PGY-1 Internal Medicine Resident Physician Harlingen, Texas, United States
Disclosure(s):
Muhammad Huzaifa Ahmed Khan, MD: No financial relationships to disclose
Background: SGLT2 inhibitors improve outcomes in chronic heart failure, but their safety and effectiveness in cardiogenic shock are uncertain, leading clinicians to often defer early initiation. We evaluated whether starting SGLT2 inhibitors within 24 hours of admission is associated with improved outcomes in cardiogenic shock among patients with pre-existing heart failure.
Methods: We performed a retrospective cohort study using a large federated electronic health record network from January 1, 2020, to December 31, 2024. Adults (≥18 years) with prior heart failure hospitalized for cardiogenic shock were identified. We excluded patients with acute myocardial infarction, end-stage renal disease, or prior sodium–glucose cotransporter-2 inhibitor (SGLT2i) use. Patients were stratified by early SGLT2i initiation within 24 hours of admission versus no SGLT2i exposure before or within 24 hours. Baseline demographics, comorbidities, lab abnormalities, and medication use were assessed up to two years before hospitalization. One-to-one propensity score matching incorporated these variables, including guideline-directed medical therapy, diuretics, and other treatments. The primary outcome was 1-year all-cause mortality. Secondary outcomes were 1-year all-cause hospitalization and 30-day mortality. Safety outcomes included acute kidney injury and hypotension or dehydration at 7 and 30 days. A composite arrhythmic outcome (cardiac arrest, ventricular tachycardia, ventricular fibrillation) was also assessed.
Outcome: Before propensity score matching, 1,764 patients were in the early SGLT2i cohort and 36,651 were in the non-SGLT2i cohort; after matching, 1,621 patients were included in each cohort. Early SGLT2i initiation was associated with lower 30-day mortality (13.5% vs 25.7%; HR 0.48, 95% CI 0.41–0.57; p< 0.0001) and lower 1-year mortality (23.8% vs 37.1%; HR 0.57, 95% CI 0.50–0.64; p< 0.0001). Early SGLT2i initiation was also associated with a reduced risk of 1-year all-cause hospitalization (49.2% vs 53.7%; HR 0.78, 95% CI 0.71–0.86; p< 0.0001). For safety outcomes at 30 days, early SGLT2i initiation was associated with lower acute kidney injury (31.5% vs 38.9%; HR 0.75, 95% CI 0.67–0.85; p< 0.0001) and a modest reduction in hypotension/dehydration (13.0% vs 14.9%; HR 0.82, 95% CI 0.68–0.99; p=0.04).
Conclusion: In a propensity-matched retrospective EHR cohort of patients with pre-existing heart failure hospitalized for cardiogenic shock, starting SGLT2 inhibitors within 24 hours was linked to lower 30-day and 1-year mortality and fewer hospitalizations at 1 year, without higher 30-day acute kidney injury or hypotension/dehydration. RCTS are required to confirm findings.
