Adverse prognostic association of SGLT2 inhibitors in hospitalized heart failure patients with very low body mass index

Abstract Introduction Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been established as key prognostic-improving drugs for heart failure (HF) patients. However, clear evidence regarding specific patient populations in which SGLT2i administration should be avoided remains insufficient. Concerns persist about the potential adverse effects of SGLT2i-induced calorie loss, particularly in Asian populations, who typically have a smaller body sizes and lower body weights. Purpose This study aimed to evaluate the impact of SGLT2i administration at hospital discharge on acute heart failure (AHF) patients with very low body mass index (BMI). Methods We conducted a single-center, retrospective observational study using the COEDO-AHF registry, which included consecutive hospitalized AHF patients. Patients were categorized into two groups using a BMI cutoff of 18 kg/m² and examined the impact of SGLT2i at discharge on prognosis within each group. The primary endpoint was a composite of all-cause death, rehospitalization for HF, and worsening HF requiringincreased diuretic dosage. Results The study included 511 hospitalized AHF patients with a median follow-up of 648 days. The average BMI was 21.7 kg/m², and 65 patients (13%) had a very low BMI (18 kg/m²). In patients with BMI 18 kg/m², those who received SGLT2i had a poorer prognosis compared to those who did not (log-rank, p=0.04, Figure A). Conversely, in patients with BMI ≥18 kg/m², the Kaplan-Meier curve was reversed, indicating a trend toward better prognosis in those who received SGLT2i (log-rank, p=0.16, Figure B). Conclusion In hospitalized AHF patients with very low BMI, SGLT2i administration was associated with a poorer prognosis. While SGLT2i is a crucial HF medication benefiting many patients, clinicians should recognize that careful consideration is necessary for certain populations, particularly those with very low BMI.