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"In-Hospital Initiation of SGLT-2 Inhibitors in Acute Heart Failure: A Systematic Review and Meta-Analysis of
Hafiz M Ahmed1, Ubaid Ur Rehman2, Muhammad Owais2
1Department of Medicine, Punjab Medical College, Faisalabad Medical University, Faisalabad, Pakistan. mohammadahmed818@yahoo.com.
Insights
Initiating sodium-glucose cotransporter-2 (SGLT-2) inhibitors during acute heart failure (AHF) hospitalization is safe and reduces clinical events. Early SGLT-2 inhibitor use improves decongestion markers and supports potential guideline updates for AHF management.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Acute heart failure (AHF) has high morbidity and mortality.
- Current AHF management includes diuretics, vasodilators, and inotropes.
- SGLT-2 inhibitors are recommended for chronic heart failure but their role in AHF hospitalization is unclear.
Purpose of the Study:
- To evaluate the efficacy and safety of initiating SGLT-2 inhibitors during AHF hospitalization.
- To conduct the largest meta-analysis on in-hospital SGLT-2 inhibitor initiation.
- To comprehensively assess decongestion outcomes in AHF patients treated with SGLT-2 inhibitors.
Main Methods:
- Systematic search of PubMed, Scopus, Cochrane CENTRAL, and Google Scholar.
- Inclusion of 18 randomized controlled trials (RCTs) with 15,560 adult patients hospitalized with AHF.
- Random-effects models used to pool clinical, decongestion, and safety outcomes.
Main Results:
- In-hospital SGLT-2 initiation reduced heart failure worsening/hospitalization (NNT=48) and improved quality of life.
- Improved decongestion markers observed: enhanced diuretic efficiency, greater weight loss, and lower NT-proBNP.
- Modest reduction in all-cause mortality, with no significant increase in adverse events like AKI or hypoglycemia.
Conclusions:
- In-hospital SGLT-2 inhibitor initiation is safe and effective for AHF.
- Early initiation improves clinical events and decongestion markers.
- Findings support early use and suggest potential updates to AHF guidelines, pending further data.
Background:
Acute heart failure (AHF) carries high morbidity and mortality and is traditionally managed with diuretics, vasodilators, and inotropes. Although guidelines recommend SGLT-2 inhibitors for chronic heart failure to reduce morbidity and mortality, their efficacy and safety when initiated during AHF hospitalization remain incompletely defined. To address this gap, we performed the largest, most contemporary meta-analysis focused exclusively on in-hospital initiation, including the first comprehensive pooled evaluation of decongestion outcomes.
Methods:
We systematically searched PubMed, Scopus, Cochrane CENTRAL, and Google Scholar from inception to February 7, 2026, following PRISMA 2020 guidelines and a pre-registered PROSPERO protocol. Eligible studies were randomized controlled trials enrolling adults hospitalized with AHF receiving in-hospital SGLT-2 inhibitors versus placebo/standard care. Random-effects models (REML) pooled clinical, decongestion, and safety outcomes.
Results:
Eighteen RCTs (n = 15,560) were included. In-hospital SGLT-2 initiation significantly reduced heart failure worsening or hospitalization (RR 0.77, 95% CI 0.67-0.88; NNT = 48) and improved quality of life (KCCQ-12 MD + 2.88 points, p = 0.01). Decongestion outcomes favored SGLT-2 inhibitors, with improved diuretic efficiency (SMD 0.52, p = 0.001), greater weight loss (MD - 0.94 kg, p < 0.001), and lower NT-proBNP (MD - 313.6 pg/mL, p = 0.04). All-cause mortality showed a modest reduction (RR 0.74, p = 0.035) but demonstrated potential publication bias and was attenuated in trim-and-fill analysis. Cardiovascular and non-cardiovascular death, and hospitalization length, were not significantly different. Critically, no increase was detected in AKI, hypotension, hypoglycemia, ketoacidosis, genitourinary infections, or other serious adverse events.
Conclusions:
In-hospital SGLT-2 inhibitor initiation appears safe and is associated with reduced clinical events and modest improvements in decongestion markers. These findings support early in-hospital initiation as a feasible and safe strategy, although the current evidence, while promising, highlights the need for further long-term confirmatory data and provides a basis for potential updates to acute heart failure guidelines.
Prospero Id:
CRD420261297253.
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