SGLT2 Inhibitor Use and Outcomes in Patients with Acute Heart Failure and Low Body Mass Index

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) improve clinical outcomes in patients with heart failure (HF) with a broad range of body mass indices (BMIs); however, concerns remain regarding their tolerability, safety, and clinical outcomes in patients with extremely low BMI.Patients hospitalized for acute HF at a single center between 2021 and 2023 were retrospectively evaluated. Low BMI was defined as < 18.5 kg/m² for patients < 70 years and < 20 kg/m² for those ≥ 70 years. We assessed the clinical characteristics, SGLT2i prescription at discharge, discontinuation within 1 year, and clinical outcomes, including cardiovascular death, HF readmission, and all-cause mortality, were assessed. Time-to-event analyses and inverse probability of treatment weighting (IPTW) were performed.Of 621 patients (median age: 81 years), 29.0% had a low BMI and 35.6% received a SGLT2i at discharge. SGLT2is were prescribed significantly less frequently in patients with low BMI (22.1% versus 41.5%, P < 0.001). Kaplan-Meier analysis showed that the overall 1-year discontinuation-free rate was 0.880, with no significant difference between the BMI groups. In crude analyses, SGLT2i use was associated with lower cardiovascular event rates in the non-low BMI group and lower all-cause mortality in the low BMI group; however, after IPTW adjustment, the latter association was attenuated.SGLT2is were underutilized in patients with HF and low BMI, yet discontinuation and adverse outcomes were not increased. These findings suggest that low BMI alone should not be a reason to avoid or discontinue SGLT2is in patients with acute HF.