EMMY: The continued expansion of clinical applications of SGLT2 inhibitors

Introduction: Myocardial infarction (MI) is a challenging clinical and public health problem and is a leading cause of morbidity and mortality worldwide. Heart failure (HF) is a common sequela of acute myocardial infarction (AMI), with an incidence of up to 40% among hospitalized patients and has important implications for treatment and prognosis. Sodium–glucose co-transporter 2 inhibitors (SGLT2i), such as empagliflozin, have been shown to reduce the risk of hospitalization and cardiovascular mortality in patients with symptomatic HF and have therefore been included in the European and American heart failure guidelines. However, trials investigating the effects of this drug class in patients following acute myocardial infarction are lacking. Study and Results: The EMMY trial was conducted to assess the safety and efficacy of empagliflozin in patients with acute myocardial infarction (AMI). A total of 476 patients with AMI were randomly assigned to empagliflozin (10 mg) or matching placebo once daily within 72 h of percutaneous coronary intervention. The primary outcome was the N-terminal pro-hormone of brain natriuretic peptide (NT-proBNP) change over 26 weeks. Secondary outcomes included changes in echocardiographic parameters. NT-proBNP reduction was significantly greater in the empagliflozin group (−15% after adjusting for baseline NT-proBNP, gender, and diabetes status (P = 0.026)). Absolute left-ventricular ejection fraction improvement was 1.5% (P = 0.029) greater, mean E/e′ reduction was 6.8% (P = 0.015) greater, and left-ventricular end-systolic and end-diastolic volumes were lower by 7.5 mL (P = 0.0003) and 9.7 mL (P = 0.0015), respectively, in the empagliflozin group, compared with placebo. Seven patients were hospitalized for HF (3 in the empagliflozin group). Other predefined serious adverse events were rare and did not differ significantly between groups. Lessons learned: The EMMY trial shows that early use of the SGLT2 inhibitor empagliflozin after acute myocardial infarction (MI) improves natriuretic peptide levels and markers of cardiac function and structure supporting the use of Empagliflozin in HF related to a recent MI.