Cardiometabolic Impact of SGLT-2 Inhibitors on Epicardial Adiposity and Left Ventricular Function in Type 2 Diabetes Mellitus and Coronary Artery Disease: Insights from Malaysian Epicad Study

BACKGROUND Epicardial adipose tissue (EAT) is an emerging cardiometabolic risk factor in type 2 diabetes mellitus (T2DM). While SGLT-2 inhibitors (SGLT-2i) offer cardiovascular benefits, their specific effects on EAT and left ventricular (LV) remodelling and function in Asian populations remain understudied. OBJECTIVE This study investigated the impact of SGLT-2i on cardiometabolic parameters, EAT thickness and LV function in Malaysian patients with T2DM and coronary artery disease (CAD). METHODS A total of 360 patients with T2DM and CAD were divided into non-SGLT-2i and SGLT-2i groups. Anthropometric, cardiometabolic, and echocardiographic measurements were analyzed at baseline and post-6 months for 302 patients who competed the study (n = 151 per group). RESULTS Both groups showed improvements in glycaemic control (fasting blood glucose − 1.7 vs − 2.6 mmol/L; HbA1c − 0.3% vs − 0.6%; all p < 0.001). Broader cardiometabolic benefits were observed predominantly among SGLT-2i group, including greater reductions in body mass index (–0.7 vs − 0.3 kg/m²) and serum lipid concentrations (all p < 0.001), a marked decrease in epicardial adipose tissue thickness (–1.5 mm vs + 0.6 mm, p < 0.001), and concomitant improvements in left ventricular structure, with reductions in LV mass (–20 vs + 7.8 g) and increased LV ejection fraction (+ 4.6% vs − 1.0%) (all p ≤ 0.01). Within the SGLT-2i group, EAT reduction was associated with lower body weight and BMI (p < 0.05) but was independent of glycaemic changes. Reductions in body weight and BMI were associated with improvements in LV diameter and mass (p < 0.05) and although not directly mediated by changes in EAT. CONCLUSION Beyond glycaemic control, SGLT-2i decreased EAT thickness and improved LV remodelling and function in Malaysian T2DM patients with CAD. The reduction in EAT thickness specifically was associated with lower body weight and BMI. These findings provide Asian population–specific evidence with distinct cardiometabolic and adiposity traits.