Early In-Hospital Initiation of Sodium-Glucose Cotransporter-2 Inhibitors After ST-Elevation Myocardial Infarction: A Clinical Review of Hemodynamic and Renal Safety
Abstract
Survivors of ST-elevation myocardial infarction (STEMI) continue to face appreciable risks of hospitalization for heart failure and acute kidney injury (AKI), even in the era of prompt primary percutaneous coronary intervention (PCI). Sodium-glucose cotransporter-2 inhibitors (SGLT2i) deliver proven cardio-renal benefits in chronic heart failure and chronic kidney disease (CKD); however, the safety profile of these agents when initiating administration during the index STEMI admission remains poorly characterized. This clinical review summarizes contemporary evidence on the hemodynamic and renal safety of initiating SGLT2i therapy 24-72 h after PCI in patients with STEMI and provides a pragmatic, evidence-informed bedside framework, supported by randomized controlled trials (RCTs) and mechanistic and observational data from January 2018 to July 2025. Trial eligibility criteria and safety endpoints were extracted qualitatively; no formal meta-analysis was performed. Among at least 11,221 participants, early SGLT2i initiation was well tolerated: rates of hypotension, volume depletion, AKI, and diabetic ketoacidosis (DKA) were comparable to placebo. The characteristic 3-6 mL/min/1.73 m2 decline in estimated glomerular filtration rate (eGFR) represented a reversible tubuloglomerular feedback (TGF) adjustment rather than nephrotoxicity. Mechanistic studies attribute these findings to mild natriuresis without sympathetic activation and to afferent arteriolar vasoconstriction,…
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