Effects of SGLT2 inhibitors on cardiac structure and function in stage A and B heart failure with type 2 diabetes: a systematic review and meta-analysis.

Abstract

Background: Stage A and B heart failure (HF) in type 2 diabetes (T2DM) represents a critical window for prevention. Although SGLT2 inhibitors (SGLT2i) are recommended for early HF risk reduction, their direct structural effects on pre-symptomatic myocardium remain insufficiently characterized in this population.

Methods: MEDLINE, Cochrane Central, Scopus, and ClinicalTrials.gov were searched from inception to February 2026 for studies comparing SGLT2i with placebo in T2DM with Stage A and B HF. Risk of bias was assessed with RoB 2.0. R (version4.5.2) was used to analyse outcomes. Certainty of evidence was assessed using GRADE.

Results: Ten trials (n = 773) showed significant reductions in LV mass (-3.37 g), LVMI (-1.84 g/m²) and E/e' (-0.81). SGLT2i improved weight, BMI, HbA1c, and systolic blood pressure. Safety outcomes were favorable, with no diabetic ketoacidosis reported.

Conclusions: SGLT2i use was associated with a significant reduction in LV mass and improvements in filling pressures, suggesting a favorable modification of underlying myocardium in Stage A and B HF. These changes likely reflect hemodynamic unloading and mass regression rather than immediate functional recovery.