"In-Hospital Initiation of SGLT-2 Inhibitors in Acute Heart Failure: A Systematic Review and Meta-Analysis of Clinical, Decongestion, and Safety Outcomes"

Why clinicians should know about it

• Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 2 August 2026): Meta‑analysis of in‑hospital SGLT‑2 initiation in AHF

Abstract

BACKGROUND: Acute heart failure (AHF) carries high morbidity and mortality and is traditionally managed with diuretics, vasodilators, and inotropes. Although guidelines recommend SGLT-2 inhibitors for chronic heart failure to reduce morbidity and mortality, their efficacy and safety when initiated during AHF hospitalization remain incompletely defined. To address this gap, we performed the largest, most contemporary meta-analysis focused exclusively on in-hospital initiation, including the first comprehensive pooled evaluation of decongestion outcomes. METHODS: We systematically searched PubMed, Scopus, Cochrane CENTRAL, and Google Scholar from inception to February 7, 2026, following PRISMA 2020 guidelines and a pre-registered PROSPERO protocol. Eligible studies were randomized controlled trials enrolling adults hospitalized with AHF receiving in-hospital SGLT-2 inhibitors versus placebo/standard care. Random-effects models (REML) pooled clinical, decongestion, and safety outcomes. RESULTS: Eighteen RCTs (n = 15,560) were included. In-hospital SGLT-2 initiation significantly reduced heart failure worsening or hospitalization (RR 0.77, 95% CI 0.67-0.88; NNT = 48) and improved quality of life (KCCQ-12 MD + 2.88 points, p = 0.01). Decongestion outcomes favored SGLT-2 inhibitors, with improved diuretic efficiency (SMD 0.52, p = 0.001), greater weight loss (MD - 0.94 kg, p < 0.001), and lower NT-proBNP (MD - 313.6 pg/mL, p = 0.04). All-cause mortality showed a modest reduction (RR 0.74, p = 0.035) but demonstrated potential publication bias and was attenuated in trim-and-fill analysis. Cardiovascular and non-cardiovascular death, and hospitalization length, were not significantly different. Critically, no increase was detected in AKI, hypotension, hypoglycemia, ketoacidosis, genitourinary infections, or other serious adverse events. CONCLUSIONS: In-hospital SGLT-2 inhibitor initiation appears safe and is associated with reduced clinical events and modest improvements in decongestion markers. These findings support early in-hospital initiation as a feasible and safe strategy, although the current evidence, while promising, highlights the need for further long-term confirmatory data and provides a basis for potential updates to acute heart failure guidelines. PROSPERO ID: CRD420261297253.

Abstract as published, via PubMed.