shown that several oral antidiabetic agents, including glucagon-like peptide-1 receptor agonists (GLP-1RAs), dipeptidyl peptidase-4 inhibitors (DPP-4is), and sodium-glucose-linked transporter-2 inhibitors (SGLT-2is), not only have good antidiabetic effects but also have a protective effect on myocardial protection. This article aims to discuss the mechanisms and effects of oral antidiabetic agents, including GLP-1RAs, DPP-4is, and SGLT-2is, on MI/RI to facilitate their clinical application.

Cardiovascular outcomes of sodium-glucose Co-transporter 2 inhibitors use after myocardial infarction: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients who had acute myocardial infarction are at high risk of negative cardiac outcomes and previous SGLT2i landmark trials excluded these patients. It therefore remains unclear if SGLT2i is safe and confers beneficial cardiovascular outcomes after acute myocardial infarction.

METHODS

We systematically reviewed randomized controlled trials that evaluated the outcomes of adding SGLT2i to conventional post-myocardial infarction care. Random-effects model meta-analysis via RevMan 5.4 was done on data extracted from pooled 11,204 patients.

RESULTS

SGLT2i use after acute myocardial infarction was significantly associated with reduced heart failure hospitalization (OR: 0.77, 95%CI: 0.62-0.96, p=0.02), but was not associated with a reduction in all-cause mortality (OR: 1.05, 95%CI: 0.77-1.43, p=0.75), cardiac-related death (OR: 1.04, 95%CI: 0.83-1.30, p=0.76), or major adverse cardiac events (OR: 0.90, 95%CI: 0.77-1.05, p=0.18).

CONCLUSION

SGLT2 inhibitor therapy after acute myocardial infarction is safe and is associated with a reduced risk of heart failure hospitalization, but not with all-cause mortality.

Autonomic modulation by SGLT2i or DPP4i in patients with diabetes favors cardiovascular outcomes as revealed by skin sympathetic nerve activity

Background

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP4i) are important second-line treatments for patients with type 2 diabetes mellitus (T2DM). Patients taking SGLT2i have favorable cardiovascular outcomes via various mechanisms, including autonomic nervous system (ANS) modulation. This study aimed to use neuro-electrocardiography (neuECG) to test the effects of SGLT2i or DPP4i on the ANS.

Methods

Patients with T2DM, who did not reach target hemoglobin (Hb)A1C levels despite metformin treatment, were enrolled. SGLT2i or DPP4i were prescribed randomly unless a compelling indication was present. NeuECG and heart rate were recorded for 10 min before and after a 3-month treatment. The patients were treated according to standard practice and the obtained data for skin sympathetic nerve activity (SKNA) and ANS entropy were analyzed offline.

Results

We enrolled 96 patients, of which 49 received SGLT2i and 47 received DPP4i. The baseline parameters were similar between the groups. No adverse event was seen during the study period. In the burst analysis of SKNA at baseline, all parameters were similar. After the 3-month treatment, the firing frequency was higher in SGLT2i group (0.104 ± 0.045 vs 0.083 ± 0.033 burst/min, p < 0.05), with increased long firing duration (7.34 ± 3.66 vs 5.906 ± 2.921, p < 0.05) in 3-s aSKNA scale; the other parameters did not show any significant change. By symbolic entropy, the most complex patterns (Rank 3) were found to be significantly higher in SGLT2i-treated patients than in DDP4i-treated group (0.084 ± 0.028 vs 0.07 ± 0.024, p = 0.01) and the direction of change in Rank 3, after SGLT2i treatment, was opposite to that observed in the DDP4i group (0.012 ± 0.036 vs. -0.005 ± 0.037, p = 0.024). Our findings demonstrated the favorable autonomic modulation by SGLTi and the detrimental effects of DPP4i on ANS.

Conclusion

We demonstrated the autonomic modulation by SGLTi and DPP4i using SKNA in patients with DM, which might provide insights into the favorable outcomes of SGLT2i. Furthermore, we refined the analytical methods of neuECG, which uses SKNA to evaluate autonomic function.

Effectiveness of Sodium-Glucose Cotransporter 2 Inhibitors in Patients With Acute Myocardial Infarction With or Without Type 2 Diabetes: A Systematic Review and Meta-analysis

ABSTRACT

Recent studies have revealed the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in heart failure patients. However, their effects on acute myocardial infarction (AMI) remain uncertain. Therefore, we conducted this meta-analysis to assess the effectiveness of SGLT2i in patients with AMI with or without diabetes. We conducted a comprehensive search of PubMed, Embase, and Cochrane Library encompassing data from inception until November 30, 2023. Relevant studies comparing SGLT2i with placebo or non-SGLT2i in patients with AMI were included. The mean difference and/or odds ratio (OR) with 95% confidence intervals were pooled using a fixed-effects model when the heterogeneity statistic (I2) was less than 50%; otherwise, a random-effects model was employed. Four randomized controlled trials and 4 observational studies involving 9397 patients with AMI were included in this meta-analysis. Patients treated with SGLT2i exhibited a significantly lower rate of hospitalization for heart failure (OR = 0.50, 95% CI: 0.32-0.80) and all-cause death (OR = 0.65, 95% CI: 0.44-0.95) compared with those treated with placebo or non-SGLT2i. Furthermore, the use of SGLT2i was associated with a significant increase in left ventricular ejection fraction (mean difference = 1.90, 95% CI: 1.62-2.17) and a greater reduction of N-terminal prohormone of brain natriuretic peptide (OR = 0.88, 95% CI 0.82-0.94). Subgroup analysis revealed that in patients with diabetes, SGLT2i exhibited similar effects. The present meta-analysis provided evidence indicating the effectiveness of SGLT2i in patients with AMI; SGLT2i may serve as an additional therapeutic option for patients with AMI, regardless of the presence or absence of diabetes.

The Renoprotective Mechanisms of Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i)-A Narrative Review

Chronic kidney disease (CKD) is a noncommunicable condition that has become a major healthcare burden across the globe, often underdiagnosed and associated with low awareness. The main cause that leads to the development of renal impairment is diabetes mellitus and, in contrast to other chronic complications such as retinopathy or neuropathy, it has been suggested that intensive glycemic control is not sufficient in preventing the development of diabetic kidney disease. Nevertheless, a novel class of antidiabetic agents, the sodium-glucose cotransporter-2 inhibitors (SGLT2i), have shown multiple renoprotective properties that range from metabolic and hemodynamic to direct renal effects, with a major impact on reducing the risk of occurrence and progression of CKD. Thus, this review aims to summarize current knowledge regarding the renoprotective mechanisms of SGLT2i and to offer a new perspective on this innovative class of antihyperglycemic drugs with proven pleiotropic beneficial effects that, after decades of no significant progress in the prevention and in delaying the decline of renal function, start a new era in the management of patients with CKD.

Empagliflozin's role in reducing ventricular repolarization heterogeneity: insights into cardiovascular mortality decline from the EMPATHY-HEART trial

BACKGROUND

The incidence of myocardial infarction (MI) and sudden cardiac death (SCD) is significantly higher in individuals with Type 2 Diabetes Mellitus (T2DM) than in the general population. Strategies for the prevention of fatal arrhythmias are often insufficient, highlighting the need for additional non-invasive diagnostic tools. The T-wave heterogeneity (TWH) index measures variations in ventricular repolarization and has emerged as a promising predictor for severe ventricular arrhythmias. Although the EMPA-REG trial reported reduced cardiovascular mortality with empagliflozin, the underlying mechanisms remain unclear. This study investigates the potential of empagliflozin in mitigating cardiac electrical instability in patients with T2DM and coronary heart disease (CHD) by examining changes in TWH.

METHODS

Participants were adult outpatients with T2DM and CHD who exhibited TWH > 80 µV at baseline. They received a 25 mg daily dose of empagliflozin and were evaluated clinically including electrocardiogram (ECG) measurements at baseline and after 4 weeks. TWH was computed from leads V4, V5, and V6 using a validated technique. The primary study outcome was a significant (p < 0.05) change in TWH following empagliflozin administration.

RESULTS

An initial review of 6,000 medical records pinpointed 800 patients for TWH evaluation. Of these, 412 exhibited TWH above 80 µV, with 97 completing clinical assessments and 90 meeting the criteria for high cardiovascular risk enrollment. Empagliflozin adherence exceeded 80%, resulting in notable reductions in blood pressure without affecting heart rate. Side effects were generally mild, with 13.3% experiencing Level 1 hypoglycemia, alongside infrequent urinary and genital infections. The treatment consistently reduced mean TWH from 116 to 103 µV (p = 0.01).

CONCLUSIONS

The EMPATHY-HEART trial preliminarily suggests that empagliflozin decreases heterogeneity in ventricular repolarization among patients with T2DM and CHD. This reduction in TWH may provide insight into the mechanism behind the decreased cardiovascular mortality observed in previous trials, potentially offering a therapeutic pathway to mitigate the risk of severe arrhythmias in this population.

TRIAL REGISTRATION

NCT: 04117763.

Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors in Patients with Acute Coronary Syndrome

The evidence for sodium-glucose cotransporter 2 inhibitors (SGLT2i) in the treatment of type 2 diabetes or chronic heart failure was sufficient but lacking in acute coronary syndrome (ACS). Our aim was to investigate the effects of SGLT2i on cardiovascular outcomes in ACS patients. Studies of SGLT2i selection in ACS patients were searched and pooled. Outcomes included all-cause death, adverse cardiovascular events, cardiac remodeling as measured by the left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD), cardiac function as assessed by the left ventricular ejection fraction (LVEF) and NT-proBNP, and glycemic control. Twenty-four studies with 12,413 patients were identified. Compared to the group without SGLT2i, SGLT2i showed benefits in reducing all-cause death (OR 0.72, 95% CI [0.61, 0.85]), major adverse cardiovascular events (MACE) (OR 0.44, 95% CI [0.30, 0.64]), cardiovascular death (OR 0.66, 95% CI [0.54, 0.81]), heart failure (OR 0.52, 95% CI [0.44, 0.62]), myocardial infarction (OR 0.68, 95% CI [0.56, 0.83]), angina pectoris (OR 0.37, 95% CI [0.17, 0.78]), and stroke (OR 0.48, 95% CI [0.24, 0.96]). Results favored SGLT2i for LVEDD (MD -2.03, 95% CI [-3.29, -0.77]), LVEF (MD 3.22, 95% CI [1.71, 4.72]), and NT-proBNP (MD -171.53, 95% CI [-260.98, -82.08]). Thus, SGLT2i treatment reduces the risk of all-cause death and MACE and improves cardiac remodeling and function in ACS patients.