Sodium-glucose Cotransporter-2 Inhibitors Stabilize Coronary Plaques in Acute Coronary Syndrome with Diabetes Mellitus

ABSTRACT Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are widely used in cardiology and are effective in treating acute coronary syndrome (ACS). Their effects on unstable plaque in ACS patients remains unclear. This study aimed to examine the effectiveness of SGLT2i in coronary plaque phenotypes based on optical coherence tomography (OCT) images and the prognosis of ACS with type 2 diabetes mellitus (T2DM). Methods This retrospective study included 109 patients in the total cohort and 29 patients in the OCT cohort. Based on SGLT2i administration after ACS, the total cohort was categorized into non-SGLT2i (n = 69) and SGLT2i (n = 40) groups. The OCT cohort had 15 and 14 patients in non-SGLT2i and SGLT2i groups, respectively. OCT images of unstable plaque were analyzed in non-stented lesions during ACS catheterization and at 6-month follow-ups. The total cohort was assessed after 1 year for major adverse cardiovascular events (MACE), including all-cause mortality, revascularization, cerebrovascular disease, and heart failure hospitalization. Results SGLT2i improved unstable lesions with a significantly thicker fibrous cap (48 ± 15 μm vs. 26 ± 24 μm, p = 0.005), reduced lipid arc (-29 ± 12° vs. -18 ± 14°, p = 0.028), and higher % decrease in total lipid arc (-35 ± 13% vs. -19 ± 18%, p = 0.01) as well as a lower MACE incidence (Log rank p = 0.023, HR 4.72 [1.08, 20.63]) and revascularization rate (adjusted HR 6.77 [1.08, 42.52]) compared to the non-SGLT2i group. Conclusions SGLT2i stabilizes atherosclerosis and improves ACS prognosis in patients with T2DM. Clinical Perspective What is new? We analyzed serial OCT images both baseline and follow-up in patients with ACS and T2DM undergoing PCI, and evaluated how effect SGLT2i had on unstable plaques. ACS patients with SGLT2i administration showed coronary atherosclerotic lesions to be stabilized on follow-up. What are the clinical implications? SGLT2i can stabilize unstable plaques by controlling the inflammatory cascade on patients with T2DM. SGLT2i administration will be one option to improve their prognosis in patients with ACS and T2DM undergoing PCI.