Unexpected Therapeutic Scenarios: Initiating SGLT2 Inhibitors in De Novo Heart Failure Without Echocardiography

Abstract In the field of heart failure, sodium–glucose cotransporter 2 inhibitors (SGLT2-i) have demonstrated robust efficacy and have received a Class I, Level A recommendation for reducing the risk of heart failure hospitalizations and cardiovascular mortality across the entire spectrum of left ventricular ejection fraction. The therapeutic effect occurs early, with the first statistical significance observed as soon as 12–28 days after treatment initiation. Evidence suggests that early introduction during hospitalization may reduce the short-term risk of cardiovascular death or worsening heart failure. SGLT2 inhibitors display a favorable safety and tolerability profile, without an increased incidence of adverse events compared with placebo. Furthermore, they are indicated for the treatment of type 2 diabetes mellitus and chronic kidney disease, irrespective of the presence of heart failure. Therefore, we propose that in patients presenting with signs and/or symptoms of heart failure and elevated natriuretic peptide levels, SGLT2 inhibitors may be initiated even before echocardiographic confirmation of the diagnosis. Given the favorable risk–benefit profile, this approach may help avoid therapeutic delay, which could otherwise be associated with an increased risk of early adverse events, and may ultimately improve prognosis.