Load-independent effects of empagliflozin contribute to improved cardiac function in experimental heart failure with reduced ejection fraction

Background and aims: Sodium–glucose linked cotransporter‑2 (SGLT2) inhibitors reduce the likelihood of hospitali‑ zation for heart failure and cardiovascular death in both diabetic and non‑diabetic individuals with reduced ejec‑ tion fraction heart failure. Because SGLT2 inhibitors lead to volume contraction with reductions in both preload and afterload, these load‑dependent factors are thought to be major contributors to the cardioprotective effects of the drug class. Beyond these effects, we hypothesized that SGLT2 inhibitors may also improve intrinsic cardiac function, independent of loading conditions. Methods: Pressure–volume (P–V) relationship analysis was used to elucidate changes in intrinsic cardiac function, independent of alterations in loading conditions in animals with experimental myocardial infarction, a well‑estab‑ lished model of HFrEF. Ten‑week old, non‑diabetic Fischer F344 rats underwent ligation of the left anterior descending (LAD) coronary artery to induce myocardial infarction (MI) of the left ventricle (LV). Following confirmation of infarct size with echocardiography 1‑week post MI, animals were randomized to receive vehicle, or the SGLT2 inhibitor, empagliflozin. Cardiac function was assessed by conductance catheterization just prior to termination 6 weeks later. Results: The circumferential extent of MI in animals that were subsequently randomized to vehicle or empagliflozin groups was similar. Empagliflozin did not affect fractional shortening (FS) as assessed by echocardiography. In con‑ trast, load‑insensitive measures of cardiac function were substantially improved with empagliflozin. Load‑independ‑ ent measures of cardiac contractility, preload recruitable stroke work (PRSW) and end‑systolic pressure volume rela‑ tionship (ESPVR) were higher in rats that had received empagliflozin. Consistent with enhanced cardiac performance in the heart failure setting, systolic blood pressure (SBP) was higher in rats that had received empagliflozin despite its diuretic effects. A trend to improved diastolic function, as evidenced by reduction in left ventricular end‑diastolic pres‑ sure (LVEDP) was also seen with empagliflozin. MI animals treated with vehicle demonstrated myocyte hypertrophy, interstitial fibrosis and evidence for changes in key calcium handling proteins (all p < 0.05) that were not affected by empagliflozin therapy.