Severe aortic stenosis is the most prevalent valvular disorder among older adults, with a rising incidence in line with global population ageing.1 Transcatheter aortic valve implantation (TAVI) has revolutionized the management of this condition by providing a minimally invasive and effective treatment option, which is particularly beneficial for patients at intermediate or high surgical risk.2,3 Nevertheless, despite the advantages offered by TAVI, up to 1 in 6 patients requires readmission for heart failure (HF) within the first year following the procedure.1–5 The presence of HF complicates the patient's clinical course and is associated with increased morbidity and mortality even after successful valvular correction.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have transformed the treatment of HF, showing substantial cardiovascular benefits regardless of ejection fraction.6–8 However, patients with severe valvular disease and those who have undergone recent valvular interventions have been systematically excluded from major clinical trials investigating these agents. In addition, patients undergoing TAVI are typically of advanced age, a population underrepresented in these studies. Therefore, evidence specifically focused on this patient profile is particularly needed.

Within this context, the DapaTAVI clinical trial assessed the role of SGLT2i in elderly patients with symptomatic aortic stenosis undergoing TAVI.9The results of this trial showed a 28% reduction in mortality and HF-related readmissions, with a generally favorable safety profile, although an expected increase in genital infections and hypotension was observed.

The recent study by Obeidat et al.,10 published in Revista Española de Cardiología, provides further evidence in support of this approach. This retrospective study, which included a large cohort of 6044 HF patients who underwent TAVI, compared outcomes between those treated with SGLT2i and those who were not. Treatment initiation was allowed up to 30 days before or after the procedure. To address potential biases inherent to an observational design, the authors applied a propensity score analysis. Regarding the primary outcome event, all-cause mortality, SGLT2i treatment was associated with significant reductions at both 12 months (7.3% vs 10.5%; hazard ratio, 0.71; 95%CI, 0.60-0.85; P <.001) and at 5 years (10.7% vs 20.6%; hazard ratio, 0.59; P=.001). In addition, the group receiving SGLT2i showed a lower incidence of HF-related hospitalizations and emergency room visits, as well as significant reductions in other cardiovascular events, including acute myocardial infarction at 5 years and stroke at 6 months.

In contrast with the DapaTAVI trial, the study by Obeidat et al.10 observed a significant reduction in all-cause mortality as an individual endpoint, likely attributable to its larger sample size, younger mean age (75 vs 82 years), and longer follow-up period. It is plausible that certain beneficial effects of SGLT2i such as cardiac remodeling, improved renal function, and optimized metabolic function require time to translate into long-term mortality benefits.

An important feature of the study is that it was not limited to dapagliflozin, but included several SGLT2i, thus strengthening the hypothesis of a class effect. Moreover, when compared with other oral antidiabetic agents, SGLT2i were shown to reduce not only mortality and hospitalizations, but also major renal and cardiovascular events, such as acute kidney injury and progression to dialysis. This supports the notion that their benefits extend beyond glycemic control, providing additional metabolic and renoprotective effects, as suggested in previous studies.11–14

The study by Obeidat et al.,10 however, has several limitations, such as its retrospective design, the use of electronic health records, and the possibility of unmeasured variables, all of which may result in residual confounding. In addition, the broad time window for initiation of treatment hampers the establishment of precise exposure-effect relationships. Although the comparative analyses with other antidiabetic agents add value, their statistical power is limited by the smaller sample size in that subgroup.

In conclusion, the study by Obeidat et al.10 strengthens the evidence supporting SGLT2i use in HF patients undergoing TAVI and provides real-world efficacy and safety data. From a clinical care perspective, incorporating SGLT2i as adjunctive therapy during the periprocedural period in TAVI constitutes a significant advance in the management of elderly high-risk patients, with the potential to improve outcomes, enhance quality of life, and reduce the health care burden associated with readmissions.