A comprehensive evaluation of cardiac reverse remodeling before and after SGLT2i therapy in a real-world cohort of patients with heart failure: an advanced imaging study

BACKGROUND: Sodium–glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated beneficial effects on cardiac reverse remodeling (RR) in patients with heart failure (HF). However, current imaging evidence mainly focuses on single cardiac chambers, particularly the left ventricle (LV) or left atrium (LA), while integrated biventricular and atrial remodeling remains poorly explored. In addition, real-world HF data are limited, flow–myocardial coupling parameters such as hemodynamic forces (HDFs) are scarcely investigated, and sex-specific differences are still unclear. PURPOSE: To evaluate cardiac RR after initiation of SGLT2i in a real-world HF population. Secondary aims were to assess whether changes in HDFs provide complementary functional information and to descriptively explore sex-related differences in echocardiographic remodeling patterns. METHODS: HF patients with ejection fraction (EF) <45%, naive to SGLT2i and on optimized HF therapy for at least 3 months, were enrolled. Cardiac chamber dimensions and function were assessed using standard and advanced echocardiography, including speckle-tracking and HDFs. NYHA class and NT-proBNP were collected. Patients were analyzed overall and stratified by sex. RESULTS: Eighty-eight patients were included. After 6 months, significant RR was observed across all three chambers. LV RR occurred in 37 patients (42%), right ventricular (RV) RR in 45 (51%), biventricular RR in 20 (23%), and LA RR in 17 (19%). HDFs showed a significative realignment. RR effects were comparable between sexes (p > 0.05). NYHA class and NT-proBNP significantly decreased. CONCLUSIONS: SGLT2i therapy was associated with significant multi-chamber cardiac RR and realignment of HDFs, indicating improved myocardial–flow coupling, without sex-related differences. Larger and longer-term randomized studies are warranted.