Timing of SGLT2i initiation after acute myocardial infarction

Abstract

Background Pharmacological post-MI treatment is routinely initiated at intensive/cardiac care units. However, solid evidence for an early start of these therapies is only available for dual platelet therapy and statins, whereas data on beta blockers and RAAS inhibitors are heterogenous and mainly limited to STEMI and heart failure patients. Recently, the EMMY trial provided the first evidence on the beneficial effects of SGLT2 inhibitors (SGLT2i) when initiated early after PCI. In patients with type 2 diabetes mellitus, SGLT2i are considered “sick days drugs” and it, therefore, remains unclear if very early SGLT2i initiation following MI is as safe and effective as delayed initiation. Methods and results The EMMY trial evaluated the effect of empagliflozin on NT-proBNP and functional and structural measurements. Within the Empagliflozin group, 22 (9.5%) received early treatment (< 24 h after PCI), 98 (42.2%) within a 24 to < 48 h window (intermediate), and 111 (48.1%) between 48 and 72 h (late). NT-proBNP levels declined by 63.5% (95%CI: − 69.1; − 48.1) in the early group compared to 61.0% (− 76.0; − 41.4) in the intermediate and 61.9% (− 70.8; − 45.7) in the late group (n.s.) within the Empagliflozin group with no significant treatment groups—initiation time interaction (pint = 0.96). Secondary endpoints of left ventricular function (LV-EF, e/e`) as well as structure (LVESD and LVEDD) were also comparable between the groups. No significant difference in severe adverse event rate between the initiation time groups was detected. Conclusion Very early administration of SGLT2i after acute myocardial infarction does not show disadvantageous signals with respect to safety and appears to be as effective in reducing NT-proBNP as well as improving structural and functional LV markers as initiation after 2–3 days.

Impact of baseline ECG characteristics on changes in cardiac biomarkers and echocardiographic metrices after acute myocardial infarction treated with Empagliflozin

“…The administration of 10 mg Empagliflozin has beneficial cardiac effects including reduction in NTproBNP levels as well as improvements in structural (LVESV and LVEDV) and functional cardiac parameters (LVEF, E/eʹ) compared to placebo after AMI if administered early after PCI 20 . Furthermore, the very early administration of SGLT2-inhibitors appears to have no disadvantages with respect to safety post AMI and was found to be effective in reducing NTproBNP levels and structural as well as functional cardiac parameters 22 .…”

Two years with GIOIA ‘Effects of gliflozins and gliptins on markers of cardiovascular damage in type 2 diabetes’: A prospective, multicentre, quasi‐experimental study on sodium‐glucose cotransporter 2 and dipeptidyl peptidase‐4 inhibitors in diabetes clinical practice

“…We found a slight improvement of ejection fraction in the only cohort with SGLT‐2i, confirming the potential CV benefit of this class of treatment. Empagliflozin already showed a significant improvement in LVEF in patients undergoing percutaneous coronary intervention for myocardial infarction in the EMMY trial 30 . Furthermore, in a trial of 88 patients with diabetes with heart failure with reduced ejection fraction the use of canagliflozin resulted in a significant improvement in LVEF compared with sitagliptin after 12 weeks 31 …”

“…Empagliflozin already showed a significant improvement in LVEF in patients undergoing percutaneous coronary intervention for myocardial infarction in the EMMY trial. 30 Furthermore, in a trial of 88 patients with diabetes with heart failure with reduced ejection fraction the use of canagliflozin resulted in a significant improvement in LVEF compared with sitagliptin after 12 weeks. 31 SGLT-2i showed multiple pleiotropic effects, including antiatherosclerotic effect by reducing vascular inflammation and oxidative stress, improving endothelial dysfunction.…”

N‐terminal pro‐B‐type natriuretic peptide concentrations, testing and associations with worsening heart failure events

“…Therefore, our findings might be partially outdated, especially as they do not mirror the introduction of sodium-glucose co-transporter 2 inhibitors as guideline-directed medical therapy in HF, and randomized controlled tri-als have shown that these drugs decrease NT-proBNP in both acute and chronic settings. [34][35][36] We lacked information on the use of intravenous diuretic treatment, and we consequently defined a WHFE only according to a hospitalization for HF.…”