Hemoglobin Trajectories on SGLT2 Inhibitor Therapy in Heart Failure: Anemia Marks Adverse Prognosis While Erythrocytosis Is Transient and Not Associated with Adverse Outcomes
Abstract
Background/Objectives: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) raise hemoglobin in patients with heart failure (HF). We characterized the prevalence, dynamics, predictors and prognostic implications of three hemoglobin states (anemia, normal, and erythrocytosis) at baseline and during the first year on SGLT2i therapy. Methods: Prospective single-center registry of 1244 HF patients with a baseline hemoglobin who initiated dapagliflozin or empagliflozin (March 2022-October 2025). Hemoglobin was categorized at baseline, 6 and 12 months using WHO sex-specific thresholds. We analyzed inter-category transitions, predictors of each hemoglobin category at each timepoint, time-to-event outcomes (all-cause death, MACE, thrombosis) in landmark analyses, and the correlation of hemoglobin change with concurrent changes in left ventricular ejection fraction and NT-proBNP. Results: At baseline, 23.6% had anemia, 71.1% were normal, and 5.3% had erythrocytosis. The prevalence of erythrocytosis remained low throughout, with a modest, transient rise to 8.0% at 6 months before returning toward baseline (5.9% at 12 months), even though the underlying composition of patients was highly dynamic. Among baseline-normal patients, downward transition to anemia (7.8% at 6 months, 9.2% at 12 months) occurred at rates equal to or greater than upward transition to erythrocytosis (7.7% and 6.0%, respectively). The prevalence of anemia decreased significantly between baseline and the follow-up…
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