Reduction in the incidence of myocardial infarction with sodium–glucose linked cotransporter-2 inhibitors: evident and plausible
KeywordsSodium–glucose linked cotransporter-2 Myocardial infarction Cardiovascular outcome trials Stroke
sodium–glucose linked cotransporter-2
Canagliflozin Cardiovascular Assessment Study
Dapagliflozin Effect on Cardiovascular Events
major adverse cardiovascular events
Coincident with the recent reporting of the Dapagliflozin Effect on Cardiovascular Events (DECLARE) trial in the New England Journal of Medicine , the Lancet published a systematic review and meta-analysis of cardiovascular outcome trials for the three widely marketed SGLT2 inhibitors: canagliflozin, empagliflozin and dapagliflozin .
The observed difference in hazard ratios among myocardial infarction, stroke and amputation suggest that a primary anti-atherosclerotic effect of the SGLT2 inhibitors is unlikely since such an effect would have been expected to reduce myocardial infarction and stroke similarly, as is the case with cholesterol lowering  and antihypertensive therapy . And though it is possible that the reduction in myocardial infarction is a chance finding, the adjudication of events, the robust numbers and the statistical testing all suggest that this is not the case. Accordingly, these data from randomized controlled trials with the support of similar findings in the so-called real world setting  should be regarded as hypothesis-generating.
Infarction occurs when the demands of the myocardium exceed the supply of O2 needed to maintain viability. As such, its likelihood can be reduced by either augmenting O2 supply or reducing its demand. Nitrates, for instance, are thought to improve symptoms in patients with flow-limiting coronary artery disease primarily by reducing preload that, in turn, leads to a diminution in left ventricular volume, wall tension and O2 demand . Nicorandil, for instance, a nitrate derivative with venodilating properties, reduces preload and the risk of myocardial infarction following percutaneous coronary intervention . Through the promotion of an osmotic diuresis, SGLT2 inhibitors also reduce preload and while detailed human studies are in progress, animal studies have demonstrated the ability of this class of agent to similarly reduce left ventricular volumes in systole and diastole and thereby wall tension . Accordingly, we hypothesize that the diminution in myocardial infarction with SGLT2 inhibitors is a consequence of preload reduction in patients with established cardiovascular disease. This drug class would therefore not be expected influence the risk of stroke or critical limb ischemia or be particularly effective in patients with multiple risk factors alone.
In conclusion, we view the meta-analysis-based finding of a statistically significant reduction in myocardial infarction risk in diabetic individuals treated with SGLT2 inhibitors as real, and consistent with the known effects of this drug class on cardiac preload.
Both authors conceived the idea related to this commentary and co-wrote the manuscript. Both authors read and approved the final manuscript.
Dr. Gilbert is the Canada Research Chair in Diabetes Complications and this work was supported in part by the Canada Research Chairs’ Program. Dr. Connelly is supported by a new investigator reward from the CIHR and an early researcher award from the Ministry of Ontario.
Dr. Connelly has received research grants from Astra Zeneca and Boehringer Ingelheim; has received travel support from Boehringer Ingelheim; and has received honoraria for speaking engagements and ad hoc participation in advisory boards from Astra Zeneca, Boehringer Ingelheim, Sevier, Merck, Novo Nordisk, and Janssen.
Dr. Gilbert has received research grants from Astra Zeneca and Boehringer Ingelheim; travel support from AstraZeneca; and honoraria for speaking engagements and ad hoc participation in advisory boards from Astra Zeneca, Boehringer Ingelheim, and Janssen. He is also a shareholder in the biotechnology companies Certa, OccuRx and Fibrocor.
Availability of data and materials
All data is available publically and has been cited.
Consent for publication
The authors consent for publication.
Ethics approval and consent to participate
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- 2.Zelniker TA, Wiviott SD, Raz I, Im K, Goodrich EL, Bonaca MP, Mosenzon O, Kato ET, Cahn A, Furtado RHM, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet. 2019;393(10166):31–9.CrossRefGoogle Scholar
- 3.Bohula EA, Wiviott SD, Giugliano RP, Blazing MA, Park JG, Murphy SA, White JA, Mach F, Van de Werf F, Dalby AJ, et al. Prevention of stroke with the addition of ezetimibe to statin therapy in patients with acute coronary syndrome in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial). Circulation. 2017;136(25):2440–50.CrossRefGoogle Scholar
- 8.Connelly KA, Zhang Y, Visram A, Advani A, Batchu S, Desjardins J, Thai K, Gilbert RE. Empagliflozin improves diastolic function in a non-diabetic rodent model of heart failure with preserved ejection fraction. JACC Basic Transl Sci. 2019 (In Press).Google Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.