Sodium-glucose Co-transporter-2 (SGLT2) inhibitors and use in patients with acute coronary syndromes: The 5th Paradigm shift?


Take Home Messages
  • Benefits of SGLT2is in patients with type 2 diabetes mellitus (T2DM) and stable atherosclerotic cardio-vascular disease (ASCVD) are established, however, their role in acute coronary syndrome is unclear.
  • There is growing evidence showing improved outcomes when initiated early post-ACS in patients with T2DM and possibly in non-diabetic patients. However, safety profile not yet clear.
  • Ongoing research, including randomized controlled trials, are currently underway to assess this and potential role in patients without diabetes.
  • If proven to be safe with improved outcomes, SGLT2is will lead to significant change in management of patients with ACS, especially those not deemed appropriate for intervention.

Sodium-glucose co-transporter 2 inhibitor (SGLT2i) precursors were discovered in 1835 and glycosuric effects confirmed in 1886. Subsequently, there have been four paradigm shifts in the use of SGLTIs as eloquently summarised by Eugene Braunwald (1). These medicines reduced cardiovascular mortality and development of heart failure in patients with type 2 diabetes (T2DM) and cardiovascular disease (2–4). Additionally, similar benefits were seen in patients with heart failure (reduced and preserved ejection fraction), irrespective of diabetes, and in patients with chronic kidney disease (5–9). The benefits and optimal initiation of SGLTIs in patients with acute coronary syndrome (ACS) are still not proven. Could this represent the fifth paradigm shift in the use of SGLTIs?