Therapeutic effects of sodium–glucose cotransporter 2 inhibitors in patients with heart failure with preserved ejection fraction: From outcome improvement to potentially favourable influences on atrial fibrillation burden, atrial fibrillation progression and atrial cardiomyopathy

Abstract

This article refers to 'Empagliflozin in heart failure with preserved ejection fraction with and without atrial fibrillation' by G. Filippatos et al., published in this issue on pages 970-977.Atrial fibrillation (AF) and heart failure (HF) frequently coexist, but the link is particularly tight in HF with preserved ejection fraction (HFpEF). Taking into account the whole spectrum of HF patients, the prevalence of AF appears to be higher when HF is diagnosed in association with higher values of left ventricular ejection fraction (EF). 1 Indeed, there is an important interdependence between HFpEF and AF, related to common pathophysiological pathways involving inflammation and fibrosis, leading to a frequent convergence of the two clinical manifestations. 2 Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a cornerstone of pharmacological treatment of both diabetes and HF, 3,4 and in consideration of the mutual interrelationships 2,3 there is growing interest in evaluating the clinical effects on the risk of AF and AF-related outcomes.In this issue of the Journal, Filippatos et al. 5 present an interesting pre-defined secondary analysis of the EMPEROR-Preserved trial, comparing the effects of empagliflozin versus placebo on primary and secondary endpoints, as well as on safety outcomes, stratified

The complex interplay between SGLT2 inhibitors and atrial fibrillation: mechanisms and clinical implications

“…This trial demonstrated that dapagliflozin could reduce the incidence of reported episodes of AF/AFL adverse events, especially in high-risk patients with T2DM. This finding underscores the potential role of dapagliflozin in reducing AF in populations at heightened cardiovascular risk (Boriani et al, 2023).…”

“…• Observational evidence: Multiple observational studies have reported a consistent association between SGLT2 inhibitor use and a reduced risk of AF in individuals with type 2 diabetes mellitus (T2DM) and heart failure. This suggests a potential protective effect of these medications against AF (Lee et al, 2021;Boriani et al, 2023;Zelniker et al, 2020).…”

“…In 2023, Giuseppe Boriani initiated a comprehensive study, demonstrating that empagliflozin yielded a significant reduction in the risk of severe heart failure events and a deceleration in the decline of estimated glomerular filtration rate (eGFR), irrespective of the presence of atrial fibrillation, in patients with heart failure and an ejection fraction greater than 40% (Boriani et al, 2023).…”

The Complex Interplay Between SGLT2 Inhibitors and Atrial Fibrillation: Mechanisms and Clinical Implications

“…• Observational Evidence: Multiple observational studies have reported a consistent association between SGLT2 inhibitor use and a reduced risk of AF in individuals with type 2 diabetes mellitus (T2DM) and heart failure. This suggests a potential protective effect of these medications against AF (60,61,62).…”

“…In 2023, Giuseppe Boriani initiated a comprehensive study, demonstrating that empagliflozin yielded a significant reduction in the risk of severe heart failure events and a deceleration in the decline of estimated glomerular filtration rate (eGFR), irrespective of the presence of atrial fibrillation, in patients with heart failure and an ejection fraction greater than 40%. (61).…”