In-Hospital Initiation of SGLT2 Inhibitors in Patients with Acute Heart Failure: A Meta-analysis of Randomized...

Acute heart failure (AHF) remains a leading cause of hospitalization and mortality despite therapeutic advances. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have shown benefits in chronic HF, but their role when initiated during hospitalization for AHF remains uncertain.

A literature search was conducted across main databases through September 10, 2025 to identify randomized controlled trials (RCTs) evaluating in-hospital initiation of SGLT2 inhibitors in patients with AHF. Primary outcomes were all-cause death and worsening HF. Secondary outcomes included cardiovascular death, HF rehospitalization, and safety endpoints. A random-effects model was used to estimate risk ratios (RRs) with 95% confidence intervals (CIs).

Eight RCTs including 4096 patients were analyzed with a weighted median follow-up of 60 days. In-hospital initiation of SGLT2 inhibitors significantly reduced all-cause death (RR, 0.61; 95% CI, 0.47-0.81) and worsening HF events (RR, 0.67; 95% CI, 0.48-0.94) compared with the control group. The risk of cardiovascular death was significantly lower with SGLT2 inhibitors (RR, 0.68; 95% CI, 0.47-0.99). No significant effect on HF rehospitalizations was observed (RR, 0.87; 95% CI, 0.70-1.09). Safety outcomes, including acute kidney injury, hypotension, hypoglycemia, urinary tract infection, and serious adverse events were comparable between groups. Trial sequential analysis confirmed firm evidence of mortality reduction, while further trials are needed for worsening HF.

In-hospital initiation of SGLT2 inhibitors in patients with AHF lowers mortality and worsening HF without increasing adverse events. Further evidence from large-scale RCTs with longer follow-ups is required to reach a definitive conclusion.