Prognostic impact of SGLT2 inhibitors in acute decompensated heart failure patients stratified by admission systolic blood pressure: a retrospective cohort study

Sodium–glucose cotransporter-2 inhibitors (SGLT2i) provide cardiovascular benefits in heart failure (HF), but their effectiveness across baseline systolic blood pressure (SBP) levels remains uncertain. This study evaluated the prognostic impact of SGLT2i in hospitalized patients with acute decompensated heart failure (ADHF), stratified by admission SBP. In this single-center retrospective cohort study, 219 adults hospitalized for ADHF between January 2020 and December 2024 were included. Patients were grouped by admission SBP into low (≤ 105 mmHg, n = 74) and high (> 105 mmHg, n = 135) categories. The primary outcome was a 12-month composite of HF rehospitalization or cardiovascular death. Secondary outcomes included changes in NT-proBNP, NYHA class, and left ventricular ejection fraction (LVEF). Cox regression and Kaplan–Meier analysis were used to assess associations with outcomes. The composite outcome occurred more frequently in the low SBP group (47.3% vs. 35.6%, P = 0.089), with a shorter median time to event (78 vs. 96 days, P = 0.048). Both groups showed LVEF and NT-proBNP improvement, but LVEF remained consistently higher in the high SBP group (P < 0.05). SGLT2i use was associated with lower event risk in the high SBP group (28.6% vs. 44.8%, P = 0.045), but no significant benefit was observed in the low SBP group (42.4% vs. 51.2%, P = 0.438). Baseline SBP may influence the clinical benefit of SGLT2i in ADHF. Patients with higher SBP may derive greater benefit. These findings underscore the potential utility of SBP-based stratification in HF management.