Sodium Glucose Cotransporter Inhibition in Acute Heart Failure: An In-Depth Review

Inhibitors of the sodium glucose cotransporters were initially developed for the treatment of type 2 diabetes but have since been shown to provide many benefits in heart failure, especially in heart failure with reduced ejection fraction (HFrEF). Already an established and foundational therapy for HFrEF, many uncertainties remain with respect to the use and initiation of SGLT2 inhibitors in hospitalized settings and in sicker individuals. Unfortunately, clear guidance or guidelines on this topic is lacking, but over the past few years, several trials have come out attempting to answer this question. This in-depth review aims at summarizing the current evidence not only as it pertains to the use of SGLT2 inhibitors in acute decompensated heart failure but also during acute myocardial infarction. From a brief examination of the history of SGLT2 inhibitor development to an appraisal on where along the spectrum of heart failure SGTL2 inhibition initiation should be considered, this review will also focus on potential advantages of starting SGLT2 inhibition in hospitals, the likely “sweet spot” in terms of timing of initiation, the diuretic augmentation effects of SGLT2 inhibition and how it compares with more traditional sequential blockade with thiazides, and, finally, an in-depth review of the safety surrounding the use of SGLT2 inhibitors in hospitalized patients.