SGLT2 inhibitors and post-ablation atrial fibrillation recurrence and cardiac remodeling in patients with atrial fibrillation and type 2 diabetes mellitus: a cohort study and meta-analysis

This study aimed to investigate the effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on atrial fibrillation (AF) recurrence and cardiac function following catheter ablation in patients with AF and type 2 diabetes mellitus (T2DM). In a cohort study involving AF and T2DM patients who underwent catheter ablation, late atrial arrhythmia (LART) recurrence rate (after the 3-month blanking period) and cardiac function improvement at different postoperative time points were compared between the SGLT2i and non-SGLT2i groups. Univariate and multivariate Cox regression models were used to identify independent risk factors for AF recurrence. Clinical studies of SGLT2i and AF recurrence were systematically retrieved and meta-analyzed. Outcome measures included LART recurrence (primary outcome), AF recurrence, all-cause mortality, rehospitalization, heart failure events, and thromboembolic events (secondary outcome). Subgroup analyses were performed for post-ablation AF recurrence. Meta-analysis was conducted using STATA 19 software. In the cohort study involving 163 patients with AF and T2DM who underwent catheter ablation (SGLT2i group, n = 80; non-SGLT2i group, n = 83), LART recurrence after 18 months of follow-up was significantly lower in the SGLT2i group compared with the non-SGLT2i group (11.25% vs. 24.10%, P = 0.032). Multivariate Cox regression analysis showed that SGLT2i use (HR 0.44, 95% CI 0.20–0.97, P = 0.043) was an independent protective factor, while severe atrial fibrosis (HR 4.28, 95% CI 1.85–9.87, P < 0.001) was an independent risk factor for post-ablation LART recurrence. Subgroup analysis indicated that the protective effect of SGLT2i was not significantly different across subgroups ( P > 0.05). At 6 and 12 months post-ablation, the SGLT2i group showed significantly smaller left atrial diameter (LAD; 6 months: 37.87 ± 4.56 mm vs. 36.20 ± 4.08 mm; 12 months: 37.48 ± 4.80 mm vs. 35.35 ± 4.66 mm; both P < 0.05). The meta-analysis included 21 trials involving 11,098 patients (4,773 in the SGLT2i group and 6,325 in the non-SGLT2i group). While SGLT2i significantly reduced the risk of atrial arrhythmia recurrence [RR = 0.61, 95% CI (0.55, 0.68), P < 0.001], its protective effect was not statistically significant in RCTs [RR = 0.68, 95% CI (0.38, 1.21), P = 0.192], suggesting that the anti-AF effect of SGLT2i may be more pronounced after prolonged use, especially in populations with coexisting heart failure (HF), diabetes, or renal dysfunction. Furthermore, SGLT2i reduced the risks of rehospitalization [RR = 0.79, 95% CI (0.72, 0.87), P < 0.001] and worsening HF [RR = 0.87, 95% CI (0.81, 0.94), P < 0.001]. In patients with AF and T2DM, SGLT2i use was associated with a lower risk of atrial arrhythmia recurrence and improved left atrial diameter. But this benefit is primarily supported by observational evidence and has not been conclusively demonstrated in randomized trials. These findings are hypothesis-generating and warrant further confirmation in adequately powered prospective randomized trials.