Safety outcomes of SGLT2i in the heart failure trials: A systematic review and Meta-analysis

Hypoglycemic agents and bone health; an umbrella systematic review of the clinical trials' meta-analysis studies

BACKGROUND

No clear consensus exists regarding the safest anti-diabetic drugs with the least adverse events on bone health. This umbrella systematic review therefore aims to assess the published meta-analysis studies of randomized controlled trials (RCTs) conducted in this field.

METHODS

All relevant meta-analysis studies of RCTs assessing the effects of anti-diabetic agents on bone health in patients with diabetes mellitus (DM) were collected in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). English articles published until 15 March 2023 were collected through the search of Cochrane Library, Scopus, ISI Web of Sciences, PubMed, and Embase using the terms "Diabetes mellitus", "anti-diabetic drugs", "Bone biomarker", "Bone fracture, "Bone mineral density" and their equivalents. The methodological and evidence quality assessments were performed for all included studies.

RESULTS

From among 2220 potentially eligible studies, 71 meta-analyses on diabetic patients were included. Sodium-glucose cotransporter-2 inhibitors (SGLT-is) showed no or equivalent effect on the risk of fracture. Dipeptidyl peptidase-4 inhibitors (DPP-4is) and Glucagon-like peptide-1 receptor agonists (GLP-1Ras) were reported to have controversial effects on bone fracture, with some RCTs pointing out the bone protective effects of certain members of these two medication classes. Thiazolidinediones (TZDs) were linked with increased fracture risk as well as higher concentrations of C-terminal telopeptide of type I collagen (CTx), a bone resorption marker.

CONCLUSION

The present systematic umbrella review observed varied results on the association between the use of anti-diabetic drugs and DM-related fracture risk. The clinical efficacy of various anti-diabetic drugs, therefore, should be weighed against their risks and benefits in each patient.

Heart Failure in Older People Part 2: Guideline-Directed Medical Therapy

Heart failure is a common cardiovascular disease that affects older people and has a high rate of mortality. Treatment for heart failure has evolved in the past 10 years to include novel evidence-based agents as well as changes in how medications are initiated and up-titrated. Despite evidence of the importance of using four guideline-directed medications, older people are often undertreated with these lifesaving therapies. Senior care pharmacists play an important role in heart failure management among older people by providing therapeutic recommendations; monitoring therapeutic interventions; and educating patients, caregivers, and/ or providers.

Efficacy and safety of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with acute heart failure: a systematic review and meta-analysis

Background

The effectiveness and safety of a novel class of hypoglycemic medications known as sodium-glucose cotransporter 2 (SGLT2) inhibitors have not been completely established in relation to acute heart failure (AHF). Consequently, we sought to compare the prognostic and safety outcomes of patients administered SGLT2 inhibitors for the treatment of AHF.

Methods

An extensive search of the Web of Science, PubMed, and EMBASE was conducted for randomized controlled trials and observational studies that have evaluated the use of SGLT2 inhibitors in AHF from the inception of these drugs to the present. We compiled data related to cardiovascular safety and prognosis. Aggregated risk ratios (RR), mean differences (MD), or standardized mean differences (SMD) were generated for all outcomes, with 95% confidence intervals (CIs), to evaluate the predictive significance of SGLT2 inhibitors in patients with AHF.

Results

We identified 4,053 patients from 13 studies. Patients experienced a substantial reduction in all-cause mortality (RR = 0.82, 95% CI: 0.70-0.96, P = 0.01), readmission rates (RR = 0.85, 95% CI: 0.74-0.98, P = 0.02), the number of heart failure exacerbation events (RR = 0.69, 95% CI: 0.50-0.95, P = 0.02), and the number of rehospitalization events due to heart failure (RR = 0.71, 95% CI: 0.58-0.86, P < 0.05) in the SGLT2 inhibitors-treatment group compared to a placebo or standard care (control group). SGLT2 inhibitors improved patient quality of life (SMD = -0.24, 95% CI: -0.40 to -0.09, P = 0.002). SGLT2 inhibitors were associated with enhanced diuresis in patients with AHF (MD = 2.83, 95% CI: 1.36-4.29, P < 0.05). Overall, treatment with SGLT2 inhibitors significantly reduced the level of serum NT-proBNP (MD = -497.62, 95% CI: -762.02 to -233.21, P < 0.05) and did not increase the incidence of adverse events (RR = 0.91, 95% CI: 0.82-1.01, P = 0.06).

Conclusions

This meta-analysis suggests that treatment with SGLT2 inhibitors is associated with a better prognosis in patients with AHF than in patients not treated with SGLT2 inhibitors. It is safe and effective to initiate SGLT2 inhibitors in patients with AHF.

Systematic Review Registration

https://www.doi.org/10.37766/inplasy2024.9.0015, identifier (INPLASY202490015).

General physicians' perspectives on SGLT2 inhibitors for heart failure

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are novel agents for heart failure (HF) and are now recommended in guidelines. Understanding general physicians' perspectives can help to optimise utilisation of this new medication.

AIM

To understand the clinical concerns and barriers from general physicians about prescribing SGLT2is in a general medicine cohort.

METHODS

A questionnaire exploring clinicians' experience, comfort level and barriers to prescribing SGLT2is in patients with HF, incorporating two clinical scenarios, was disseminated to Internal Medicine Society of Australia and New Zealand members over a 2-month period.

RESULTS

Ninety-eight participants responded to the questionnaire (10.8% response rate). Most respondents (66.3%) were senior medical staff. Most participants worked in metropolitan settings (64.3%) and in public hospital settings (83.7%). For HF with reduced ejection fraction, 23.5% of participants reported prescribing SGLT2is frequently (defined as prescribing SGLT2is frequently over 75% of occasions). For HF with preserved ejection fraction, 57.1% of participants reported prescribing SGLT2is less than 25% of the time. Almost half of the participants (44%) expressed a high level of familiarity with therapeutic knowledge of SGLT2is, while 47% indicated high familiarity with potential side effects. Patient complexity, cost of medications and discontinuity of care were identified as important barriers. Euglycemic diabetic ketoacidosis was the side effect that caused the most hesitancy to prescribe SGLT2is in 48% of the respondents.

CONCLUSION

General physicians in Australia and Aotearoa New Zealand are familiar with the therapeutic knowledge and side effects of SGLT2is. Patient complexity, medication cost and discontinuity of care were significant barriers to the use of SGLT2is for HF among general physicians.

Sodium-Glucose Cotransporter 2 Inhibitors and Mycotic Genital or Urinary Tract Infections in Heart Failure

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) improve clinical outcomes in persons with heart failure (HF). This class of agents has been consistently associated with an increased risk of mycotic genital infections (MGIs), and in some, but not all trials, urinary tract infections (UTIs). Other medications widely used for cardiac conditions do not cause MGIs and UTIs, so cardiologists and their supporting teams will be encountering clinical questions that they previously did not have to address. This review provides clinicians with practical recommendations about SGLT2i use in individuals with HF as related to the associated MGI and possible UTI risks. Overall, given the benefit of SGLT2is in clinical outcomes, the threshold for not initiating or discontinuing SGLT2is due to concerns for MGIs or UTIs should be high for persons with HF. Likewise, when SGLT2is are discontinued for such concerns, the threshold for reinitiation should be low.

Sodium-Glucose Transporter 2 Inhibitors in Heart Failure: An Overview of Systematic Reviews

Background: Several studies have shown that sodium-dependent glucose transporter 2 inhibitors can be used in the treatment of heart failure. This article summarized systematic reviews of sodium-dependent glucose transporter 2 inhibitors in the treatment of heart failure in order to evaluate efficacy and safety. Methods: We systematically searched eight electronic databases from inception to July 2023. We used Assessment of Multiple Systematic Reviews 2 to evaluate the methodological quality, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 to assess report quality, Risk of Bias in Systematic Review to assess the risk of bias, and Grading of Recommendations Assessment, Development, and Evaluation to rate the quality of evidence. Outcome: A total of 36 systematic reviews were included. Our results were classified as clear evidence of benefit: hospitalization for heart failure; possible benefit: cardiovascular death (mortality) and renal outcome composite; clear evidence of no effect or equivalence: atrial arrhythmias, ventricular arrhythmia, atrial fibrillation, and hypotension; possible harm: genital infection; insufficient evidence to draw a conclusion: atrial flutter, major adverse cardiovascular events, urinary tract infection, acute kidney injury, hypoglycemia, and bone fracture. Conclusions: Sodium-dependent glucose transporter 2 inhibitors are beneficial for the treatment of heart failure, especially in terms of heart failure hospitalization.

Genito-urinary infectious adverse events related to sodium glucose cotransporter-2 inhibitors: a network meta-analysis and meta-regression

INTRODUCTION

Sodium glucose cotransporter-2 inhibitors (SGLT2is) are an emerging class of drugs with wide indications. Controversial evidence exists regarding the risk of urinary tract infection (UTI) and genital infections (GI) with SGLT2is paving way for undertaking this network meta-analysis and meta-regression study.

METHODS

Data from randomized trials evaluating SGLT2is reporting the number of patients with UTI and GI were included. Odds ratios (OR) with 95% confidence intervals (95% CI) were the effect estimates. Meta-regression analysis identified risk factors. Number needed to harm (NNH) was estimated.

RESULTS

Two hundred and sixty-four articles were included [UTI (213 studies; 150,140 participants) and GI (188 studies; 121,275 participants)]. An increased risk of UTI (OR: 1.11; 95% CI: 1.06, 1.16) and GI (OR: 3.5, 95% CI: 3.1, 3.9) was observed. Men showed a lower risk of UTI (OR: 0.2; 95% CI: 0.2, 0.3) and GI (OR: 0.4; 95% CI: 0.4, 0.5). Meta-regression analyses revealed BMI ≥ 30 kg/m2 and duration of SGLT2i treatment for ≥6 months as risk factors. NNH was 16 for UTI and 25 for GI.

CONCLUSION

SGLT2is increase the risk of UTI and GI that needs to be incorporated in the treatment guidelines with precautions in high-risk patients.

PROSPECTIVE PROTOCOL REGISTRATION

https://osf.io/5fwyk.

Comparative Genitourinary Safety of In-class Sodium-Glucose Cotransporter-2 Inhibitors among Patients with Heart Failure with Preserved Ejection Fraction: A Cohort Study

PURPOSE

The American Heart Association recommended sodium-glucose cotransporter-2 inhibitors (SGLT2i) for the management of heart failure with preserved ejection fraction (HFpEF). However, little is known about their real-world in-class comparative safety in patients with HFpEF. We aimed to assess the comparative safety of SGLT2i in the risk of urinary tract infection (UTI) or genital infection separately or as a composite outcome among patients with HFpEF.

METHODS

This cohort study using MarketScan® Commercial and Medicare supplemental databases (2012-2020) included patients aged ≥ 18 years with a diagnosis of HFpEF who initiated SGLT2i therapy. Three pairwise comparison groups were established: cohort 1, dapagliflozin versus canagliflozin; cohort 2, empagliflozin versus canagliflozin; and cohort 3, dapagliflozin versus empagliflozin. After stabilized inverse probability treatment weighting, Cox proportional hazards regression was used to compare the risk of UTI or genital infection separately or as a composite outcome in each cohort.

RESULTS

The risk of the composite outcome did not significantly differ between canagliflozin and dapagliflozin (adjusted hazard ratio [aHR] 0.64; 95% confidence interval [CI] 0.36-1.14) or between empagliflozin and canagliflozin (aHR 1.25; 95% CI 0.77-2.05). Similarly, there was no evidence of difference between dapagliflozin and empagliflozin in this risk (aHR 0.76; 95% CI 0.48-1.21). The results of analyses separately assessing UTI or genital infection were similar.

CONCLUSIONS

There was no significant difference in the risk of UTI or genital infection among patients with HFpEF who initiated canagliflozin, dapagliflozin, or empagliflozin.

Adverse effects of sodium-glucose cotransporter-2 inhibitors in patients with heart failure: a systematic review and meta-analysis

Sodium-glucose cotransoporter-2 inhibitors (SGLT-2Is) improve prognosis in heart failure (HF) patients both with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, these drugs can have some side effects. To estimate the relative risk of side effects in HF patients treated with SGLT-2Is irrespective from left ventricular EF and setting (chronic and non-chronic HF). Five randomized controlled trials (RCTs) enrolling patients with HFrEF, 4 RCTs enrolling non-chronic HF, and 3 RCTs enrolling HFpEF were included. Among side effects, urinary infection, genital infection, acute kidney injury, diabetic ketoacidosis, hypoglycemia, hyperkalemia, hypokalemia, bone fractures, and amputations were considered in the analysis. Overall, 24,055 patients were included in the analysis: 9020 (38%) patients with HFrEF, 12,562 (52%) with HFpEF, and 2473 (10%) with non-chronic HF. There were no differences between SGLT-2Is and placebo in the risk to develop diabetic ketoacidosis, hypoglycemia, hyperkalemia, hypokalemia, bone fractures, and amputations. HFrEF patients treated with SGLT-2Is had a significant reduction of acute kidney injury (RR = 0.54 (95% CI 0.33-0.87), p = 0.011), whereas no differences have been reported in the HFpEF group (RR = 0.94 (95% CI 0.83-1.07), p = 0.348) and non-chronic HF setting (RR = 0.79 (95% CI 0.55-1.15), p = 0.214). A higher risk to develop genital infection (overall 2.57 (95% CI 1.82-3.63), p < 0.001) was found among patients treated with SGLT-2Is irrespective from EF (HFrEF: RR = 1.96 (95% CI 1.17-3.29), p = 0.011; HFpEF: RR = 3.04 (95% CI 1.88-4.90), p < 0.001). The risk to develop urinary infections was increased among SGLT-2I users in the overall population (RR = 1.13 (95% CI 1.00-1.28), p = 0.046) and in the HFpEF setting (RR = 1.19 (95% CI 1.02-1.38), p = 0.029), whereas no differences have been reported in HFrEF (RR = 1.05 (95% CI 0.81-1.36), p = 0.725) and in non-chronic HF setting (RR = 1.04 (95% CI 0.75-1.46), p = 0.806). SGLT-2Is increase the risk of urinary and genital infections in HF patients. In HFpEF patients, the treatment increases the risk of urinary infections compared to placebo, whereas SGLT-2Is reduce the risk of acute kidney disease in patients with HFrEF.

SGLT2i‑treated heart failure patients with a reduced ejection fraction: A meta‑analysis

The aim of this study was to investigate the effects of SGLT2 inhibitors (SGLT2i) on patients with heart failure (HF) and reduced ejection fraction, with or without diabetes. A systematic review of randomized controlled trials (RCTs) was conducted, comparing SGLT2i to a placebo for HF patients. Relevant studies from PubMed, Web of Science, and EMBASE were searched from inception to July 2021, without any language restrictions. The pooled effect was estimated using the odds ratio (OR) and 95% confidence interval (CI). Depending on the heterogeneity test results, either random effects or fixed effects models were selected to estimate the pooled effects. Sensitivity analysis was conducted by gradually removing each study to evaluate the results' stability. A total of 5 RCT studies were included in the analysis. The fixed-effects model demonstrated that the patients in the SGLT2i group had a lower risk of hospitalization for HF/cardiovascular death (OR=0.72; 95% CI, 0.67-0.78), P<0.0001; I2=0.0%, P=0.966), cardiovascular death (OR=0.84, 95% CI (0.77, 0.93), P<0.0001; I2=0.0%, P=0.633), hospitalization for HF (OR=0.69, 95% CI (0.63, 0.75), P<0.0001; I2=0.0%, P=0.933), and all-cause mortality (OR=0.79, 95% CI (0.71, 0.89), P<0.0001; I2=3.3%, P=0.376) compared to the placebo group. Sensitivity analysis showed that the pooled effect value remained stable within the corresponding range, even after each study was gradually removed. In conclusion, SGLT2i can reduce the risk of HF hospitalization, cardiovascular death, and all-cause mortality in patients with HF and a reduced ejection fraction, regardless of the presence or absence of diabetes.

Sodium Glucose Co-Transporter 2 Inhibitors and the Cardiovascular System: Current Knowledge and Future Expectations

Diabetic cardiomyopathy is a well-recognized clinical entity and reflects a complex relationship between metabolic substrates and myocardial function. Sodium glucose co-transporter 2 (SGLT2) inhibitors are antidiabetic agents that are found to exert multiple cardioprotective effects. Large clinical trials showed their beneficial effects on patients with heart failure, reducing the rates of rehospitalizations and improving kidney function. The aim of this review is to summarize the latest evidence in the literature regarding the multiple effects of SGLT2 inhibitors on patients across the spectrum of cardiovascular diseases.

[Introduction of treatments for heart failure and reduced ejection fraction under 50 % : In-hospital optimization using an algorithmic approach]

Recent international guidelines recommend rapid initiation and titration of basic treatments of heart failure but do not explain how to achieve this goal. Despite these recommendations, implementation of treatment in daily practice is poor. This may be partly explained by the profile of the patients (frailty, comorbidities), safety considerations and tolerability issues related to kydney function, low blood pressure or heart rate and hyperkalaemia. In this special article, we intended to help the physician, through an algorithmic approach, to quickly and safely introduce guideline-directed medical therapy in the field of heart failure with ejection fraction under 50%.

Adverse events and drug-drug interactions of sodium glucose co-transporter 2 inhibitors in patients treated for heart failure

INTRODUCTION

Sodium glucose co-transporter 2-inhibitors (SGLT2-I), antihyperglycemic agents, are increasingly prescribed in chronic heart failure (CHF). Their risk for drug-drug interactions (DDI) seems low. Safety-data derive mainly from diabetes-patients. This review aims to summarize adverse-events (AE) and DDI of the SGLT2-I dapagliflozin, empagliflozin and sotagliflozin in patients with CHF.

AREAS COVERED

Literature-search-terms in PubMed were 'adverse event/drug-drug interaction' and 'heart failure AND 'dapagliflozin' OR 'empagliflozin' OR 'sotagliflozin.'AEreported in randomized controlled trials (RCT) comprisegenitaland urinary-tract infections, hypotension, ketoacidosis, renal impairment, hypoglycemia, limb-amputations, Fournier's gangrene, bone-fractures, hepatopathy, pancreatitis, diarrhea, malignancy and venous thromboembolism. Their incidence is largely unknown, since they were not consistently evaluated in RCT of CHF. Further AE from meta-analyses, pharmacovigilance reports, case-series and case-reports include erythrocytosis, hypertriglyceridemia, myopathy, sarcopenia, skin problems, ventricular tachycardia, and urinary retention. The maximal observation period of RCT in CHF was 26 months.DDI were mainly studied in healthy volunteers for 3-8 days. In CHF or diabetes-patients, DDI were reported with interleukin-17-inhibitors, linezolid, lithium, tacrolimus, valproate, angiotensin-receptor-neprilysin-inhibitors and intravenous iron.

EXPERT OPINION

Guidelines recommend treatment with SGLT2-I for CHF but no data on AE during long-term therapy and only little information on DDI are available, which stresses the need for further research. Evidence-based recommendations for ketoacidosis-prevention are desirable.

Efficacy and safety evaluation of SGLT2i on blood pressure control in patients with type 2 diabetes and hypertension: a new meta-analysis

BACKGROUND

The clinical efficacy and safety of SGLT2i in treating patients with type 2 diabetes mellitus and hypertension lack immense data support.

OBJECTIVE

To systematically evaluate the clinical efficacy and safety of SGLT2i in patients with type 2 diabetes mellitus and hypertension by collecting the previously published randomized controlled trials on SGLT2i to provide data support for SGLT2i as an adjuvant in the first-line antihypertensive regimen in patients with type 2 diabetes mellitus and hypertension.

METHODS

Randomized controlled trials comparing SGLT2i with a placebo in treating type 2 diabetes with hypertension were screened strictly according to inclusion and exclusion criteria. The primary efficacy endpoints included 24H systolic blood pressure, 24H diastolic blood pressure, office systolic blood pressure, and office diastolic blood pressure. The secondary efficacy endpoints included HbA1c. The safety indicators were hypoglycemia, urinary tract infection, genital infection, and renal impairment.MD was the combined effect size for continuous variables, and RR was the combined effect size for dichotomous variables.

RESULTS

10 RCTs with 9913 participants (6293 in the SGLT2i group and 3620 in the control group) were included for analysis.SGLT2i is effective in reducing blood pressure compared with placebo in patients with type 2 diabetes and hypertension, 24HSBP (- 5.06 mmHg, 95% CI [- 7.10, - 3.01], t = - 6.19, P < 0.05), 24HDBP (- 2.39 mmHg, 95% CI [- 4.11, - 0.67], t = - 4.15, P = 0.004), Office SBP (- 4.53 mmHg, 95% CI [- 5.66, - 3.40], t = - 9.50, P < 0.05), Office DBP (- 2.12 mmHg, 95% CI [- 3.42, - 0.82], t = - 4.88, P = 0.001). HbA1c decreased significantly (- 0.57%, 95% CI [- 0.60, - 0.54], z = 37.02, p < 0.01). SGLT2i did not increase hypoglycemia compared to placebo (RR = 1.22, 95% CI [0.916, 1.621], z = 1.36 p = 0.174), urinary tract infection (RR = 1.56, 95% CI [0.96, 2.52], z = 1.79 p = 0.073), risk of renal injury (RR = 0.78, 95% CI [0.54, 1.13], Z = 1.31, P = 0.19), but the risk of genital tract infection increased by 2.32 times (RR = 2.32, 95% CI [1.57, 3.42], Z = 4.23, P = 0.00).

CONCLUSION

SGLT2i can effectively control blood pressure and blood glucose and generally has high safety. For patients with type 2 diabetes mellitus and hypertension with a low risk of genital infection, SGLT2i should be considered as an adjuvant drug for a first-line antihypertensive regimen.

SGLT2 inhibition in heart failure with reduced or preserved ejection fraction: Finding the right patients to treat

Sodium-glucose transport inhibitors (SGLT2i) are effective in heart failure (HF) with ejection fraction (EF) <40% (referred to as HF with reduced EF - HFrEF) and left ventricular EF (LVEF) >40%. Current evidence suggests that SGLT2i should be initiated across a large spectrum of EFs and renal function in patients with HF and with and without diabetes. We reviewed the benefits of SGLT2i in the entire spectrum of HF and provided some clues that may guide physicians in their strategy of initiating and maintaining SGLT2i (with or without SGLT1i effect) therapy. Taken together, the evidence thus far arises from an array of trials performed in different settings (acute/chronic), risk categories, and phenotypes of HF (HFrEF/HFpEF), and in addition to the most common HF therapies, supports the homogenous effect of SGLT2i across a large spectrum of patients with HF. SGLT2i appear to be effective and well-tolerated drugs in the majority of clinical HF scenarios, regardless of LVEF, estimated glomerular filtration rate, diabetic status or the level of the acuteness of the clinical setting. Therefore, most patients with HF should be treated with SGLT2i. However, in the face of the therapeutic inertia that has been observed in HF over the past decades, the actual implementation of SGLT2i in routine practice remains the most significant challenge.

Sodium-glucose co-transporter 2 inhibitors in heart failure with mildly reduced or preserved ejection fraction: an updated systematic review and meta-analysis

OBJECTIVES

Heart failure with mildly reduced ejection fraction (HFmrEF)  or  heart failure with preserved ejection fraction (HFpEF)  are associated with significant morbidity and mortality, as well as growing health and economic burden. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are very promising for the outcome improvement of patients with HFpEF or HFmrEF. The meta-analysis was performed to investigate the effects of SGLT2 inhibitors in HFpEF or  HFmrEF, by pooling data from all clinically randomized controlled trials (RCTs) available to increase power to testify.

METHODS

Studies were searched in electronic databases from inception to November, 2022. We performed a meta-analysis to estimate the effect of SGLT2 inhibitors on clinical endpoints in patients with HFpEF or HFmrEF, using trial-level data with consistent endpoint definitions. The primary outcome was the composite of heart failure (HF) hospitalization or cardiovascular death. Hazard ratio (HR) was pooled with 95% confidence interval (CI) for dichotomous data. This study was registered with INPLASY 2022110095.

RESULTS

Six studies involving 15,989 participants were included into the final analysis. Pooled analyses revealed that SGLT2 inhibitors significantly reduced the composite of HF hospitalization or cardiovascular death [HR: 0.79 (0.72-0.85); I² = 0%; P < 0.00001] and HF hospitalizations [HR: 0.74 (0.67-0.82); I² = 0%; P < 0.00001]. This finding was seen in both HFmrEF trials [HR: 0.76 (0.67-0.87); I² = 49%; P < 0.0001] and HFpEF subgroup studies [HR: 0.70 (0.53-0.93); I² = 0%; P = 0.01]. The incidence of any serious adverse events [OR: 0.89 (0.83-0.96); I² = 0%; P = 0.002] was significantly lower in the SGLT2 inhibitor arm. No significant differences were observed between the two groups with regard to cardiovascular death and all-cause death.

CONCLUSIONS

This meta-analysis of patients with heart failure of left ventricular ejection fraction (LVEF) > 40% showed that SGLT2 inhibitors significantly reduce the risk of  the composite of cardiovascular death and hospitalization for heart failure, but not cardiovascular death and all-cause death. Nevertheless, given that SGLT2 inhibitors may reduce the risk of hospitalization for heart failure, they should be considered the fundamental treatment for all patients with HFpEF or  HFmrEF.