Early In-Hospital Initiation of Sodium–Glucose Cotransporter-2 Inhibitors After ST-Elevation Myocardial Infarction: A Clinical Review of Hemodynamic and Renal Safety

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, which lowers intraglomerular pressure. Synthesizing trial exclusion criteria with clinical judgement, we propose the START checklist (stable hemodynamics, tubular reserve, acid-base stability, risk factors, timing (24-72 h)) as provisional guidance to support bedside decision-making while large outcome studies, such as the empagliflozin after acute myocardial infarction (EMPACT-MI) trial and the extended empagliflozin to prevent worsening of left ventricular volumes and systolic function after myocardial infarction (EMPRESS-MI) trial read-outs, are awaited. Current evidence supports the hemodynamic and renal safety of commencing SGLT2i soon after PCI in hemodynamically stable STEMI patients with preserved tubular reserve. In the absence of ongoing trials, cautious adoption guided by the START framework can help clinicians capture potential cardio-renal benefits without compromising acute care.