Resident Physician Galveston, Texas, United States
Disclosure(s):
Chandler Oleary, DO, MBA: No financial relationships to disclose
Background: Sodium–glucose cotransporter-2 (SGLT2) inhibitors improve outcomes in chronic and acute heart failure, yet patients with cardiogenic shock have been excluded from major randomized trials. Whether SGLT2 inhibitor therapy is associated with outcomes among patients who develop cardiogenic shock remains unknown.
Methods: We conducted a retrospective cohort study using the TriNetX U.S. Collaborative Network. Adults with a first diagnosis of cardiogenic shock (ICD-10 R57.0) were identified. The exposure cohort included patients with prior SGLT2 inhibitor therapy, defined as documented dapagliflozin or empagliflozin use 1 to 12 months before shock; patients without prior SGLT2 inhibitor therapy served as comparators. The primary analysis excluded patients with ST-elevation myocardial infarction (STEMI) occurring within 30 days before or after shock to reduce confounding from ischemic cardiogenic shock. A prespecified sensitivity analysis was performed among patients with STEMI occurring within 1 day on or before shock. Propensity score matching (1:1) was performed for demographics and major cardiometabolic comorbidities. Outcomes assessed from day 1 to day 30 after shock included all-cause mortality, invasive mechanical ventilation, renal failure (acute kidney injury or dialysis), and mechanical circulatory support (MCS).
Outcome: In the non-STEMI cohort, 15,850 matched patients were included in each group. Prior SGLT2 inhibitor therapy was associated with lower 30-day mortality (21.6% vs 30.3%; hazard ratio [HR] 0.66, 95% CI 0.63–0.69) and lower invasive mechanical ventilation (12.2% vs 16.7%; HR 0.70, 95% CI 0.66–0.73). Rates of renal failure were similar between groups, while MCS utilization was higher among patients with prior SGLT2 inhibitor therapy (8.2% vs 6.8%).
In the STEMI-associated cardiogenic shock sensitivity analysis (2,117 matched patients per group), prior SGLT2 inhibitor therapy remained associated with lower mortality (20.0% vs 30.8%; HR 0.59, 95% CI 0.52–0.67) and lower invasive mechanical ventilation (11.6% vs 15.5%; HR 0.71, 95% CI 0.60–0.84), without differences in renal failure or MCS utilization.
Conclusion: Among patients with first-episode cardiogenic shock, prior SGLT2 inhibitor therapy was associated with lower short-term mortality and reduced invasive mechanical ventilation in analyses excluding STEMI, with consistent findings in STEMI-associated shock. No excess renal failure was observed, and phenotype-specific MCS utilization patterns emerged, supporting a protective role warranting prospective study.
