Coronary Flow Reserve increase after Dapagliflozin Treatment in patients with type 2 diabetes is maintained after 4 years: a 4-Year DAPAHEART Follow-up Study

Background Cardiovascular (CV) outcome trials have shown that sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce CV mortality in type 2 diabetes (T2DM). We previously found that 4 weeks of SGLT2i treatment increased coronary flow reserve (CFR) by 30% and reduced epicardial adipose tissue (EAT) thickness by 19% in T2DM patients with stable coronary artery disease (CAD). However, long-term effects remain unclear. This study aimed to assess the long-term impact of dapagliflozin on CFR and EAT thickness in T2DM patients. Methods Patients with T2DM and stable CAD were enrolled in the DAPAHEART trial, a single-center, 4-week, randomized (1:1 dapagliflozin 10 mg vs placebo), double-blind, controlled study. At the end of the trial, placebo group patients also transitioned to dapagliflozin. CFR and EAT thickness were measured at baseline, after 4 weeks, and after 4 years using 13N-ammonia PET/CT. Results CFR increased 34.4% after 4 years (from 2.15±0.19 at baseline to 2.85±0.26, p=0.001) with 29.18% reduction in EAT thickness (p=0.03). BMI decreased in all patients (p=0.001), but changes in BMI and EAT thickness were not significantly correlated (R² = 0.0662; p = 0.5038), suggesting a weight-independent effect of dapagliflozin on EAT. Conclusions The 30% CFR improvement seen after 4 weeks of dapagliflozin persisted at 4 years, together with a significant reduction in EAT thickness, possibly explaining CFR improvement. Similar results in the placebo group after treatment, strongly support a causal relationship and underscore the long-term CV benefits of dapagliflozin and its role in reducing CV risk in T2DM patients.