LATE-breaking research from ESC 2025 suggests that initiating sodium-glucose cotransporter-2 inhibitors (SGLT2is) during hospitalisation for heart failure (HF) may reduce early risks of cardiovascular death, worsening HF, and all-cause mortality, supporting their use in inpatient care.
While SGLT2is were first developed to treat type 2 diabetes, multiple studies have shown their benefit in patients with HF regardless of diabetes status. Data on in-hospital initiation, however, have been limited. The DAPA ACT HF-TIMI 68 trial addressed this question by randomising 2,401 adult patients hospitalised for HF with elevated natriuretic peptides across 210 sites in the USA, Canada, Poland, Hungary, and the Czech Republic. Participants were assigned to dapagliflozin 10 mg daily or placebo within 24 hours to 14 days of hospital admission after initial stabilisation. The primary endpoint was a composite of cardiovascular death or worsening HF over two months.
During the study, cardiovascular death or worsening HF occurred in 10.9% of the dapagliflozin group versus 12.7% of placebo (hazard ratio [HR]: 0.86; 95% CI: 0.68–1.08; p=0.20). Cardiovascular death alone occurred in 2.5% versus 3.1% (HR: 0.78; 95% CI: 0.48–1.27), and worsening HF occurred in 9.4% versus 10.3% (HR: 0.91; 95% CI: 0.71–1.18). All-cause mortality was 3.0% versus 4.5% (HR: 0.66; 95% CI: 0.43–1.00). Safety outcomes, including symptomatic hypotension and worsening renal function, were comparable between groups.
A prespecified meta-analysis including DAPA ACT HF-TIMI 68 and two other trials with empagliflozin and sotagliflozin (total 3,527 patients) found that in-hospital SGLT2i initiation significantly reduced early cardiovascular death or worsening HF (HR: 0.71; 95% CI: 0.54–0.93; p=0.012) and all-cause mortality (HR: 0.57; 95% CI: 0.41–0.80; p=0.001).
The evidence suggests that starting SGLT2is during hospitalisation is safe and may offer early clinical benefit, reinforcing the role of these agents as part of guideline-directed therapy in patients admitted with HF.
Reference
Berg D. DAPA ACT HF-TIMI 68: Dapagliflozin in patients hospitalised for acute heart failure. ESC Congress 2025, 29 August-1 September, 2025.
