Effect of SGLT2i on Cardiovascular Outcomes in Patients With Preserved Ejection Fraction Heart Failure After Acute Myocardial Infarction

Dear Editor,

We read the article by Calcagno et al ¹ entitled “Impact of SGLT2i on Cardiovascular Outcomes Following Acute Myocardial Infarction With Heart Failure With Preserved Ejection Fraction: Propensity matched Registry Study” with great interest. We congratulate the authors for conducting a valuable multicenter study using real-life data involving 4086 patients. We would like to make some additional comments.

Heart failure (HF) remains a leading cause of death and poses a challenge to the effectiveness of current treatment developments since it is frequently the last stage of several cardiovascular disorders.^2,3 Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have become mainstay therapies in patients with HF with reduced ejection fraction (HFrEF) due to their cardioprotective and hematologic effects. SGLT2i can reduce HF-related hospitalization, independent of left ventricular ejection fraction (LVEF). ⁴ SGLT2i reduce plasma glucose levels by inhibiting glucose reabsorption in the renal tubules. Through their inhibition of sodium reabsorption, they also have a natriuretic effect. The osmotic diuresis that results decreases blood pressure by causing volume depletion. SGLT2i further contribute to weight loss and decreased sympathetic activity. They also exhibit positive effects on lipid profiles.^4,5

In the Calcagno et al ¹ study, it is unclear when SGLT2 inhibitors were started after acute myocardial infarction (AMI). Because this timing may have influenced the results, subgroup analyses could have been performed. Additionally, it is unclear how long after AMI, LVEF was measured. Because a transient decrease in LVEF (stunning) can occur during AMI, it would be important to include this information.

The study evaluated different SGLT2i agents together. It did not investigate whether the effects differed by agent. This could have been addressed in the discussion section.

Approximately 60% of both groups had chronic kidney failure. The study could have addressed whether these patients were able to continue SGLT2i use during follow-up.

As the study authors note, ¹ SGLT2i use has been associated with significantly lower rates of major adverse cardiovascular events (MACE), all-cause mortality, HF, myocardial infarction, stroke, and major bleeding in several studies. ⁴ These findings suggest that SGLT2i may play a potentially important role in patients with a history of AMI. Prospective, randomized, multicenter studies are needed to confirm these results.