SGLT2 Inhibitors in Patients Undergoing Transcatheter Aortic-Valve Implantation: Real-World Evidence for Reduced Mortality

Background:

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated substantial cardiovascular and renal benefits in patients with heart failure. Until recently, their role following transcatheter aortic valve implantation (TAVI) was not well defined. The DAPA-TAVI trial has now shown that dapagliflozin significantly reduced the composite endpoint of all-cause death or worsening heart failure in patients post-TAVI with prior heart failure decompensation; however, the reduction in all-cause mortality alone did not reach statistical significance. Thus, we sought to address this question using a large international electronic health record database.

Methods:

We conducted a retrospective, propensity score–matched cohort analysis using the TriNetX global health research network. Adult patients who underwent TAVI with a history of heart failure decompensation (hospitalization or urgent diuretic therapy) and either chronic kidney disease (eGFR 25–75 ml/min/1.73 m²), type 2 diabetes, or left ventricular ejection fraction (LV-EF) ≤40% were included. Patients receiving SGLT2i (dapagliflozin or empagliflozin) were compared to matched controls not treated with SGLT2i. After matching, 4,073 patients remained in each group, balanced for key baseline characteristics (mean age 78.6 ± 8.6 years, 59.9% male, diabetes 68.7%, CKD 60.7%, mean LV-EF 49.3%). The primary outcome was all-cause mortality; secondary outcomes included all-cause rehospitalization and incidence of genital infections. Median follow-up was 356 days in the SGLT2i group and 633 days in controls.

Results:

SGLT2i treatment was associated with a significant reduction in all-cause mortality compared to controls (16.8% vs. 28.3%; hazard ratio [HR] 0.815, 95% confidence interval [CI] 0.741–0.897; log-rank p < 0.0001). All-cause rehospitalization was also significantly lower among SGLT2i users (59.7% vs. 68.2%; HR 0.869, 95% CI 0.823–0.918; p < 0.0001). The incidence of genital infections was low and not significantly different between groups (0.42% SGLT2i vs. 0.27% control; HR 2.10, 95% CI 0.98–4.51; p = 0.051).

Conclusions:

In our large real-world cohort, SGLT2i therapy after TAVI in high-risk patients with prior heart failure decompensation was associated with significant reductions in all-cause mortality and rehospitalization, without a relevant increase in adverse events. These results complement the findings of the DAPA-TAVI trial and support the broader use of SGLT2i after TAVI in patients with heart failure and multiple comorbidities.