Timing of sodium–glucose cotransporter 2 inhibitor initiation and post‐discharge outcomes in acute heart failure with diabetes: A population‐based cohort study

AimsResults from randomized trials suggest benefit of sodium–glucose cotransporter 2 (SGLT2) inhibitor initiation in clinically stable acute heart failure. We aim to examine the real‐world effectiveness of early versus delayed post‐discharge SGLT2 inhibitor initiation in people with acute heart failure and type 2 diabetes.Methods and resultsUsing linkable administrative databases in Ontario, Canada, individuals aged 66 years or older with type 2 diabetes who were discharged to the community from acute care hospitals for heart failure between 1 July 2016 and 31 March 2020 were included in this retrospective, population‐based cohort study. The primary outcome was hospitalization for heart failure (HHF) or cardiovascular mortality as a composite. Follow‐up started from discharge for maximum 1 year. We compared outcomes between post‐discharge SGLT2 inhibitor initiation within 3 days, 4–90 days, or 91–180 days, versus delayed initiation for at least 180 days. The ‘clone‐censor‐weight’ approach with a target trial emulation framework was used to address time‐related biases. There were 9641 eligible individuals. After cloning and artificial censoring, there were 38 564 clones, 12 439 person‐years, and 7584 events. Compared to delayed initiation for at least 180 days, initiation within 3 days post‐discharge was associated with a lower 1‐year risk of HHF or cardiovascular mortality (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.45–0.83), while initiation 4–90 days (RR 0.83, 95% CI 0.72–0.93) or 91–180 days (RR 0.89, 95% CI 0.79–0.97) showed smaller risk reduction.ConclusionReal‐world evidence supports early SGLT2 inhibitor initiation to reduce HHF or cardiovascular mortality in acute heart failure and type 2 diabetes.