Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2025 Nov 3;14(21):7799.
doi: 10.3390/jcm14217799.

SGLT2-is in Acute Heart Failure

Matteo Bianco  1   2 , Concetta Di Nora  1   3 , Renata De Maria  1   4 , Amir Hassan Mousavi  2 , Samuela Carigi  1   5 , Luisa De Gennaro  1   6 , Paolo Manca  1   7 , Maria Vittoria Matassini  1   8 , Vittoria Rizzello  1   9 , Maria Denitza Tinti  1   10 , Giovanna Geraci  11 , Attilio Iacovoni  12 , Furio Colivicchi  13 , Massimo Grimaldi  14 , Fabrizio Oliva  15
Affiliations
Review

SGLT2-is in Acute Heart Failure

Matteo Bianco et al. J Clin Med. .

Abstract

Despite the wealth of evidence in favour of SGLT2 inhibitor use in patients with chronic heart failure, their role in the very early stages of heart failure is still unclear. While the latest update of the European Society of Cardiology guidelines on heart failure advocates the use SGLT2 inhibitors in the acute phases of heart failure based on the results of the latest trials, it does not clarify the appropriate timing to start this therapy, leaving the clinician to decide whether SGLT2 inhibitors should be started directly during hospitalization or at discharge. Conversely, the recently published focused update of the American College of Cardiology expert consensus decision pathway on the clinical assessment, management, and trajectory of patients hospitalized with heart failure clearly supports the safety and early clinical benefit use of SGLT2 inhibitors based on evidence coming from the EMPULSE and SOLOIST-WHF trials. The expert consensus decision pathway states that SGLT2 inhibitors can be initiated regardless of left ventricular ejection fraction at any time during hospitalization and places a greater emphasis on implementing the other pillars of therapy for heart failure with reduced ejection fraction after stabilization. Moreover, the results of the very recent DAPA ACT HF-TIMI 68 trial on dapagliflozin in patients with acute heart failure, although limited by a follow-up of only 2 months, did not show a reduction in mortality or heart failure hospitalizations. Based on the currently available published data, we will review what is already known about the use of these drugs in the early phases of acute heart failure and analyze their pathophysiological rationale from a practical perspective.

Keywords: SGLT2i; acute heart failure; decongestion.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Summary of the main effects of SGLT2is. Abbreviations: ROS, reactive oxygen species; EPO, erythropoietin.
Figure 2
Figure 2
Site of action and main compensatory mechanism of SGLT2is. (A): Site of action of SGLT2is in the kidney. (B): Main compensatory mechanism of SGLT2is in patients with acute heart failure.
Figure 3
Figure 3
Practical approach to the use of SGLT2is in patients with acute decompensated heart failure.
Figure 4
Figure 4
Flowchart for practical use of SGLT2is in patients with acute heart failure.
See this image and copyright information in PMC

References

    1. McDonagh T.A., Metra M., Adamo M., Gardner R.S., Baumbach A., Böhm M., Burri H., Butler J., Čelutkienė J., Chioncel O., et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur. Heart J. 2021;42:3599–3726. doi: 10.1093/eurheartj/ehab368. - DOI - PubMed
    1. Packer M., Anker S.D., Butler J., Filippatos G., Pocock S.J., Carson P., Januzzi J., Verma S., Tsutsui H., Brueckmann M., et al. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. N. Engl. J. Med. 2020;383:1413–1424. doi: 10.1056/NEJMoa2022190. - DOI - PubMed
    1. Anker S.D., Butler J., Filippatos G., Ferreira J.P., Bocchi E., Böhm M., Brunner-La Rocca H.P., Choi D.J., Chopra V., Chuquiure-Valenzuela E., et al. Empagliflozin in Heart Failure with a Preserved Ejection Fraction. N. Engl. J. Med. 2021;385:1451–1461. doi: 10.1056/NEJMoa2107038. - DOI - PubMed
    1. ElSayed N.A., Aleppo G., Aroda V.R., Bannuru R.R., Brown F.M., Bruemmer D., Collins B.S., Hilliard M.E., Isaacs D., Johnson E.L., et al. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46((Suppl. S1)):S267–S278. doi: 10.2337/dc23-S016. - DOI - PMC - PubMed
    1. Korytkowski M.T., Muniyappa R., Antinori-Lent K., Donihi A.C., Drincic A.T., Hirsch I.B., Luger A., McDonnell M.E., Murad M.H., Nielsen C., et al. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 2022;107:2101–2128. doi: 10.1210/clinem/dgac278. - DOI - PMC - PubMed

LinkOut - more resources