Do SGLT2 Inhibitors Improve Prognosis of Acute Myocardial Infarction?

Mikhail N

Published on: 2024-05-15

Abstract

Whether sodium-glucose co-transporters-2(SGLT2) inhibitors have beneficial effects on cardiovascular (CV) events and mortality if given within few days from acute myocardial infarction (AMI) is unknown. The DAPA-MI trial (n= 4,107) evaluated the impact of administration of dapagliflozin on CV outcomes and mortality if started within 10 days from occurrence of an AMI. Using the win-ratio approach, the primary outcome of the DAPA-MI trial was the hierarchical composite of death, hospitalization for heart failure (HFF), nonfatal myocardial infraction (MI), atrial fibrillation/flutter, incident type 2 diabetes,  New York Heart Association Functional Class (NYHAFC) at the last visit, and weight decrease of 5% or greater. After a median duration of follow-up of 11.6 months, the win ratio was in favor of dapagliflozin being 1.34 (95% CI, 1.20 to 1.50, P< 0.001). This improvement in win ratio was mainly attributed to weight reduction (-1.65 kg versus placebo), 47% lower rates of incident type 2 diabetes [hazard ratio (HR) 0.53, 95% CI, 0.36 to 0.77)], and mild amelioration in NYHAFC. However, there was tendency  toward increase in all-cause death  (HR 1.22, 95% CI, 0.77 to 1.92), CV death (HR 1.15, 95% CI, 0.66 to 2.01), all-cause hospitalization (HR 1.12, 95% CI, 0.98 to 1.29), and non-fatal MI (HR 1.11, 95% CI, 0.72 to 1.71) with dapagliflozin. The EMPACT-MI trial (n=6,522) evaluated empagliflozin administered within 14 days after admission for MI. The primary outcome of the EMPACT-MI trial was a composite of first HHF or death from any cause. After a median follow-up of 17.9 months, no significant difference was demonstrated between the empagliflozin and placebo groups in the primary outcome, HR 0.90 (95% CI, 0.76 to 1.06; P=0.21). Empagliflozin decreased rates of the first HHF; HR 0.77 (95% CI, 0.60 to 0.98) and total number of HHF; rate ratio 0.67 (95% CI, 0.51 to 0.89) but did not decrease all-cause death or cardiovascular (CV) death. Both SGLT2 inhibitors were generally safe when started shortly after AMI. In conclusion, early use of dapagliflozin after AMI may reduce incidence of type 2 diabetes and body weight but was associated with a trend toward increased all-cause death, CV death, and MI. Empagliflozin decreased HHF but did not affect mortality. Therefore, shortly after AMI, use of dapagliflozin should be avoided whereas empagliflozin may be used to decrease rates of HHF.