Impact of early initiation of sodium-glucose cotransporter 2 inhibitors on cardiac remodeling in patients with acute myocardial infarction: a meta-analysis and trial sequential analysis of controlled
D D'amario, S Elia, R Laborante, G PattiAbstract
Aims
An early initiation of sodium–glucose co-transporter-2 inhibitors (SGLT2i) after acute myocardial infarction (AMI) might reduce the rates of heart failure hospitalization and attenuate adverse ventricular remodeling. However, the published evidence is inconsistent and individual study can be underpowered. Thus, we performed a meta-analysis aimed at evaluating the impact of an early initiation of SGLT2i on echocardiographic measurements and laboratory markers of cardiac remodeling in patients with acute myocardial infarction (AMI).
Methods and results
PubMed, Embase, Scopus and Cochrane Library were searched up to November 2025 for controlled randomized trials comparing early initiation (i.e. within 0-24 weeks) of SGLT2i with placebo or standard therapy in patients with AMI. Study endpoints were pooled mean differences (MD) in left-ventricular ejection fraction (LVEF %), end-diastolic volume (LVEDV), end-systolic volume (LVESV), mass index (LVMi), ratio of peak early diastolic trans-mitral flow velocity to peak early diastolic mitral annular velocity (E/e') and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP) at the longest follow-up. A total of nine trials (n = 1199) met eligibility. As compared with control, SGLT2i significantly increased LVEF (MD +1.72%; 95 % CI 0.75–2.69, p<0.01) and reduced LVEDV (MD −4.70 ml, 95% CI −9.20 - −0.20, p=0.04) and NT-proBNP (MD − 40.02 pg/mL, 95 % CI − 78.73 - − 1.30, p=0.04). A significant reduction in E/e′ (MD −0.54, 95% CI −1.01 - −0.07) was also observed. No significant effect was found for LVESV (MD −2.63, 95% CI −5.71 - 0.45, p=0.09) or LVMi (MD −3.80, 95% CI −8.77 - 1.18, p=0.13). A Trial-sequential analysis was carried out to assess the conclusiveness of the results: the increase in LVEF% revealed to be a robust and conclusive evidence among the trials, whereas additional data are required for the remaining echocardiographic and laboratory outcomes.
Conclusion
In patients with AMI, early SGLT2i therapy initiation modestly yet meaningfully reduced adverse remodeling, indicating that focusing treatment on those at greatest risk for these maladaptive ventricular changes could maximize clinical benefit.