Early Initiation of Sodium-Glucose Cotransporter 2 Inhibitors in Acute Decompensated Heart Failure: Efficacy, Safety, and Implementation in Stabilized Patients

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have fundamentally reshaped the pharmacological management of chronic heart failure (HF). However, the role of these inhibitors during the vulnerable phase of acute decompensated heart failure (ADHF) has historically been limited by concerns regarding hemodynamic stability and renal function. Recent clinical evidence suggests that the intensive care unit (ICU) and coronary care unit (CCU) may be optimal settings for initiating these disease-modifying therapies. This narrative review aims to evaluate the safety, efficacy, and clinical impact of early in-hospital initiation of SGLT2 inhibitors in patients admitted for ADHF, focusing on hemodynamic recovery, decongestion, and prevention of early readmission. Early initiation of SGLT2 inhibitors is associated with significant clinical benefits, including rapid decongestion, shorter length of hospital stay, and a reduction in the 30-day composite endpoint of death or worsening HF. Furthermore, SGLT2 inhibitors exhibit synergistic effects with loop diuretics, helping to overcome diuretic resistance. Safety profiles remain favorable when patients satisfy basic clinical stability criteria. The traditional wait-and-see approach to initiating SGLT2 inhibitors is being replaced by a proactive early-start strategy. In the cardiac intensive care setting, SGLT2 inhibitors are no longer viewed solely as metabolic agents but also as tools for acute hemodynamic optimization. Further research is required to refine the management of euglycemic ketoacidosis and to determine the optimal timing of initiation in patients requiring mechanical circulatory support.